Medic Up!

An excellent read by FOAMFrat. An introduction to fluid resuscitation and cautions there of.

https://www.foamfratblog.com/post/the-sodium-trap?fbclid=IwAR2dwx-AvRSw8gBB1GyPpl_Rwp2c-HeAc3-k6wkmxZ5jTFIioAjA9jSmrfY_aem_AcRQYH3b3e3NdPGZHu20QhrQnf7RGfqFKEh7PwwGIFcvOALtfrFuWkUV2uvPLy3exw9EHKNaxVvuCFKp1IMEiB2WHZSMmKFHfHCkdFHKwweZSw

View the full article

This podcast is a panel discussion from providers in Australia. Their EMS sounds like light years ahead of where I work. They utilize blood products, plasma, and can activate a trauma OR.

It’s amazing to hear what other places are doing. Especially when you feel lost in your own career and wish to see your service progress.

Please give it a listen and tell me what you think!

TLDR (or didn’t listen): lives can be saved if all departments work together!

View the full article

Advanced airways in EMS are in heated debate today. There are two extremes. Give it or cut it. Some medical directors are granting crews RSI (rapid sequence intubation) in the field. While others are cutting intubation as a whole and utilizing devices like the iGel.

There are so many combinations of medications you can use for induction in a chemically assisted intubation. The one that was recently brought to my attention was Ketamine.

Ketamine has been a wonder drug in EMS. It has been beneficial in taking down the giant muscled bound tweeker that’s fighting a gaggle of police officers. It is excellent in pain management. But, as an induction agent in intubation it has been scrutinized highly as there is a lot of complications that come with a wonder drug. This paper discusses some of those complications.

Ketamine lost in the unfair fight against RSI. There were too many variables including spontaneous breathing and vomiting.

Take a look for yourself!

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                Let’s talk about TXA and brain injuries. Maybe we can put to rest the suspicion that TXA creates further injury in patient’s with a TBI. TXA is an amazing tool to use for our trauma patients. There has been so much success TXA that there are trials to see how effective it is for GI bleeds.

                As with most medications new to a service (mine has had standing orders on TXA for about a year), there are always questions and concerns. One that continually comes forward is, “does TXA create further harm in a patient with a brain injury?”

                Curious and in an effort to self educate, I searched and found an article on my favorite blog, EMcrit.

                The CRASH studies were used to see the effectiveness of TXA and the trauma patient. The CRASH 3 study was specifically a sub study for the TBI patient. It was ran as a pragmatic study. Meaning, it was a non-controlled atmosphere and based in a real life setting with unpredictable variables. Much like a bad trauma patient.

“CRASH-3 was designed to further investigate using tranexamic acid for patients with traumatic brain injury.  This study utilized the following inclusion criteria:

Enrollment within hours of injury

Either Glasgow Coma Scale <13 or intracranial hemorrhage on CT scan

No major extracranial bleeding

This was a massive, pragmatic, double-blind RCT involving 175 hospitals in 29 countries, with a target enrollment of 10,000 patients.  Patients were randomized to receive either saline or tranexamic acid (1 gram loading dose over 10 minutes followed by a second gram infused over the following 8 hours; this is the same regimen used in CRASH-2).  The primary endpoint was head injury-related death in the hospital within 28 days of injury.”

                The utilized saline as the placebo versus TXA. The results showed a reduced mortality rate in patient’s with non-severe TBIs. With an emergency room study such as this, the results were “not statistically significant.” The criteria for a TBI patient is vast. There are too many complications. What proceeded forward was the need to take out the obviously brain dead patients (GCS>9 and fixed pupils). The severe TBI patients would not benefit from TXA just due to the impact of their injury. More severe, the less of a chance of effectiveness.

                Now, the mildly injured patient’s proved effective. There was a significant increase in the decrease of mortality with in 28 days of the patients who received TXA while suffering from a brain injury. To receive the proper and fair outcome, it was just a matter realizing that some patients were too sick to save.

“ Subgroup analysis shows benefit from tranexamic acid among patients with a greater hope of recovery.  Specifically, tranexamic acid reduced head injury-related death in the subgroup of patients with GCS>8 and also the subgroup of patients with reactive pupils.”

What were the take away and conclusions of the study?

“The conclusion of this article sums things up nicely:  “tranexamic acid is safe in patients with TBI and treatment within 3 hours of injury reduces head injury-related death.  Patients should be treated as soon as possible after injury.”

The greatest strength of this study might be an extremely thorough evaluation for possible adverse events among 12,639 patients.  Tranexamic acid was found to be safe, without increased rates of any adverse events (including thrombosis, seizure, and stroke).

The primary endpoint of this study was technically negative (p-value slightly above 0.05).  This likely reflects the inclusion of moribund patients, who diluted out the signal of benefit from tranexamic acid.  Numerous subgroup analyses indicate that among patients with a greater hope of recovery, tranexamic acid is beneficial (figure below).  As a statistical rebel, I would consider this trial to be positive, despite having a technically negative primary endpoint.”

