Charting is one of the more neglected skills from an EMS educational emphasis standpoint.  As a result, what the medical director ends up reading during chart review is often wildly variable.  Join the MCHD Paramedic Podcast team as they discuss some charting pitfalls to avoid and some specific tips on improving your ePCR narratives.

Episode 110 - EMS Charting Pearls And Pitfalls

We’ve recently rolled out a new medication protocol here at MCHD.  Join the medical directors to discuss the why, when, and how behind MCHD’s droperidol protocol.  Like many pharmacologic treatments in emergency medicine, old becomes new again!

REFERENCES
1. Page CB, Parker LE, et al. A Prospective Before and After Study of Droperidol for Prehospital Acute Behavioral Disturbance. Prehosp Emerg Care. 2018 Nov-Dec;22(6):713-721.

2. https://www.mchd-tx.org/wp-content/uploads/2022/08/MCHDPP-115.pdf

Episode 115 - Digging Up Droperidol

Join the podcast crew and MCHD medic Lily Trosclair as she discusses our MCHD Case of The Quarter for Q4 2021.  This one began with a pediatric cardiorespiratory arrest but fortunately has a happy ending.

REFERENCES
1. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012 Aug;27(4):417.e9-13.

2. http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/

Episode 124 - Awful Asthma - MCHD COTQ Q4 2021

Episode 127 - Airway Patency Vs. Protection

The medical directors revisit one of our old favorites "The Serial Killers Series" to discuss 5 trauma killers to keep in your front brain as you are preparing or caring for a sick trauma patient.  If you've not considered your differential diagnosis until patient contact and initial evaluation then you're too late.  Following this episode, you'll be ready to evaluate, act and prevent acute hemorrhage, obstructive shock, hypoxia, traumatic brain injury and DIC in your sickest trauma patients.

PDF Summary: https://www.mchd-tx.org/wp-content/uploads/2022/09/MCHDPP-129.pdf

REFERENCES
1.	Childress K, et al. Prehospital End-tidal Carbon Dioxide Predicts Mortality in Trauma Patients. Prehosp Emerg Care. 2018 Mar-Apr;22(2):170-174.

2.	Androski CP Jr, et al. Case Series on 2g Tranexamic Acid Flush From the 75th Ranger Regiment Casualty Database. Journal of Special Operations Medicine : a Peer Reviewed Journal for SOF Medical Professionals. 2020 ;20(4):85-91. 

3.	Taghavi S, et al. An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients. J Trauma Acute Care Surg. 2021 Jul 1;91(1):130-140. 

4.	Sims CA, et al. Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Surg. 2019 Nov 1;154(11):994-1003. 

5.	Kupas DF, et al. Glasgow Coma Scale Motor Component ("Patient Does Not Follow Commands") Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients. Ann Emerg Med. 2016 Dec;68(6):744-750.

6.	Rankin CJ, et al.  A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020 Mar;88(3):434-439. 

7.	Laan DV, et al. Chest wall thickness and decompression failure: A systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury. 2016 Apr;47(4):797-804.

Episode 129 - Serial Killer Series - Trauma

MCHD paramedic, Lily Trosclair, joins the podcast to discuss some in-depth hyperkalemia treatment details, including BRASH syndrome.  We'll also pivot to the dangers of giving amiodarone to a hyperkalemic patient that's mistaken for ventricular tachycardia.  

REFERENCES
1. https://emcrit.org/pulmcrit/brash-syndrome-bradycardia-renal-failure-av-blocker-shock-hyperkalemia/

2. https://www.youtube.com/watch?v=UXh8PS9dtmo&t=2s

3. McArthur R, Rafique Z, Ward B, Rodriguez L, Dickson R, Patrick C. Treatment of Presumed Hyperkalemia in the Prehospital Setting. Prehosp Disaster Med. 2022 Oct;37(5):693-697.

Episode 150 - Hyperkalemia, BRASH syndrome, And Amiodarone BEWARE

True anaphylactic shock can be one of the most harrowing calls in all of EMS and emergency medicine.  However, as is true with much of our core clinical content, dogma and myths persist. MCHD District Chief Spencer Hall joins the podcast crew to discuss anaphylaxis diagnostic criteria, treatment, and much more.  

