Gestalt. You hear it in almost anything you hear or see in pre hospital as well as the majority of medical education. It's really fancy, chic way of describing something we do every day in the field: make decisions on how and why we treat our patients. It's been termed a hunch, a gut instinct; but it's much more than that.
Mike takes the gang on a tour of some upper airway emergencies that you may (or may not have) seen in your practice, and we discuss some best practices for taking care of these challenging patients.
This is a short episode for us; but packed with information!
Feedback from Dr. Josh Farkas (@PulmCrit): https://twitter.com/PulmCrit/status/1195103809745440768
The articles:
https://journalfeed.org/article-a-day/2019/management-of-upper-airway-obstruction
https://journalfeed.org/article-a-day/2019/will-this-patient-be-difficult-to-intubate
https://www.ncbi.nlm.nih.gov/pubmed/30721300?dopt=AbstractPlus
The gang jumps back in from the holiday with both feet as we discuss another What The Actual episode. This time, we take a look at the Rhode Island intubation saga!
What happened? Why? How can we learn from this and continue to advance our practice?
Dan and Ed talk about what they hope they get for the holidays and 2020....we also bring our medical director, Dr. Mark Merlin to talk about his wishes for the coming year in prehospital medicine!
We talk about a lot of different topics: whole blood, trauma, developing our younger colleagues, and Ed's current disappointment with his sports teams.
For more info and a free online course on whole blood resuscitation:
www.rdcr.org
Check out MD1 physician response at:
www.md1program.org
The gang went on the road to the National Conference on EMS to do a live-recorded episode discussing how new media is changing medical and EMS education.
Why do we continue to use things we’ve used for centuries? What is new media, and what can it bring to you and your students? How have the Internet, blogging, and podcasting made some of our techniques obsolete? And how do we move forward fearlessly to improve education for our profession? We get into it in front of a live audience!
There are a LOT of shout-outs and FOAMed colleagues that we credit in this episode, and we hope that you check out their blogs, sites, and podcasts as well!
Dan sits down in a pre-Conference interview with Dr. Mark Merlin, the head of the New Jersey MD1 physician response program, the largest EMS physician program in the USA
Dr. Merlin discusses the idea of physician response, how EMS physicians interact in the prehospital environment with paramedics and EMTs, the technology that they bring to the table, and using whole blood in resuscitation, to mention just a few things!
Physician response can augment your prehospital care and bring life-saving procedures right to the patient. Check it out!
MD1 is a fully-charity funded program, no patient or agency receives a bill; EVER. Check them out at:
The New Jersey EMS Fellowship:
University of Pittsburgh EMS Fellowship:
https://www.emergencymedicine.pitt.edu/fellowships/ems-fellowship
Paper on the impact of EMS Physicians on OHCA:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4706668/
EMS Physicians on decision making at scenes:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4492931/
A couple items on the use of fresh whole blood in field resuscitation:
https://www.emra.org/emresident/article/group-o-whole-blood/
Here’s evidence that shows interruption of compressions for any reason has a negative impact on patient survival:
https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.115.014016
We pull another episode out of our vault to talk about con ed...Dan, Kevin, and Jess talk about continuing education! We all have to do it; but some is better than others. Why is yours bad? Why is someone else's good? And what is the value of "alphabet soup" classes in EMS continuing education? Do we need to think about another way?
Continuing Education is more than reading slides off a page; it's about instructors with expertise and passion, sharing their experience with students and encouraging them to learn and practice the material.
PCU, the movie....since we made the reference:
https://www.imdb.com/title/tt0110759/
Bretylium is BACK! Maybe??
https://www.resus.com.au/should-we-bring-bretylium-back-in-cardiac-arrest/
Ashley Liebig on nurse-led codes at dasSMACC:
https://rebelem.com/lessons-learned-and-take-home-messages-from-dassmacc-day-2/
Anna and Dan talk about some of the more...let's say "out there" news items in EMS, and how culture and social media can hurt us as professionals.
This is a controversial topic, and yes, we hope that we get some discussion on it. But the bottom line:
If you're not doing the right thing for your patient; you're wrong.
Article on starting IV on 13 year old:
Firefighters bringing dead patients to station for practice in endotracheal intubation:
https://www.bellinghamherald.com/news/local/article218955030.html
Check out suppurative thrombophlebitis:
https://www.uptodate.com/contents/suppurative-septic-thrombophlebitis
IV access and pain:
https://www.ncbi.nlm.nih.gov/pubmed/29772984
Dr John Hinds was a master clinician, and we miss him every day. Please watch this and see if you don't learn anything.
https://litfl.com/crack-the-chest-get-crucified/
Check out the MD1 program at:
For this episode, we joined up with Frank Melillo and the Pin The Q podcast! Frank is a fire officer and former volunteer and career EMT, and his show takes a close look at the culture and tradition of the fire service, which got us thinking: Why DON'T we have culture and traditions in EMS?