Check out the article at; https://emcrit.org/pulmcrit/crash3/

View the full article

                Let’s talk about TXA and brain injuries. Maybe we can put to rest the suspicion that TXA creates further injury in patient’s with a TBI. TXA is an amazing tool to use for our trauma patients. There has been so much success TXA that there are trials to see how effective it is for GI bleeds.

                As with most medications new to a service (mine has had standing orders on TXA for about a year), there are always questions and concerns. One that continually comes forward is, “does TXA create further harm in a patient with a brain injury?”

                Curious and in an effort to self educate, I searched and found an article on my favorite blog, EMcrit.

                The CRASH studies were used to see the effectiveness of TXA and the trauma patient. The CRASH 3 study was specifically a sub study for the TBI patient. It was ran as a pragmatic study. Meaning, it was a non-controlled atmosphere and based in a real life setting with unpredictable variables. Much like a bad trauma patient.

“CRASH-3 was designed to further investigate using tranexamic acid for patients with traumatic brain injury.  This study utilized the following inclusion criteria:

Enrollment within hours of injury

Either Glasgow Coma Scale <13 or intracranial hemorrhage on CT scan

No major extracranial bleeding

This was a massive, pragmatic, double-blind RCT involving 175 hospitals in 29 countries, with a target enrollment of 10,000 patients.  Patients were randomized to receive either saline or tranexamic acid (1 gram loading dose over 10 minutes followed by a second gram infused over the following 8 hours; this is the same regimen used in CRASH-2).  The primary endpoint was head injury-related death in the hospital within 28 days of injury.”

                The utilized saline as the placebo versus TXA. The results showed a reduced mortality rate in patient’s with non-severe TBIs. With an emergency room study such as this, the results were “not statistically significant.” The criteria for a TBI patient is vast. There are too many complications. What proceeded forward was the need to take out the obviously brain dead patients (GCS>9 and fixed pupils). The severe TBI patients would not benefit from TXA just due to the impact of their injury. More severe, the less of a chance of effectiveness.

                Now, the mildly injured patient’s proved effective. There was a significant increase in the decrease of mortality with in 28 days of the patients who received TXA while suffering from a brain injury. To receive the proper and fair outcome, it was just a matter realizing that some patients were too sick to save.

“ Subgroup analysis shows benefit from tranexamic acid among patients with a greater hope of recovery.  Specifically, tranexamic acid reduced head injury-related death in the subgroup of patients with GCS>8 and also the subgroup of patients with reactive pupils.”

What were the take away and conclusions of the study?

“The conclusion of this article sums things up nicely:  “tranexamic acid is safe in patients with TBI and treatment within 3 hours of injury reduces head injury-related death.  Patients should be treated as soon as possible after injury.”

The greatest strength of this study might be an extremely thorough evaluation for possible adverse events among 12,639 patients.  Tranexamic acid was found to be safe, without increased rates of any adverse events (including thrombosis, seizure, and stroke).

The primary endpoint of this study was technically negative (p-value slightly above 0.05).  This likely reflects the inclusion of moribund patients, who diluted out the signal of benefit from tranexamic acid.  Numerous subgroup analyses indicate that among patients with a greater hope of recovery, tranexamic acid is beneficial (figure below).  As a statistical rebel, I would consider this trial to be positive, despite having a technically negative primary endpoint.”

Check out the article at; https://emcrit.org/pulmcrit/crash3/

View the full article

My AHA BLS quiz application was just released on Android. Check it out!

https://play.google.com/store/apps/details?id=com.wBLSQuiz2019_9477418

View the full article

My AHA BLS quiz application was just released on Android. Check it out!

https://play.google.com/store/apps/details?id=com.wBLSQuiz2019_9477418

View the full article

2,000 law suits and appeals have been pushed forward against Johnson and Johnson. The state of Oklahoma has started proceeding in regards to damages done to the state.

As stated in the New York Times; ” Oklahoma had said it would need $17 billion to repair the damage done by the epidemic. About 6,000 Oklahomans have died from opioid overdoses since 2000, according to officials there.”

It is about time some one has step forward and pursued dealers in this rich man drug war!

View the full article

2,000 law suits and appeals have been pushed forward against Johnson and Johnson. The state of Oklahoma has started proceeding in regards to damages done to the state.

As stated in the New York Times; ” Oklahoma had said it would need $17 billion to repair the damage done by the epidemic. About 6,000 Oklahomans have died from opioid overdoses since 2000, according to officials there.”

It is about time some one has step forward and pursued dealers in this rich man drug war!

View the full article

There was a time I was burnt out. Well, that’s not exactly true. There was a time that every three months I was burnt to the core. I wanted to quit. I wanted to go to nursing school. Hell, I even put in an application to Fed Ex.