REFERENCES
1. Anagnostou K, Turner PJ. Myths, facts, and controversies in the diagnosis and management of anaphylaxis. Arch Dis Child. 2019 Jan;104(1):83-90.
2. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000 Aug;30(8):1144-50.
3. Prince BT, Mikhail I, Stukus DR. Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy. 2018 Jun 20;11:143-151.

Episode 134 - All Things Anaphylaxis

Join this discussion of some of the recent literature surrounding EMS care of traumatic brain injury with Dr. Al Lulla.  This is the perfect confluence of advancing evidence, relatively straightforward interventions, and a patient population where we can definitely improve prehospital outcomes.  See where the literature, education, and protocol implementation can meet to improve TBI outcomes in your EMS service.  

REFERENCES
1. Spaite DW, Hu C, Bobrow BJ, et al. Optimal Out-of-Hospital Blood Pressure in Major Traumatic Brain Injury: A Challenge to the Current Understanding of Hypotension. Ann Emerg Med. 2022 Jul;80(1):46-59.

2. Spaite DW, Bobrow BJ, Keim SM, et al. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg. 2019 Jul 1;154(7):e191152.

Episode 144 - The TBI "H-Bombs" With Dr. Al Lulla

Join us as Dr. Dickson brings a couple of extremely difficult recent emergency department cases to take a hard look in his own clinical mirror.  These will highlight the difficult and often dynamic nature of assessing airway patency and protection in real time.  Speaking of dynamic, vascular emergencies like stroke and STEMI often progress unexpectedly.  

REFERENCES
1. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015 Mar;70(3):272-81.

Episode 151 - MMQ#4 - Dr. Dickson's Strokes

The Podcast Crew is joined by Spokane Valley Fire Paramedic Noah Martinez to discuss a recent patient that he delivered to Dr. Patrick.  After you hear what Noah found on the scene, this story will likely not end exactly how you expect.  Learn some foundational hypothermia management pearls AND why early emergency neuro-prognostication can be exceedingly difficult.

Episode 153 - MMQ#5 From The PNW - Spokane Frozen Solid

Chemical sedation is one of the riskiest decisions made in EMS clinical care, period.  We've been working overtime at MCHD over the past couple of years to decrease the risk and improve our safety profile for the entire clinical package when we sedate patients for severe agitation in Montgomery County.  Join us to learn about the MCHD SNORES safety bundle based on the 5 P's and how you can easily implement this into your service.

•	Partnerships
•	Preparation
•	Pharmacology
•	Positioning
•	Possibilities

REFERENCES
1.  Nørskov AK, Rosenstock CV, Wetterslev J, et al. Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015 Mar;70(3):272-81.

Episode 152 - The MCHD SNORES Sedation Safety Bundle

The concept of emphasizing, discussing, and training on giving prehospital death notification is, unfortunately for medics and our patient's families, a relatively new concept.  Additionally, newer evidence shows that an increased frequency of fatality exposure increases EMS burnout rates.  So...everyone wins by an increased focus on improving our skills and comfort with telling families that their loved ones have died.  We were initially leery of doing an episode on death notification as The Medic Mindset podcast recently hit a home run on this topic recently. But, after educating over 500 EMS professionals, Dr. Dickson and I learned some valuable lessons from our crews that we felt were worth sharing.  Enjoy!

REFERENCES
1. https://medicmindset.com/2023/01/09/death-notification-choreography/

2. Hobgood C, Mathew D, Woodyard DJ, et al. Death in the field: teaching paramedics to deliver effective death notifications using the educational intervention "GRIEV_ING". Prehosp Emerg Care. 2013 Oct-Dec;17(4):501-10.

3. Campos A, Ernest EV, Cash RE, et al. The Association of Death Notification and Related Training with Burnout among Emergency Medical Services Professionals. Prehosp Emerg Care. 2021 Jul-Aug;25(4):539-548.

4. Toy J. Family-Witnessed Cardiopulmonary Resuscitation during Emergency Department Cardiac Arrest Care: A Resident Perspective. Ann Emerg Med. 2023 Feb 23:S0196-0644(23)00041-0.

Episode 154- Death Notification Lessons Learned

Join the podcast crew as they discuss one of the more sticky situations in all of emergency care: stable vs. unstable narrow complex tachycardia.
1. How do we even define unstable?
2. Is it cardiac versus an underlying illness?
3. How do we approach undifferentiated rapid atrial tachycardia in the ED setting?

