mchd podcast

Dr. Jerry Snow, a medical toxicologist and emergency medicine physician from Phoenix  joins the show for an interesting discussion about the opiate crisis facing America today, with a specific emphasis on fentanyl and its derivatives.  We discuss EMS/first responder exposure risks and preventative measures along with patient care pearls when treating patients with fentanyl overdose.


References:

American Academy of Clinical Toxicology Statement on Fentanyl Exposure Risks - https://www.acmt.net/_Library/Fentanyl_Position/Fentanyl_PPE_Emergency_Responders_.pdf

https://www.whitehouse.gov/ondcp/key-issues/fentanyl/

Bonus Episode - Fentanyl Fever: Unnecessary Hysteria

Join Dr. Patrick for a discussion of common drugs, both OTC and prescription, that can be deadly to our pediatric patients in doses as small as a single pill.  This knowledge will allow us to properly educate families and know when to expect a potential crashing kid.  

References:  Michael J.B., Sztajnkrycer M.D. Deadly pediatric poisons: Nine common agents that kill at low doses. (2004). Emergency Medicine Clinics of North America, 22, 1019-1050.

Episode 17 - One Pill Killers

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

Pregnancy complications make us all a little diaphoretic and tachycardic.  On this episode, Dr. Patrick and Dr. Dickson break down the must know aspects of caring for the obstetric patient prior to delivery in the EMS setting.  

References:
https://www.acog.org/Clinical-Guidance-and-Publications/Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy

Episode 19 - OB Part I

Concussions and management of mild head injury are topics that are rapidly evolving.  Dr. Greg Faris joins Dr. Patrick to lend his pediatric emergency expertise on these important and commonly seen injuries.  With youth and high school football season coming soon, get your concussion refresher now.

References:
CDC Heads up.  www.cdc.gov/headsup

Kupperman N, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160-70.

McCrory P, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;0:1–10.

Davis GA, et al. Sports Concussion Assessement Tool 5th Edition. Br J Sports Med 2017;0:1–8

Episode 20 - Pediatric Concussion With Dr. Greg Faris

Dr. Dickson and Dr. Patrick take on one of our favorite topics here at MCHD - Ketamine and the agitated patient.  Agitated patients come in a wide spectrum of severity.  This discussion starts with a framework for stratifying agitated patients.  We discuss the MCHD ketamine experience along with a less discussed patient population that may need ketamine control quicker than we often think. ***Remember that Ketamine is only to be used for patient protection and is never intended to be used out of convenience.***

References:
1.	https://www.ems1.com/medical-clinical/articles/78100048-Ketamine-for-Excited-Delirium-Syndrome-Results-of-a-3-year-case-series/
2.	Green et al. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation. Ann Emerg Med. 2011; 57:449-61
3.	Cole J et al. A prospective study of ketamine as primary therapy for prehospital profound agitation.  Am J Emerg Med. October 2017
4.	Parsch C et al. Ketamine reduces the need for intubation in patients with      acute severe mental illness and agitation requiring transport to definitive care: An observational study. Emerg Med Australas. 2017;29(3):291-296

Episode 21 - Ketamine For Agitation

Tranexamic Acid (TXA) has been a hot topic in emergency medicine over the past several years with increasing acceptance for use in patients with hemorrhagic shock.  Casey Patrick and Jordan Anderson review the pharmacology of TXA, discuss the literature supporting its use, and close with MCHD’s TXA administration protocol.

References

1.	 	Gayet-Ageron A et al. Effect of Treatment Delay on the Effectiveness and Safety of Antifibrinolytics in Acute Severe Haemorrhage: A Meta-Analysis of Individual Patient-Level Data From 40138 Bleeding Patients. Lancet 2017. 

2.		Effects of Tranexamic Acid on Death, Vascular Occlusive Events, And Blood Transfusion in Trauma Patients With Significant Haemorrhage (CRASH-2): A Randomised, Placebo-Controlled Trial. Lancet 2010. 
	
3.  	Effect of Early Tranexamic Acid Administration on Mortality, Hysterectomy, and Other Morbidities in Women with Post-Partum Haemorrhage (WOMAN): An International, Randomised, Double-Blind, Placebo-Controlled Trial. Lancet 2017.