                Unfortunately, there was one time that my burn out led to injuring a patient.

                You see, I was burning the candle from all ends. I was going through a terrible separation with a woman who had two kids I cared for and adored. I was a supervisor of a shift that was falling apart. I worked nights, went to school during the day, and had to attend meetings in the mid afternoon (peak night shift sleep hours).

                I turned into the medic who would blow up about too many gloves being on the truck. Trash cans would fly across the bay floor after a mighty frustrated kick. Mop handles would shatter on the side of the ambulance like I was swinging a samurai sword. My off shift drinking was constant. My anger was out of control and would occasionally come out on a patient. My refusal numbers were rising and the end of the road was coming closer.

                One morning, my partner and I were called out to a patient complaining of abdominal pain. Before the call even came in, we were in the mood that this patient was going to be a refusal. We were both exhausted from outside life and had no intention of transporting. We were a dangerous crew that had lost all interest in their job. We wanted to be anywhere except on the ambulance.

                We arrived at the home of the patient and in all honesty, I barely remember the call. I am sure I talked her out of going. I probably made her feel stupid for calling 911. I probably took the anger of my personal life out on her.

                The only thing I remember was waking up in the afternoon to numerous missed calls from members of our upper leadership. The patient ended up have a ruptured appendix and was rushed to surgery after another crew, an hour after we left the residence, did their job and transported the patient.  

                I was close to being fired. I was close to losing my license. I was having the biggest wake up call in not only my career, but my life. I hurt someone. Yes. She signed the refusal AMA form. But at what cost? And with how much encouragement?

                I like to share my mistakes for others to learn from. Burn out is dangerous. Burn out hurts patients.  

                In the paper posted on Medium, the greatest cure for burn out is to regain the awe of your job, or life.

                “If this path to burn out is, as Aldous Huxley wrote, ‘a reducing valve’ of awareness, it’s awe that helps to open us back up. Dacher Keltner, a professior of psychology at the University of California, Berkeley, has shown that awe is tied directly to feeling of expansiveness, transcendence, and connection.”

I was working too much OT and my personal life was falling apart. I had to make huge changes in my life, step down from positions, say no to projects, and budget my spending so I could say no to OT shifts. I stepped down as supervisor (surprisingly, I didn’t get demoted) and transferred myself to a county known to be strict. I wanted to remind myself why I not only got into the field, but to also get back to the basics of patient care. I was not taking care of people and most of all, I was not taking care of myself.

                My love for the job came with helping people. Where did my love for care go? My personal life was spiraling out of control and I was not feeding myself creatively. My tank for the awe was ran dry.

                “Awe doesn’t just shift the way we think, it changes our biology. According to a 2015 study in the journal Emotion, awe, more than any other positive feeling, is linked to lower loves of a molecule called Interleukin-6, which is associated with stress and inflammation.”

                The awe for the job came back when I chose to learn again. There is something to learn every shift. You just have to look for it.

                Even if I haven’t taken the chance to learn about something, I enjoy creating hilarious back stories for patient’s and their family. Everyone has a story.

                “Perspective allows me to see that ‘my’ world is tiny when compared to the actual world. I feel more open and energetic, and less burnt out.”

                It’s all about perspective and reminding myself why I got into the job in the first place. It’s the greatest way to help someone and it’s so damn interesting.

Check out the article; “The natural cure for burnout is profound and utter awe” by Brad Stulberg on the site Medium.

View the full article

There was a time I was burnt out. Well, that’s not exactly true. There was a time that every three months I was burnt to the core. I wanted to quit. I wanted to go to nursing school. Hell, I even put in an application to Fed Ex.

                Unfortunately, there was one time that my burn out led to injuring a patient.

                You see, I was burning the candle from all ends. I was going through a terrible separation with a woman who had two kids I cared for and adored. I was a supervisor of a shift that was falling apart. I worked nights, went to school during the day, and had to attend meetings in the mid afternoon (peak night shift sleep hours).

                I turned into the medic who would blow up about too many gloves being on the truck. Trash cans would fly across the bay floor after a mighty frustrated kick. Mop handles would shatter on the side of the ambulance like I was swinging a samurai sword. My off shift drinking was constant. My anger was out of control and would occasionally come out on a patient. My refusal numbers were rising and the end of the road was coming closer.

                One morning, my partner and I were called out to a patient complaining of abdominal pain. Before the call even came in, we were in the mood that this patient was going to be a refusal. We were both exhausted from outside life and had no intention of transporting. We were a dangerous crew that had lost all interest in their job. We wanted to be anywhere except on the ambulance.

                We arrived at the home of the patient and in all honesty, I barely remember the call. I am sure I talked her out of going. I probably made her feel stupid for calling 911. I probably took the anger of my personal life out on her.

