ems and chemotherapy jerry myers, emt-p/ems-i lieutenant, ambulance supervisor ridgefield fire...
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EMS and Chemotherapy
Jerry Myers, EMT-P/EMS-I
Lieutenant, Ambulance Supervisor
Ridgefield Fire Department
What we will talk about
• What is Cancer
• What causes Cancer
• How is it treated
• What is Chemotherapy
• Assessment tips for chemotherapy patients
• Treating chemotherapy patients
What is Cancer?
Cancer is what happens when part of your body grows in an uncontrollable way and damages healthy parts.
Cancer cells grow and multiply when they should not.
Cancer cells are capable of crossing the normal boundaries of the tissue they start in.
Cancer cells can get in to the bloodstream or other means of travel.
Cancer cells can establish secondary tumors at distant areas.
Cancer cells may produce substances that interfere with normal body functions.
Some Scary Numbers
• Since 1990 there have been 17 million cases of cancer diagnosed in the US.
• In 2003 there were 1,334,100 new cases of cancer diagnosed in the US.
• 556,500 will die annually. This amounts to 1,500 a day!
• 1 in 4 deaths in the US are due to cancer.
There is still hope!
• In 1999 there were 8.9 million Americans alive with a previous history of cancer.
• The 5 year survival rate for all cancers combined is 62%.
• I’m still here, they must be doing something right!
Where does Cancer come from?
• External Sources:
• Tobacco
• Radiation
• Chemicals
• Infectious Organisms
Where does Cancer come from?
• Internal Factors:
• Inherited Mutations
• Hormones
• Immune Conditions
• Mutations from Metabolism
Cancer is not contagious
• No type of cancer is contagious!
• Cancer can not be spread to others.
• There is no need to fear being around cancer patients. You will not catch cancer from them!!!!!
• Cancer is not contagious!
My Story(How this subject became near and dear to me!)
• Summer 2001, I notice a lump.• September 7, 2001 I visit the urologist.• September 11, 2001, surgical intervention.• September 14, 2001. Cancer diagnosis made.• October 2001, CT Scan shows spread of Cancer.• November/December 2001 - Chemotherapy.• May 2002, Tumor doubles in size.• July/August 2002. In patient Chemotherapy.• September 2002, PET Scan shows no cancer.
How is Cancer Treated?
Surgery
Radiotherapy
Chemotherapy
Surgical Treatment of Cancer
Surgery has been used to cut out tumors for probably over two thousand years.
Surgery still offers the best chance of cure when the cancer can be totally contained in the area that is removed.
Surgical removal of cancer may be followed by additional treatments such as chemotherapy or radiation.
Surgery can be preventative, Diagnostic, or Curative in nature.
Radiotherapy
Radiation is created by machines, or given off by substances such as cobalt.
Radiation is applied to the cancer and kills the cancer cells.
The dose needs to be high enough to kill the cancer, but not the tissue surrounding it.
The skill of the radiation oncologist and the radiotherapy department can have a significant effect of the success of this treatment.
Radiation treatment is given in daily fractions lasting a few minutes each day.
Chemotherapy
• Chemotherapy basically means treating Cancer with chemicals.
• Often used in conjunction with other treatment modalities such as surgery.
• Chemotherapy is still rapidly evolving as new anti-cancer drugs are developed.
• The exact type of cancer and the stage it is in guides the decision to use chemotherapy.
Origins of Chemotherapy
Chemotherapy was accidentally discovered when a ship carrying mustard gas exploded during WW-2.
Pathologists were amazed by the damage to lymph systems and bone marrow of the sailors who died.
Yale University Physicians experimented with nitrogen mustard to treat cancers of the blood and lymph systems.
This gave birth to what we now know as chemotherapy.
Chemotherapy
• Normally used to treat cancer “systemically”
• These chemicals circulate through the body and kill cancer cells.
• Seeks out and kills cancer cells not yet even detected.
• Unfortunately this creates undesirable symptoms because it kills healthy cells as well.
Chemotherapy
• In simple terms, chemotherapy is a poison.
• The poison must be taken to kill the disease.
• Chemo works most effectively on fast growing diseases.
• It is less effective on slower diseases such as prostrate cancer, which is why other options are used in these cancers.
Chemotherapy
• Can be given as pills, injected into the body, or applied to skin patches and allowed to soak into the skin.
• Often the patient has a Port-a-cath or PIC line to facilitate multiple transfusions.
Other Medications
• Nausea is a significant problem with chemotherapy and patients receive both I.V. and P.O. anti-nausea medications.
• Patients also receive steroids and anti-histamines to counteract allergic reactions.
• Patients may take these medications after chemotherapy for “break through” symptoms.
Blood Components
• Plasma
• Red Blood Cells
• White Blood Cells
• Platelets
• Average adult has about 5 liters of blood
Plasma
• Plasma is the liquid portion of blood
• Clear, straw colored liquid
• 92% Water, 8% proteins etc.