Episode 22 - TXA (Tranexamic Acid)

Dr. Patrick went where?  Dr. Dickson interviews Dr. Patrick about his recent medical journey to Uganda.  Learn about the state of prehospital medicine in Uganda, several interesting cases that you probably won’t see here in the United States, and find out how you can help the cause.

References 
www.globalemergencycare.org

Episode 23 - EMS systems and Emergency Care in Uganda

On today’s cast our medical directors talk traumatic arrest care with Dr. Justin Hensley, the medical director of Robstown EMS, and lover of all things trauma resuscitation related.  We'll review the history, training and implementation of the simple finger thoracostomy procedure at MCHD while also discussing our general approach to the traumatic arrest patient.  Below are links to the papers and video training that are mentioned in the episode.

Journal of Emergency Medicine MCHD Simple Thoracostomy Paper:
https://www.jem-journal.com/article/S0736-4679(18)30598-5/fulltext

JEMS Simple T: 
https://www.jems.com/articles/print/volume-39/issue-4/features/simple-thoracostomy-moving-beyond-needle.html

Tension pneumothorax model video:
https://www.youtube.com/watch?v=kCKZ4y843ts

Dr Hensley’s website:
http://ebmgonewild.com/

The late Dr. John Hinds on traumatic arrest care:
https://emcrit.org/emcrit/trauma-thoughts-john-hinds/

Episode 24 - Simple Thoracostomy

Join Dr. Patrick and Dr. Dan O'Donnell, medical director for Indianapolis EMS/Fire/SWAT, as we discuss multiple hot topics in the world of Tactical EMS.

Episode 25 - Tactical EMS With Dr. Dan O'Donnell

Hypotension is one of our number one enemies in prehospital care.  In this episode, Dr. Patrick and Dickson begin with a review of vasopressor physiology and then they dive into the evidence and rationale behind push dose epinephrine use.     

References: 

https://emcrit.org/emcrit/push-dose-pressor-update/
https://www.nejm.org/doi/full/10.1056/NEJMoa0907118

Episode 26 - Push Dose Pressors

Falls are one of our most common calls in the EMS world.  The potential disease processes and injuries can be wide ranging and difficult to sort.  Join Dr. Patrick and Dr. Dickson as they break falls down into two main questions that must be answered on every fall patient.  Learn the high risk characteristics and diagnoses to consider and rule out.

Episode 27 - Slips, Trips, And Falls

Many of the sickest of the sick patients that we see as EMS providers are hypotensive.  These folks are often altered and come with spotty histories at best.  This episode turns our B2B series to the prehospital management and recognition of shock.  How can we better classify then treat our undifferentiated patients in shock?  Dr. Patrick and Dr. Dickson build a framework around common sense pathophysiology and treatment.

Episode 28 - Shock States - B2B

Peds EMS wizard, Dr. Greg Faris, joins us again on the podcast to discuss pediatric out-of-hosiptal cardiac arrest.  This topic gives us all a bit of nausea and tachycardia.  We’ll review some recent literature that will, hopefully, nudge us to change the practice of “scoop and run” in our pediatric cardiac arrests.

Pediatric OHCA References
Tijssen JA, et al. Time on the scene and interventions are associated with improved survival in pediatric out-of-hospital cardiac arrest. Resuscitation. 2015 September; 94: 1-7.

Munoz MG, et al. An ethical justification for termination of resuscitation protocols for pediatric patients. Pediatric Emerg Care 2017; 33: 505-515.

American College of Surgeons Committee on, T., et al. (2014). "Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest." Pediatrics 133(4): e1104-1116.

Goto, Y., et al. (2016). "Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study." Circulation 134(25): 2046-2059.

Capizzani AR, et al. Assessment of termination of trauma resuscitation guidelines: are children small adults. J of Peds Surg; 2010: 45, 903-907.

Episode 29 - Pediatric Arrest With Dr. Greg Faris

Lowering tidal volumes in effort to reduce lung injury following initiation of mechanical ventilation is far from a new idea, the original ARDS-NET data are nearly 20 years old.  Lung protective ventilatory strategies have progressively been shown, from the ICU and now into the ED setting, to decrease ventilator days, ICU/hospital stay and overall mortality.  This discussion covers the original ARDS-NET study, causes of ventilator induced lung injury, and closes with MCHD’s efforts to initiate lung protective settings in ventilated patients in the prehospital setting.