                The only thing I remember was waking up in the afternoon to numerous missed calls from members of our upper leadership. The patient ended up have a ruptured appendix and was rushed to surgery after another crew, an hour after we left the residence, did their job and transported the patient.  

                I was close to being fired. I was close to losing my license. I was having the biggest wake up call in not only my career, but my life. I hurt someone. Yes. She signed the refusal AMA form. But at what cost? And with how much encouragement?

                I like to share my mistakes for others to learn from. Burn out is dangerous. Burn out hurts patients.  

                In the paper posted on Medium, the greatest cure for burn out is to regain the awe of your job, or life.

                “If this path to burn out is, as Aldous Huxley wrote, ‘a reducing valve’ of awareness, it’s awe that helps to open us back up. Dacher Keltner, a professior of psychology at the University of California, Berkeley, has shown that awe is tied directly to feeling of expansiveness, transcendence, and connection.”

I was working too much OT and my personal life was falling apart. I had to make huge changes in my life, step down from positions, say no to projects, and budget my spending so I could say no to OT shifts. I stepped down as supervisor (surprisingly, I didn’t get demoted) and transferred myself to a county known to be strict. I wanted to remind myself why I not only got into the field, but to also get back to the basics of patient care. I was not taking care of people and most of all, I was not taking care of myself.

                My love for the job came with helping people. Where did my love for care go? My personal life was spiraling out of control and I was not feeding myself creatively. My tank for the awe was ran dry.

                “Awe doesn’t just shift the way we think, it changes our biology. According to a 2015 study in the journal Emotion, awe, more than any other positive feeling, is linked to lower loves of a molecule called Interleukin-6, which is associated with stress and inflammation.”

                The awe for the job came back when I chose to learn again. There is something to learn every shift. You just have to look for it.

                Even if I haven’t taken the chance to learn about something, I enjoy creating hilarious back stories for patient’s and their family. Everyone has a story.

                “Perspective allows me to see that ‘my’ world is tiny when compared to the actual world. I feel more open and energetic, and less burnt out.”

                It’s all about perspective and reminding myself why I got into the job in the first place. It’s the greatest way to help someone and it’s so damn interesting.

Check out the article; “The natural cure for burnout is profound and utter awe” by Brad Stulberg on the site Medium.

View the full article

My new PALS study app just went live today!

If you are an android and getting ready to take PALS, check it out!

https://play.google.com/store/apps/details?id=com.wPALSQuiz2019_9326200

View the full article

My new PALS study app just went live today!

If you are an android and getting ready to take PALS, check it out!

https://play.google.com/store/apps/details?id=com.wPALSQuiz2019_9326200

View the full article

apple.news/APWZMplLkQp28qw0aiF26Vw

I couldn’t imagine being first on scene… prays for EVERYONE involved.

View the full article

apple.news/APWZMplLkQp28qw0aiF26Vw

I couldn’t imagine being first on scene… prays for EVERYONE involved.

View the full article

This study will have two versions written about it. This version is my “cut the fat” version I am trying encapsulate in this blog. As well, with my venture in medical free lance writing, I will have a “medical education” category for those who want the juicy morsels of dense medical language.

With out further wait… here is sepsis study on a plate.

Sepsis is a hot button topic in the world of prehospital medicine. There has been alot of literature put out by hospitals that declare more than 50% of in hospital deaths are due to multiple organ death (MODs), which is the ultimate deathly out come of sepsis.

The problem with sepsis and EMS is not only figuring out what we are looking for, but also to relay to the ER what we are seeing. Granted, we are not allowed to fully “diagnose” a patient, but effect EMS education teaches differential diagnosis to create a “field diagnosis.” We want to start drawing the picture of what the patient will need for continuity of care. Depending where you work, ER nurses and docs alike appreciate a field diagnosis. Again, depending where you work. In order to have that continuity of care, the EMS provider has to be ready to give the facts and findings of your field diagnosis.

Center stage at hospital night at the Apollo. Your are taking your patient to bay 1. There are 20 people in lead vests and gowns and goggles. You begin to speak loudly (que Eminem walking to the mic) and clearly. Then you are interrupted by questions you don’t know. The whole set falls apart. The crowd begins to boo. The doctors glare. The nurses snicker. The a clown with a long curved cane scoops you up and drags you to the ambulance bay…

But never fear! Sepsis study’s for ambulances are here!

For a potential Sepsis activation, you need to first understand the steps of infection and it’s relation to the human body. I’m sure many of us have had the case of chest pain that ended up being pneumonia. Productive cough? Elevated temp? Could still be cardiac but through our deferential diagnosis we know we have a higher chance or treating pneumonia instead of angina. Breathing treatment and fluid versus aspirin/nitro.

There are three steps in the chain of fatal sepsis. First step is Systemic Inflammatory Response. This is the time when majority of people of who feel ill take tylenol and get rest. The body is giving basic signals that it is fighting an infection.