Episode 155 - MMQ#6 - A Rapid AFib Riddle

The podcast crew is joined by MCHD In-Charge Paramedics, Ben Breaux, and Jesus Contreras to discuss a critical case that demonstrates why continuing education and intentional mental reps are vital in emergency care.  We've discussed the "how-to" when approaching the crashing tracheostomy patient. Let's add an actual MCHD case and a little review on top of that previous foundation.

REFERENCES
1.https://www.tracheostomy.org.uk/storage/files/NTSP_GREEN_Tracheostomy_Algorithm.pdf

Episode 158 - Terrible Tracheostomy 2023

Sometimes it's easy on the individual level to miss the positive drift within EMS as systems of care evolve and change toward positive innovation.  Dr. Patrick hits the hot seat on this episode to discuss two recent cases where some of MCHD's favorite initiatives come together to improve patient outcomes and diagnostic recognition.

REFERENCES:
1. Dickson RL, Crowe RP, Patrick C, Crocker K, Aiken M, Adams A, Gleisberg GR, Nichols T, Mason C, Panchal AR. Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service. Prehosp Emerg Care. 2019 Sep-Oct;23(5):612-618.

2. Patrick C, Crowe RP, Ward B, Mohammed A, Keene KR, Dickson R. Feasibility of prehospital esmolol for refractory ventricular fibrillation. J Am Coll Emerg Physicians Open. 2022 Apr 9;3(2):e12700.

Episode 156 - MMQ#7 A Shocking Save And Sneaky Serial Killer

Dr. Dickson leads the discussion with recent cases involving the PECARN pediatric head injury decision rule and some super sneaky toxicology.  There is some high-level detective work happening during this episode.  Listen so you don't miss vital clues in your clinical practice.

REFERENCES
1. Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.

2. https://www.mchd-tx.org/wp-content/uploads/2023/09/Sodium-Channel-Blocker-Before-1.pdf

3. https://www.mchd-tx.org/wp-content/uploads/2023/09/Sodium-Channel-Blocker-After-2.pdf

Episode 159 - MMQ#8 - The Head and the Heart

There is nothing more stressful than seeing EMS peri-arrest progress to pulseless.  CARES data suggest that cardiac arrest during transport is not an uncommon event.  Additionally, there is new evidence that these patients may not be as difficult to recognize as we might've thought.  Join the podcast crew as we introduce the MCHD "MOVES" algorithm for a proactive approach to providing a safety net before transporting our critical patients.

REFERENCES
1.  Clemency BM, Murk W, Moore A, Brown LH. The EMS Modified Early Warning Score (EMEWS): A Simple Count of Vital Signs as a Predictor of Out-of-Hospital Cardiac Arrests. Prehosp Emerg Care. 2022 May-Jun;26(3):391-399.

2.  Burnett SJ, Innes JC, Varughese R, Frazer E, Clemency BM. A Qualitative Analysis of the Experiences of EMS Clinicians in Recognizing and Treating Witnessed Cardiac Arrests. Prehosp Emerg Care. 2022 Sep 28:1-9.

Episode 157 - Cardiac Arrest During EMS Care - Making MOVES

MCHD District Chief April Currie joins the podcast crew to discuss an angioedema case that repeatedly left more questions than answers.  Dr. Patrick was tasked with managing the airway and definitely has some lessons learned to share with the listeners.

Episode 161 - MMQ#9 - The Angioedema Airway

The podcast crew dives deep into one of the early "STEMI equivalent" ECG patterns: ST elevation in aVR with diffuse ST depression. What does the evidence say about this pattern? Is there a FOAM lesson to be learned? How should we incorporate this ECG into our practice?  

REFERENCES
1. Harhash AA, Huang JJ, Reddy S, Natarajan B, Balakrishnan M, Shetty R, Hutchinson MD, Kern KB. aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion. Am J Med. 2019 May;132(5):622-630.

2. https://www.mchd-tx.org/wp-content/uploads/2023/10/ST-elevation-AVR-ECGs-DeIDd.pdf

Episode 160 - ST Elevation in aVR With Diffuse ST Depression

We recently made a significant vasopressor protocol change at MCHD, prioritizing norepinephrine in all shock situations except anaphylaxis and bradycardia. The evidence supporting norepinephrine in septic and even cariogenic shock is relatively solid. However, recent data has emerged suggesting norepinephrine may be safer in post-ROSC shock as well. 