If you're looking for the typical Fire vs. EMS slamfest; you're not going to find it on this episode. You may take away an idea, you might find something that changes how do you things in the future, you may get a new perspective. But you won't be bored, that's for sure.
Frank also tells us about the great stuff Next Rung is doing for emergency services peer support, and why you should have Next Rung in YOUR gear bag.
You can find Pin The Q at:
Insta: pintheq_podcast
YouTube: PintheQ Podcast
FB: PintheQ
Next Rung can be found at:
Anna and Dan sit down with attorney and former paramedic Margaret Keavney to discuss end-of-life issues in EMS. How do we honor patient wishes, and the law? What is our standard, and how does our culture and training sometimes work against us?
We don't get great initial training in the end of life, although EMS is present at the majority of these events. Check it out!
Keavney-Streger Law Firm can be found here:
OPALS study on cardiac arrest termination of care:
https://jamanetwork.com/journals/jama/fullarticle/182615
https://www.nejm.org/doi/full/10.1056/NEJMoa052620
New Jersey's POLST:
https://www.nj.gov/health/advancedirective/polst/
About the late Dr John Hinds and his mission to bring advanced care to the patient:
http://www.delta7hems.com
#DoBetter
We talk about a wide variety of all things cricothyroidotomy: mental prep and training, the difference in the techniques that are out there, which one might work better, and lots of other stuff. We also shoutout to a LOT of other resources that will help you to really understand this low frequency, but critical procedure.
If this is in your scope of practice; or possibly in a situation where a clinician will use this; you need to know about this to be able to care for your patient.
Dr. Rich Levitan’s website:
Dr. Scott Weingart’s website:
The EMCrit podcast can be found on iTunes (just like us!)…it’s one of the best around with literally hundreds of topics!
SMACC was an amazing prehospital/emergency/and critical care conference that changed how many of us looked at conferences and learning. Check out their stuff here:
https://smacc.net.au/blog/
New England Journal of Medicine paper on comparing cric techniques:
https://www.jwatch.org/em200503300000002/2005/03/30/open-cricothyroidotomy-vs-seldinger-technique
Here’s the case study about the NG tube going into the spinal column…
https://www.sciencedirect.com/science/article/abs/pii/S0196070911000755
Dr. Peter Antevy joins Ed to discuss a few pearls about pediatric care and resuscitation in the field. Dr. Antevy wears many hats in EMS and has served as the medical director for Davie fire rescue, Coral Springs-Parkland Fire Rescue, Palm Beach County Fire Rescue. Additionally, he is the President of the Greater Broward EMS Medical Directors’ Association, the 2018 NAEMT Medical Director of the Year, a JEMS top-ten innovator of 2015, and an attending pediatric emergency physician at Joe Dimaggio Children’s Hospital in Hollywood, FL.
Are kids just small adults? How do we handle a pediatric cardiac arrest scene? How involved should parents be in the care of the acutely ill child? Is Ketamine safe to use on children (Spoiler: yes.) These and many more questions are discussed.
Dr. Antevy’s videos and protocols can be found here
2008 Pediatric Emergency Care- Ketamine study
Ed, Mike and Dan get nerdy again talking about IV fluids and vasopressors! What works, why, and what do you need to know about the stuff we put into patients…and why it may be hurting more than helping!
2008 JAMA article on fluid resuscitation:
R Bellomo, C Hegarty, D Story, L Ho, M Bailey – Jama, 2012 – jamanetwork.com… “Normal” 0.9 per cent salt solution is neither “normal” nor physiological. JAMA … The
biochemical effects of restricting chloride-rich fluids in intensive care. Crit Care Med … Crit
Care Resusc. 2008;10(3):225-23018798721PubMedGoogle
Cochrane Review on colloids or crystalloids:
https://www.cochrane.org/…/INJ_colloids-or-crystalloids-fluid-replacement-critically-…
Costs involved in using colloids:
https://jamanetwork.com/journals/jamasurgery/fullarticle/401980
ATLS 10th edition changes:
ATLS 10th edition offers new insights into managing trauma patients
The State of New Jersey, in the throes of an enormous opioid epidemic, has unveiled allowing their Mobile Intensive Care Units (Paramedics) to administer buprenorphine as a part of an optional formulary.
What does this mean? Paramedics and EMTs can rescue patients with naloxone, but are we the right avenue to start people toward recovery? Trail-blazing tactics change in a battle we’ve been losing, or just another windmill to tilt at?
We’re going to discuss buprenorphine, what it does, (and doesn’t), how it can be implemented in the field, and what the potential pearls and pitfalls are for clinicians.
It’s a radical idea. But, just maybe, radical is what we need in this fight.