Next is Sepsis. This in an untreated infection. The infection is now spreading into the blood stream (septicemia) and fluids begin shunting to organs to protect the body from shutting down. A patient can be altered, have low BP, elevated heart rate, tachypnia and elevated temperature. The blood vessels dilate, in effort to protect the organs, and the patient starts to present with signs of shock.

“The situation is usually made worse by the damaging effects of the toxins on tissues combine with the increased cell activity caused by accompanying fever.”

The next phase can be the deadly end. Multiple Organ Death (MODs) is when one by one the organs begin dying off. The body begins losing the battle against the infection.

EMS’s mission in this equation is early recognition.

Criteria for sepsis activation in prehospital is still developing. IStats. Sports medicine lactate testers. Many tools have been dropped off in our jump bags.

A study performed in Albequre, New Mexico, hospitals worked along side EMS in order to start prehospital sepsis activation. The study hypothesized that, “in patients that EMS sepsis alert criteria, there is a strong relationship between prehospital ETCO2 readings and the outcome of diagnosed infection. The secondary hypothesis was that ETCO2 also predicted hospital admission, ICU admission and death.”

Yup. The same tool used to treat respiratory problems and help declare ROSC can be extremely useful in alerting the hospital if your patient is about to go into septic shock.

Alburqure created a field sepsis protocol. Hospital alerts were initiated if there was a suspicion of infection and certain criteria met with; temperature reading >38.3 or <36 c, heart rate greater than age expectation, hypotension, elevated lactate readings, elevated respiratory rate, and hypocapnia.

As with any form of shock, a body that is in a sepsis state compensates to save valuable life saving organs. As vessels begin to shunt, you have standard shock symptoms included with infection symptoms.

So what was the result with the study?

Out of the 351 patients that met criteria over the course of a year for Field Sepsis, all patient’s MET the criteria! It worked!! EMS was successful in diagnosing sepsis in the field. Plus, they created a form of communication and trust with their local hospital.

I know many of us are cardiology gurus. We love what we can fix in the field. Truly, it is amazing what we can do to the human heart for survival. Now infection is the next focus for saving lives.

Study quoted: Sepsis alerts in EMS and the results of pre-hospital ETCO2; from American Journal of Emergency Medicine, 2018

Sepsis 3.0 https://www.ems1.com/ems-products/Capnography/articles/82616048-Sepsis-3-0-Implications-for-paramedics-and-prehospital-care/

From the hospital view. https://emcrit.org/pulmcrit/ssc-1-hour/

View the full article

This study will have two versions written about it. This version is my “cut the fat” version I am trying encapsulate in this blog. As well, with my venture in medical free lance writing, I will have a “medical education” category for those who want the juicy morsels of dense medical language.

With out further wait… here is sepsis study on a plate.

Sepsis is a hot button topic in the world of prehospital medicine. There has been alot of literature put out by hospitals that declare more than 50% of in hospital deaths are due to multiple organ death (MODs), which is the ultimate deathly out come of sepsis.

The problem with sepsis and EMS is not only figuring out what we are looking for, but also to relay to the ER what we are seeing. Granted, we are not allowed to fully “diagnose” a patient, but effect EMS education teaches differential diagnosis to create a “field diagnosis.” We want to start drawing the picture of what the patient will need for continuity of care. Depending where you work, ER nurses and docs alike appreciate a field diagnosis. Again, depending where you work. In order to have that continuity of care, the EMS provider has to be ready to give the facts and findings of your field diagnosis.

Center stage at hospital night at the Apollo. Your are taking your patient to bay 1. There are 20 people in lead vests and gowns and goggles. You begin to speak loudly (que Eminem walking to the mic) and clearly. Then you are interrupted by questions you don’t know. The whole set falls apart. The crowd begins to boo. The doctors glare. The nurses snicker. The a clown with a long curved cane scoops you up and drags you to the ambulance bay…

But never fear! Sepsis study’s for ambulances are here!

For a potential Sepsis activation, you need to first understand the steps of infection and it’s relation to the human body. I’m sure many of us have had the case of chest pain that ended up being pneumonia. Productive cough? Elevated temp? Could still be cardiac but through our deferential diagnosis we know we have a higher chance or treating pneumonia instead of angina. Breathing treatment and fluid versus aspirin/nitro.

There are three steps in the chain of fatal sepsis. First step is Systemic Inflammatory Response. This is the time when majority of people of who feel ill take tylenol and get rest. The body is giving basic signals that it is fighting an infection.

Next is Sepsis. This in an untreated infection. The infection is now spreading into the blood stream (septicemia) and fluids begin shunting to organs to protect the body from shutting down. A patient can be altered, have low BP, elevated heart rate, tachypnia and elevated temperature. The blood vessels dilate, in effort to protect the organs, and the patient starts to present with signs of shock.