REFERENCES
1. Bougouin W, Slimani K, Renaudier M, et al; Sudden Death Expertise Center Investigators. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med. 2022 Mar;48(3):300-310.

2. Wender ER, Counts CR, Van Dyke M, et al. Prehospital Administration of Norepinephrine and Epinephrine for Shock after Resuscitation from Cardiac Arrest. Prehosp Emerg Care. 2023 Sep 14:1-6.

Episode 162 - Post-ROSC Pressor Choice

MCHD's POCUS program has definitely involved both forward progress and lessons learned. In this episode, we'll discuss some of the reasons POCUS can be a game changer in the prehospital setting. However, unintended consequences do exist. We've begun to make the move to utilizing carotid ultrasound in OHCA, and we'll tell you exactly why.

REFERENCES
1.	Badra K, Coutin A, Simard R, Pinto R, Lee JS, Chenkin J. The POCUS pulse check: A randomized controlled crossover study comparing pulse detection by palpation versus by point-of-care ultrasound. Resuscitation. 2019 Jun;139:17-23.
2.	Kang SY, Jo IJ, Lee G, Park JE, Kim T, Lee SU, Hwang SY, Shin TG, Kim K, Shim JS, Yoon H. Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation. Resuscitation. 2022 Oct;179:206-213. 
3.	Clattenburg EJ, Wroe P, Brown S, Gardner K, Losonczy L, Singh A, Nagdev A. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: A prospective cohort study. Resuscitation. 2018 Jan;122:65-68.
4.	Clattenburg EJ, Wroe PC, Gardner K, Schultz C, Gelber J, Singh A, Nagdev A. Implementation of the Cardiac Arrest Sonographic Assessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks. Resuscitation. 2018 Oct;131:69-73.
5.	Ochoa FJ, Ramalle-Gómara E, Carpintero JM, García A, Saralegui I. Competence of health professionals to check the carotid pulse. Resuscitation. 1998 Jun;37(3):173-5. 
6.	Zengin S, Gümüşboğa H, Sabak M, Eren ŞH, Altunbas G, Al B. Comparison of manual pulse palpation, cardiac ultrasonography and Doppler ultrasonography to check the pulse in cardiopulmonary arrest patients. Resuscitation. 2018 Dec;133:59-64.

Episode 164 - EMS HOCUS POCUS

MCHD paramedic Wes Hall joins the podcast crew to discuss a recent seemingly mundane back pain call. Please listen to find out how avoidance of premature closure, a thorough exam, and professional patient advocacy led to an excellent outcome in a SCARY case.

REFERENCES
1. https://www.mchd-tx.org/wp-content/uploads/2023/12/Image-Episode-163.jpg

Episode 163 - Back Pain Beware

Applied EKG interpretation is often a difficult task in EMS and emergency medicine education. Getting bogged down in minutiae can obscure the patient. While an understanding of EKG foundational physiology is an absolute must, consideration of how to combine the 12-lead and patient presentation is vital as well. Join the podcast crew as they start at the end with the killer/"can't miss" EKG patterns and combine those with common chief complaints. Hopefully, this framework will click for you.

REFERENCES
1. https://www.youtube.com/watch?v=UXh8PS9dtmo

2. Walker P, Jenkins CA, Hatcher J, Freeman C, Srica N, Rosell B, Hanna E, March C, Seamens C, Storrow A, McCoin N. 2022. Seamens’ Sign: a novel electrocardiogram prediction tool for left ventricular hypertrophy. PeerJ 10:e13548

Episode 166 - The MCHD EKG Manifesto - Part 1

We've spent countless hours (rightfully so) discussing ischemic stroke management over the past several years. Sometimes, the other 20% of strokes, the hemorrhagic version, can get neglected. No, we don't have stroke-mobiles at MCHD to diagnose an ICH in the field, but there are some patient care keys to emphasize for EMS when we suspect non-traumatic, acute intracranial bleeding.

REFERENCES
1. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016 Sep 15;375(11):1033-43. 

2. Zeiler FA, Sader N, West M, Gillman LM. Sodium Bicarbonate for Control of ICP: A Systematic Review. J Neurosurg Anesthesiol. 2018 Jan;30(1):2-9.

Episode 165 - Intracerebral Hemorrhage

The podcast crew is joined by a special guest, Dr. Andrew Partain, an EMS Fellow from UTSW in Dallas.  We will dissect his recent data surrounding ketamine-only intubation from MedStar in Fort Worth. This is not just another boring data rehash. There are some vital and applicable pearls that must be applied to the world of prehospital airway management.  