Check out New Jersey Office of EMS:
https://www.state.nj.us/health/ems/
National statistics from the Center for Disease Control:
https://www.cdc.gov/drugoverdose/data/statedeaths.html
New Jersey’s statistics on a county level:
https://www.state.nj.us/health/populationhealth/opioid/opioid_deaths.shtml
Federal summary of the New Jersey situation:
https://www.drugabuse.gov/opioid-summaries-by-state/new-jersey-opioid-summary
Journal of Substance Abuse paper on initiating outpatient buprenorphine in high-risk populations:
https://www.ncbi.nlm.nih.gov/pubmed/31229187
Reuben Strayer is an emergency physician in NYC, and is doing amazing work on this topic. If you get a chance to hear him speak, do it. You can find him on Twitter: @emupdates and on the internet at www.emupdates.com. He also has several podcasts on the SMACC podcast.
https://emupdates.com/helpcard-and-opioid-misuse/
The National Registry…what is it, and why should it matter to you? As the only national organization of credentialing in the USA, the guidelines and structure they use has a huge impact on your license or certification.
We dig into the Overrun vault to find this episode….let us know what YOU think!
Is NREMT the be-all, end-all solution; or can it be improved to be a truly national licensing standard? We look at the strengths and weaknesses, and what we would like to see from the NREMT!
The National Registry of EMTs is at:
Does absence of evidence indicate evidence of absence? Resuscitative Endovascular Balloon Occulsion of the Aorta (REBOA) is a hot topic in prehospital care, especially with London’s Air Ambulance using it in the field.
What does it require? Are we ready for this? And what’s the benefit to the patient?
We break it down for you in this episode…and you’ll be surprised!
London HEMS can be found at:
https://www.londonsairambulance.org.uk
Paris SAMU is another program you should look at:
The Knick was a cable series about turn of the century medicine:
https://www.cinemax.com/the-knick
Original Journal of Surgery paper on REBOA:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6249899/
REBOA at the R. Adams Cowley Shock Trauma Center:
https://www.ncbi.nlm.nih.gov/pubmed/29190256
The latest study on REBOA:
Dan recaps the MD1 EMS Conference and shares what he learned from a room full of EM/EMS physicians speaking to EMS clinicians! If you saw the Facebook Live and Instagram streams from this show; you know there was an enormous amount of knowledge being put out!
Check out Dr. Mark Merlin on Twitter at : @ccareanywhere
The NJ EMS and Disaster Medicine Fellowship can be found at: www.emsfellowship.com
The MD1 physician response program: www.md1program.org
Dr. Qasim is on Twitter at: @emeddoc
Dr. Callelo: @DrDianeC, @njpoisoncenter, also at @ToxAndHound
The COMBAT trial for prehospital plasma:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31553-8/fulltext
The PAMPHER trial:
https://www.nejm.org/doi/full/10.1056/NEJMoa1802345
BOKUTOH criteria study:
https://www.jem-journal.com/article/S0736-4679(17)30471-7/pdf
PARAMEDIC2 study of Epinephrine in OHCA:
https://www.nejm.org/doi/full/10.1056/NEJMoa1806842
Pediatric airway management in cardiac arrest:
https://www.ncbi.nlm.nih.gov/pubmed/30862528
Heads up CPR in OHCA:
And, why it may NOT be ready for EMS use, yet…..
Ultrasound in Cardiac Arrest:
The gang let Anna handle this episode, and she crushed it! Anna talks with Robert (Pip) Piparo, firefighter, paramedic, and driving force behind the 555 Fitness team, bringing physical fitness to public safety professionals!
We ask why, if we're so smart as clinicians, why do we do things we KNOW are bad for us, and why we absolutely have to Do Better.
And here's an easy way to start: Anna and Pip created The Overrun Challenge! All you have to do is commit to walk ONE mile every day for 30 days. That's it! If you commit to the Challenge, let us know on social media and send pics at Day 1 and Day 30! We will share your success and commitment with our audience!
555 Fitness website:
http://www.555fitness.org
The 555 Fitness APP!
https://itunes.apple.com/us/app/555-fitness-wod/id1067233204?mt=8
Ed, Jess, and Dan discuss where we've been with sepsis, where we are, and maybe where we're going. Fluids, pressers, scoring....there's a LOT of information out there, and we try to sort through it for you
The Early Goal-Directed Therapy paper from 2001:
https://www.nejm.org/doi/full/10.1056/NEJMoa010307
Listen to Dr. Weingart (@emcrit) tale with the author himself in a two-part interview:
Podcast 054 – Dr. Rivers on Severe Sepsis – Part I
https://emcrit.org/emcrit/rivers-sepsis-i/
Copy and paste this URL into your WordPress site to embed
Podcast 055 – Dr. Rivers on Severe Sepsis – Part II
https://emcrit.org/emcrit/rivers-sepsis-ii/
Center for Disease Control sepsis information:
https://www.cdc.gov/sepsis/clinicaltools/index.html
Dutch PHANTASi trial:
https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(17)30469-1.pdf