“The situation is usually made worse by the damaging effects of the toxins on tissues combine with the increased cell activity caused by accompanying fever.”

The next phase can be the deadly end. Multiple Organ Death (MODs) is when one by one the organs begin dying off. The body begins losing the battle against the infection.

EMS’s mission in this equation is early recognition.

Criteria for sepsis activation in prehospital is still developing. IStats. Sports medicine lactate testers. Many tools have been dropped off in our jump bags.

A study performed in Albequre, New Mexico, hospitals worked along side EMS in order to start prehospital sepsis activation. The study hypothesized that, “in patients that EMS sepsis alert criteria, there is a strong relationship between prehospital ETCO2 readings and the outcome of diagnosed infection. The secondary hypothesis was that ETCO2 also predicted hospital admission, ICU admission and death.”

Yup. The same tool used to treat respiratory problems and help declare ROSC can be extremely useful in alerting the hospital if your patient is about to go into septic shock.

Alburqure created a field sepsis protocol. Hospital alerts were initiated if there was a suspicion of infection and certain criteria met with; temperature reading >38.3 or <36 c, heart rate greater than age expectation, hypotension, elevated lactate readings, elevated respiratory rate, and hypocapnia.

As with any form of shock, a body that is in a sepsis state compensates to save valuable life saving organs. As vessels begin to shunt, you have standard shock symptoms included with infection symptoms.

So what was the result with the study?

Out of the 351 patients that met criteria over the course of a year for Field Sepsis, all patient’s MET the criteria! It worked!! EMS was successful in diagnosing sepsis in the field. Plus, they created a form of communication and trust with their local hospital.

I know many of us are cardiology gurus. We love what we can fix in the field. Truly, it is amazing what we can do to the human heart for survival. Now infection is the next focus for saving lives.

Study quoted: Sepsis alerts in EMS and the results of pre-hospital ETCO2; from American Journal of Emergency Medicine, 2018

Sepsis 3.0 https://www.ems1.com/ems-products/Capnography/articles/82616048-Sepsis-3-0-Implications-for-paramedics-and-prehospital-care/

From the hospital view. https://emcrit.org/pulmcrit/ssc-1-hour/

View the full article

If you haven’t checked out Life in The Fast Lane, you HAVE to give it shot. This site’s ECG library helped me not only get through medic school, but also helped me learn what I was seeing on strange 12-leads my first year as a medic.

I receive their email updates to keep myself informed, but it had been awhile since I’ve visited their site. They now have a library of just about any emergency medical topic you can think of.

I was extremely impressed with their trauma library!

Please stop by and check them out!

Trauma Library

View the full article

If you haven’t checked out Life in The Fast Lane, you HAVE to give it shot. This site’s ECG library helped me not only get through medic school, but also helped me learn what I was seeing on strange 12-leads my first year as a medic.

I receive their email updates to keep myself informed, but it had been awhile since I’ve visited their site. They now have a library of just about any emergency medical topic you can think of.

I was extremely impressed with their trauma library!

Please stop by and check them out!

Trauma Library

View the full article

True story behind the title…

I am a huge advocate for prehospital intubation. Though, I do strongly believe in good equipment, drugs, lots of practice (more than just simulators) and fail-safe options (iGel, etc). Every service has a different type of patient population. Every service has access to different equipment/protocols. Each patient has a different airway.

Grants have helped many services obtain video laryngoscopes. Granted, less ambulances, the greater chance you will have to cool toys in your airway bag. Much like the cardiac monitor was a luxury in the past, I see these devices becoming first line airway in the future.

To adapt and overcome. That’s how we survive in EMS.

https://www.ems1.com/ems-products/medical-equipment/airway-management/articles/394417048-NC-county-EMS-adds-video-guided-intubation-tool-to-ambulances/

View the full article

*True story behind the title… Use your imagination; rookie, code, view the airway, tube.. tube… yo man! you are stepping on the tube!*

I am a huge advocate for prehospital intubation. Though, I do strongly believe in good equipment, drugs, lots of practice (more than just simulators) and fail-safe options (iGel, etc). Every service has a different type of patient population. Every service has access to different equipment/protocols. Each patient has a different airway.

Grants have helped many services obtain video laryngoscopes. Granted, less ambulances, the greater chance you will have to cool toys in your airway bag. Much like the cardiac monitor was a luxury in the past, I see these devices becoming first line airway in the future.

To adapt and overcome. That’s how we survive in EMS.

https://www.ems1.com/ems-products/medical-equipment/airway-management/articles/394417048-NC-county-EMS-adds-video-guided-intubation-tool-to-ambulances/

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I don’t know how it is in other service areas, but my service is unable to obtain ANY dopamine… what-so-ever! I’m not sure if it is a manufacture problem (think back to 2010 when a huge company of our ACLS drugs changed to erectile dysfunction pills over night). Or maybe our hospitals are having an ordering issue. The real situation is, I LOVE DOPAMINE!