REFERENCES:
1. Driver BE, Prekker ME, Reardon RF, Sandefur BJ, April MD, Walls RM, Brown CA 3rd. Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department. J Emerg Med. 2021 Mar;60(3):265-272.

Episode 167 - Ketamine Only Intubations With Dr. Andrew Partain

Dr. Patrick is joined on this episode by Dr. Elizabeth Weinstein.  Elizabeth is a dual trained in Emergency Medicine and Pediatrics, and she delivers clinical pearl after clinical pearl on how to recognize and manage non-accidental trauma in the prehospital environment.

Resources:
http://www.identifychildabuse.org

Episode 18 - Pediatric Non-Accidental Trauma With Dr. Elizabeth Weinstein

We often start with a diagnosis and teach from there – for example CHF, asthma, and COPD are all podcast topics we have previously tackled.  But, how to get to the final diagnosis is often a process that all levels of emergency providers struggle with.  To go from a chaotic chest pain scene with unstable vitals then filter to a differential of #1 PE, #2 ACS, #3 TAD is often quite challenging.  The “Serial Killer Series” is going to target the most common chief complaints and the killer diagnoses that you should always consider.  We’re not going to spend time with non-emergent/chronic diagnoses, just the ones that are deadly when missed.  That’s where we, as emergency providers, must begin.  Today we’ll kick things off with acute chest pain.


REFERENCES
1.	http://www.emdocs.net/em-in-5-approach-to-chest-pain/

2.	https://litfl.com/ecg-findings-in-massive-pericardial-effusion/

3.     https://www.mchd-tx.org/wp-content/uploads/2022/08/MCHDPP-79.pdf

Episode 79 - Serial Killer Series - Chest Pain

We often start with a diagnosis and teach from there – for example CHF, asthma, and COPD are all podcast topics we have previously tackled.  But, how to get to the final diagnosis is often a process that all levels of emergency providers struggle with.  To go from a chaotic scene with unstable vitals then filter to an organized differential.  The “Serial Killer Series” is going to target the most common chief complaints and the killer diagnoses that you should always consider.  We’re not going to spend time with non-emergent/chronic diagnoses, just the ones that are deadly when missed.  That’s where we, as emergency providers, must begin.  Today we’ll address the killers associated with the dyspneic patient.

REFERENCES

https://www.ebmedicine.net/media_library/files/Calculated%20Decisions%20E1212%20PERC%20Rule.pdf

https://www.mchd-tx.org/wp-content/uploads/2022/08/MCHDPP-80-Final-PDF.pdf

Episode 80 - Serial Killer Series - Shortness of Breath

We often start with a diagnosis and teach from there – for example CHF, asthma, and COPD are all podcast topics we have previously tackled.  But, how to get to the final diagnosis is often a process that all levels of emergency providers struggle with.  To go from a chaotic scene with unstable vitals then filter to an organized differential.  The “Serial Killer Series” is going to target the most common chief complaints and the killer diagnoses that you should always consider.  We’re not going to spend time with non-emergent/chronic diagnoses, just the ones that are deadly when missed.  That’s where we, as emergency providers, must begin.  Today we’ll address the killers associated with acute abdominal pain.

Episode 81 - Serial Killer Series - Abdominal Pain

We often start with a diagnosis and teach from there – for example CHF, asthma, and COPD are all podcast topics we have previously tackled.  But, how to get to the final diagnosis is often a process that all levels of emergency providers struggle with.  To go from a chaotic scene with unstable vitals then filter to an organized differential.  The “Serial Killer Series” is going to target the most common chief complaints and the killer diagnoses that you should always consider.  We’re not going to spend time with non-emergent/chronic diagnoses, just the ones that are deadly when missed.  That’s where we, as emergency providers, must begin.  Today we’ll wrap up the series with the killers associated with acute altered mental status.

Episode 82 - Serial Killer Series - Altered Mental Status

The MCHD Paramedic Podcast is a place for prehospital providers to discuss best practices and offer clinical insights relevant to our daily practice. MCHD Medical Directors Dr. Robert Dickson and  Dr. Casey Patrick invite you to explore the many aspects of prehospital care. Along the way you can expect guest appearances by some of the brightest minds that influence modern EMS.

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