• Cells and Platelets suspended in the plasma
• Plasma shifts in and out of circulatory system as needed
Platelets (Thrombocytes)
• Platelets are not complete cells
• In circulation the fragments break down into smaller fragments
• Platelets cause the blood to clot
• The lack of platelets will result in bleeding
• Normal platelet count is 130-360K/cubic mm
Red Blood Cells(Erythrocytes)
• Tiny biconcave disk shaped cells related to cells function
• Main function is to transport gasses
• What gasses?
• Oxygen and Carbon Dioxide.
• Normal RBC count 4,600,000-6,200,000 per cubic mm
White Blood Cells(Leukocytes)
• There are several types of WBC’s
• Their primary function is to fight infection and disease
• Normal WBC count is 5-10K per cubic mm
• High WBC indicates possible infection
• Low WBC means patient is vulnerable to infection
Normal Lab Values
• WBC 5.0 - 10.0
• RBC 4.5 - 5.9
• Platelets 150. - 350.
• HCT 41.0 - 53.0
• Hematocrit (HCT) is the percentage of red cells to plasma. Normally around 45%.
Typical Chemotherapy Cycle
• Patient has chemo in week one.
• In week two, cell counts drop off.
• In week three patient recovers somewhat.
• Patient starts cycle again by receiving chemo.
• Cycles run one week on, two weeks off or variations of that.
Common Chemotherapy Drugs
Taxol Ifosamide Platinum
Altretamine Aminoglutethimide Bleomycin
Carboplatin Cytarabine Docetaxel
Doxorubicin Etoposide Floxuridine
Fluorouracil Gemcitabine Interferons
Levamisole Lomustine Methotraxate
Mitomycin Procarbazine Rituximab
Streptozocin Tamoxifen Vincristine
Most common side effects
Nausea Hair Loss Loss of appetite
Fatigue Anemia Infection
Clotting Problems Diarrhea Constipation
Nerve/Muscle problems Mouth/Gum/Throat problems
Skin/Nail effects Kidney/Bladder problems
Fluid Retention Tooth decay
Sexual/Reproductive changes
When patients are advised to call their physician.
Fever higher than 100.5 F
Shaking or Chills
Unusual bleeding or bruising
Shortness of breath
Severe constipation or diarrhea
Vomiting that continues 72 hours after treatment
Painful or burning urination
Blood in urine or stool
Soreness of the intravenous site
When does EMS get called for Chemotherapy patients?
• Allergic Reaction
• Weakness/Dizziness
• Shortness of breath
• Infection or Fever
• Medical/Trauma problem where chemotherapy is secondary to the reason for the call.
Weakness/Dizziness
• Red Blood Cell counts get low.
• Patient becomes anemic.
• Pt. may become hypovolemic due to reduced oral intake.
• Vomiting and Diarrhea may also reduce patients overall volume.
• Internal bleeding from loss of platelets may also be a factor.
Shortness of Breath
• Loss of RBC,s results in loss of oxygen transportation capabilities.
• Patients are easily exhausted and often have marked dyspnea on exertion as demand exceeds available supply.
• Other medical conditions such as COPD may be exacerbated by this situation.
Fever/Infection
• White Blood Cells combat infection, but are also attacked by chemotherapy causing an overall reduction of WBC’s.
• The body becomes susceptible to outside pathogens.
• Chemotherapy Patients must wash hands regularly, avoid fresh fruits, salad bars etc. or they risk developing a systemic infection.
What to ask when getting history(Specific to the chemotherapy patient)
• Type of cancer, and type of treatment patient is undergoing.
• Where in the cycle is the patient.
• How have the side effects been. What are the counts like.
• What caused the patient to call EMS now.
Assessment of the Chemotherapy Patient
• Assess like all other patients. Start with the ABC’s
• Initial Assessment, Physical Exam, and History – Type of Cancer?– Where in the cycle is the patient?– How have their blood counts been?
• Pulse Oxymetry can be very helpful for both respiratory and circulatory status
Providing care to Chemotherapy Patients
• Treatment is based on symptoms present
• Start with ABC’s
• Oxygen may be helpful
• Fluids may help dehydration but avoid overload
• Handle gently and avoid over exerting the patient
• Remember the patient is the decision maker
• Follow local protocols
Emotional Aspects of Care
• Cancer patients may be reluctant to go to the hospital fearing a loss of control
• Like all patients, they need to be in control of their destiny
• Remember the patient may live with the threat of death hanging over them.
• They may not respond to normal arguments as to why they should be transported.
Fluid/Medication Administration
• Is IV access absolutely necessary?
• When the patient says they have bad veins, believe them!
• Use pre-existing access whenever possible. (Portacath, PIC Line, etc.) if allowed by Medical Control.
A Word on Portacath Access
PICC Lines
Peripherally Inserted Central Catheter
Infection Control
• Chemotherapy patients need to be protected from infection.
• Wash your hands, use gloves.
• Use a mask if you have any cold symptoms.
• Use aseptic technique when performing procedures such as IV’s.