As a new medic, I was terrified of it. The confusing dosage. The simple down and dirty math equation that escaped me in the opportune moment of a ROSC patient. Even it’s shiny aluminum bag made it more intimidating than other meds. Why aluminum? What was in there? Is it looking at me? Radioactive goop? A demon? A dopamine demon? A dopa-demon?

Years later another medic and I were obtaining ROSC with early administration of dopamine. It was something we began testing when running a code in a rural area. Dopamine improves function of the heart (one day I will write some science-y thing on cardiac drugs)? Why not give the heart a helping hand when we are having trouble keeping a pulse?

Witchcraft!! I already hear the torches lighting and the medical villagers chanting.

But it worked. Every time we would lose pulses, we would hang dopamine and get ROSC.

*DISCLAIMER: I am not a doctor. I am street medicine. I do not substitute the decisions or protocols of you medical director. Our protocols differ from national registry and the rest of the country. Do what you will with what I print here. Just food for thought. Shop talk.*

Then… Then the forces that be, the EMS Gods that give you a late call, took my favorite med away. The poachers at the ICU took the last dopamine bird from me. They burned all the dopamine trees.

So what do we have now as a pressor? Witchcraft!!! I mean… push dose epi!!

Push dose epi (PDE) is the newest talk on the pharmaceutical cat walk. Flashing its extra zeros in a 1:100,000 vial… Like it owns this hemodynamic fashion show. Rawr.

Apparently PDE was used by anesthesiologist for years in the OR. It’s a temporary  reaction for hypotension, which is perfect in the OR. OR is stabilization of the patient during the surgery. Long term stabilization happens in PACU and ICU. Places where pressor drips are ran so the nurse can get a damn cup of coffee before her other patient crashes.

My trusty dope drip would keep that patient stable while I tripped over cables as we pulled the cot out of the ambulance. Bringing a code into the ambulance bay at the ER is never a smooth task. It’s like that dreaded day in March, when your wife has had enough and forces you to take down the Christmas lights. Cables and cords EVERYWHERE.

PDE has been gaining good scores in the transport world. A study was performed on a 100 pushes during critical care transports (study info at bottom). The goal of the study was to “characterize the hemodynamic effects and adverse events that occur following PDE administration by critical care transport providers to correct documented hypotension.”

*yawn* Please, go on…

The result, 58.5% (55 of 94 pushes) resolved hypotension. Granted, this is a new procedure and EMS is slow to change, and there are no variables discussed in the paper. I can visualize the back of that ambulance, sweating, cracking the tiny vial of tiny epi hoping to keep ROSC. Then an alarm on the monitor goes off. Mind you, this drug is not premixed. While pushing 1 ml out of the flush you notice the patient’s ETCO2 dropping because the rookie firefighter riding in with you is pumping that bag like an excited monkey. Crap. Did I check glucose yet? Five minutes from the hospital now. Push the epi. What’s this guys name? Give report.

The language also states they were looking for a resolution for the hypotension. Tiny epi will create changes for a tiny while. So use it accordingly and continuous. Just know that its effective is limited. 58% of the time, it worked every time.

I am not dissing push dose epi. It’s what I have to use right now and I would rather have it than no vasopressor. This is my review of a new drug in my tool box. I always enjoy feed back! What has your experience been like?

Study quoted: Push Dose Epi use in management of hypo… blah blah blah… just click the link

My man crush, EmCrit, made a great .pdf you can keep in your truck: pressor .pdf

MDEdge has something to say on the minimal effects of push dose pressors. minimal at best

View the full article

I don’t know how it is in other service areas, but my service is unable to obtain ANY dopamine… what-so-ever! I’m not sure if it is a manufacture problem (think back to 2010 when a huge company of our ACLS drugs changed to erectile dysfunction pills over night). Or maybe our hospitals are having an ordering issue. The real situation is, I LOVE DOPAMINE!

As a new medic, I was terrified of it. The confusing dosage. The simple down and dirty math equation that escaped me in the opportune moment of a ROSC patient. Even it’s shiny aluminum bag made it more intimidating than other meds. Why aluminum? What was in there? Is it looking at me? Radioactive goop? A demon? A dopamine demon? A dopa-demon?

Years later another medic and I were obtaining ROSC with early administration of dopamine. It was something we began testing when running a code in a rural area. Dopamine improves function of the heart (one day I will write some science-y thing on cardiac drugs)? Why not give the heart a helping hand when we are having trouble keeping a pulse?

Witchcraft!! I already hear the torches lighting and the medical villagers chanting.

But it worked. Every time we would lose pulses, we would hang dopamine and get ROSC.