References:

1.	Fuller BM, Ferguson I, Mohr NM, et al. Lung-protective ventilation initiated in the emergency department (LOV-ED): a study protocol for a quasi-experimental, before-after trial aimed at reducing pulmonary complications BMJ Open 2016;6:e010991.

2.	Boyer AF, Schoenberg N, Babcock H, et al. A prospective evaluation of ventilator-associated conditions and infection-related ventilator-associated conditions. Chest 2015;147:68–81. 

3.	Ranieri VM, Rubenfeld GD, Thompson BT, et al. The ARDS definition task force. Acute respiratory distress syndrome. JAMA 2012;307:2526–2533. 

4.	(No authors listed). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301–1308.

5.	Austin Michael A, Wills Karen E, Blizzard Leigh, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial BMJ 2010; 341

6.	Turner JS, et al. Feasibility of upright patient positioning and intubation success rates at two academic emergency departments, American Journal of Emergency Medicine 2017.

7.	Stoltze AJ, Wong TS, Harland KK, et al. Prehospital tidal volume influences hospital tidal volume: A cohort study. J Crit Care. 2015 Jun;30(3):495–501.

Episode 30 - Lung Protective Ventilation With Dr. Nick Mohr

Too much of a good thing can always end up being bad.  On this episode, Dr. Patrick summarizes the ever increasing evidence that not only does supplemental oxygen not help in patients with reasonable O2 saturations, it likely is harmful in many commonly encountered disease states.  Join us for some first-class mythbusting.

References: 
1.	https://dundeechest.wordpress.com/2009/08/12/why-do-copd-patients-retain-co2-when-given-too-much-oxygen/

2.	Chu DK et al. Mortality and Morbidity in Acutely Ill Adults Treated with Liberal Versus Conservative Oxygen Therapy (IOTA): A Systematic Review and Meta-Analysis. Lancet 2018.

Episode 31 - Hyperoxygenation - Too Much of a Good Thing??

Dr. Dan O’Donnell serves as the Medical Director for Indianapolis EMS, as well as Medical Director for the Indianapolis Metropolitan Police S.W.A.T. team.  Central Indiana has been one of the epicenters for the growing opiate epidemic and Dan joins us to discuss a novel approach that IEMS has taken to combat this devastating public health crisis.

Episode 32 - EMS Opiate Interventions With Dr. Dan O'Donnell

The decision to administer paralytics may well be the most significant decision that we make as emergency providers.  We have to understand and know paralytic pharmacology 100% stone cold.  Join Dr. Patrick today for a review of our two most commonly encountered paralytic medications - succinylcholine and rocuronium.  Homage to the old school and an investigation of newer practice shifts will be given equal airtime.      


References: 

1.	Tran DT et al. Rocuronium Versus Succinylcholine for Rapid Sequence Induction Intubation. Cochrane Database Syst Rev 2015.

2.	Shoenberger JM, Mallon WK. Rocuronium Versus Succinylcholine Revisited:   Succinylcholine Remains the Best Choice. Ann Emerg Med 2018; 71(3): 398-9.

3.	Swaminathan A, Mallemat H. Rocuronium Should Be the Default Paralytic in Rapid Sequence Intubation. Ann Emerg Med 2018; 71(3): 397-8.

Episode 33 - Paralytic Pharma Phun

What would you do if you encountered a patient who you were unable to transport or even extract due to extremity entrapment?  At MCHD, we asked ourselves this exact question and decided provide an answer in the form of a field amputation protocol.  Dr. Justin Hensley joins the MCHD medical directors to discuss the details and pitfalls associated with implementing a plan to amputate a limb in the field.

Episode 34 - Field Amputations With Dr. Justin Hensley

Join Dr. Dickson and Dr. Patrick live from the Texas EMS Conference with a special guest! Today we’ll discuss prehospital ventilator management as a precursor to the lectures Dr. Patrick and Clinical Chief Jordan Anderson will be giving at the conference.

mchd podcast

Ron Jordan