*DISCLAIMER: I am not a doctor. I am street medicine. I do not substitute the decisions or protocols of you medical director. Our protocols differ from national registry and the rest of the country. Do what you will with what I print here. Just food for thought. Shop talk.*

Then… Then the forces that be, the EMS Gods that give you a late call, took my favorite med away. The poachers at the ICU took the last dopamine bird from me. They burned all the dopamine trees.

So what do we have now as a pressor? Witchcraft!!! I mean… push dose epi!!

Push dose epi (PDE) is the newest talk on the pharmaceutical cat walk. Flashing its extra zeros in a 1:100,000 vial… Like it owns this hemodynamic fashion show. Rawr.

Apparently PDE was used by anesthesiologist for years in the OR. It’s a temporary  reaction for hypotension, which is perfect in the OR. OR is stabilization of the patient during the surgery. Long term stabilization happens in PACU and ICU. Places where pressor drips are ran so the nurse can get a damn cup of coffee before her other patient crashes.

My trusty dope drip would keep that patient stable while I tripped over cables as we pulled the cot out of the ambulance. Bringing a code into the ambulance bay at the ER is never a smooth task. It’s like that dreaded day in March, when your wife has had enough and forces you to take down the Christmas lights. Cables and cords EVERYWHERE.

PDE has been gaining good scores in the transport world. A study was performed on a 100 pushes during critical care transports (study info at bottom). The goal of the study was to “characterize the hemodynamic effects and adverse events that occur following PDE administration by critical care transport providers to correct documented hypotension.”

*yawn* Please, go on…

The result, 58.5% (55 of 94 pushes) resolved hypotension. Granted, this is a new procedure and EMS is slow to change, and there are no variables discussed in the paper. I can visualize the back of that ambulance, sweating, cracking the tiny vial of tiny epi hoping to keep ROSC. Then an alarm on the monitor goes off. Mind you, this drug is not premixed. While pushing 1 ml out of the flush you notice the patient’s ETCO2 dropping because the rookie firefighter riding in with you is pumping that bag like an excited monkey. Crap. Did I check glucose yet? Five minutes from the hospital now. Push the epi. What’s this guys name? Give report.

The language also states they were looking for a resolution for the hypotension. Tiny epi will create changes for a tiny while. So use it accordingly and continuous. Just know that its effective is limited. 58% of the time, it worked every time.

I am not dissing push dose epi. It’s what I have to use right now and I would rather have it than no vasopressor. This is my review of a new drug in my tool box. I always enjoy feed back! What has your experience been like?

Study quoted: Push Dose Epi use in management of hypo… blah blah blah… just click the link

My man crush, EmCrit, made a great .pdf you can keep in your truck: pressor .pdf

MDEdge has something to say on the minimal effects of push dose pressors. minimal at best

View the full article

Please stop by and check out my new ACLS Quiz App. It is full of challenging questions and gives you a score at the end. The app is free to download and is only on Android. This is a step into my new venture of adding more online accessible free medical education. I have a PALS Quiz App in the works currently. Give me honest reviews! Send me messages of how I can make it better! This is my first app and I only want to make our trade even better in the education realm.

ACLS Quiz 2019 for Android

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Currently, I work full-time with an EMT partner. When it comes to airway, I am a believer in prehospital intubation. Though, when a call is out of control, and airway is immediate, I love my back up airways and an aggressive EMT.

Now, with that said, I do not believe that iGel needs to be the first line of airway protection on an ALS truck. If we lose intubation, we lose an amazing tool as paramedics. There are several districts across the United States that are taking intubation away from their medics and handing them the iGel. Their explanation for the decision is simply a lack of education and mistrust from their medical director.

I can understand a medical directors apprehension… While a physician is still paying off their student loans, they have medics out practicing their skills under a license you technically don’t own yet!! So, when you find out that their have been esophageal placements it make them apprehensive to continue granting this skill. But, when I think of a paramedics bread and butter skill, I think of ACLS and advanced airways. If that is our pride in skill, then why our we losing it??

My answer is in three parts; education, practice, and time constraints.

Our short staffing of paramedics nation wide and an ever-growing increase in call volume is currently making us stagnant. As some one who holds an associate degree and expected to make physician like decisions, I want to be as fresh on my skills as possible. Fortunately, I work frequently in education, so I am able to maintain a lot of time in the lab and reading articles. I am extremely grateful for this opportunity. As an educator, I try to get as many crews involved as possible in training and education. If you don’t use the skill you will lose it. Our own apathy is what will destroy our services.

How can we fix this? This a system approach. My system is extremely short-staffed and struggling on paying over time keeping cars on the street, none the less paying over time to keep people in the class room. Granted, we maintain quarterly training and education with acts of miracles.

Managers how a complex role. They have to juggle so many aspects just to keep the base doors open. Though, keeping an understanding of not only keeping employees up to date on their basic skills, but giving them the challenge of advancing their skills and understanding will push our trade even further.

Dream big!!

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