MHCD Medic

Welcome to MCHD's Paramedic Podcast - a biweekly podcast dedicated to EMS Providers across the world.

Introduction to THE MCHD Paramedic Podcast

Featuring Dr. Peter Antevy

Today’s show will focus on the evolution in the EMS approach to pediatric resuscitations. Historically these high stress resuscitations focused on rapid transport of these children to the hospital and have resulted in sub par resuscitation efforts and increased stress for both providers and families. There is mounting evidence that mirrors the adult resuscitation data that staying on scene and providing focused resuscitation efforts improves outcomes in these patients. Dr. Antevy provides a unique perspective as both a pediatric EM specialist/EMS medical director and inventor of the Handtevy pediatric resuscitation system.

https://www.handtevy.com

Episode 2 - Pediatric Resuscitation Featuring Dr. Peter Antevy

Syncope is a common and often confusing presentation.  Dr. Casey Patrick leads a lecture style discussion with tips to approaching the syncopal patient in the prehospital setting.  ECG pointers and an impossible to forget “crappy” mnemonic will leave you with a more focused approach to your next syncopal patient.

References

1.	http://www.jem-journal.com/article/S0736-4679(17)30868-5/pdf

LINKS:
1.  WPW - https://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/
2.  Brugada syndrome - https://www.aliem.com/2013/06/brugada-syndrome-an-ecg-pattern-you-need-to-know/
3.  Prolonged QT interval - https://lifeinthefastlane.com/wp-content/uploads/2011/01/waves-of-the-ecg.gif
4.  Hypertrophic Obstructive Cardiomyopathy - http://www.wikidoc.org/images/b/b0/Hypertrophic_cardiomyopathy.jpg

Episode 3 - Syncope

Dr. Patrick and Clinical Manager Jordan Anderson discuss intubation and ventilator settings to help avoid lung injuries in the intubated patient.

Episode 1 - Lung Protective Ventilation

Hyperkalemia can send our patients to cardiac arrest in an instant.  Casey Patrick and Jordan Anderson begin with some background physiology review on the importance of potassium to cellular function.  They then move on to describing specific patient characteristics and ECG findings found in patients with hyperkalemia, and close with MCHD’s current protocol to preemptively treat these patients en route to the hospital.

PDF Summary: https://www.mchd-tx.org/wp-content/uploads/2022/09/MCHDPP-04.pdf

Episode 4 - Hyperkalemia Management

EMS implementation of Community Paramedicine and Mobile Integrated Health programs is exploding.  Dr. Peter Antevy joins Dr. Dickson for an informative discussion surrounding the role of Community Paramedicine and Mobile Integrated Health in today’s EMS systems.  Dr. Antevy has built an impressive CP program from the ground up in South Florida.  He shares his experiences and thoughts on both the ideal role and future of CP.

Episode 5 - Mobile Integrated Health/Community Paramedicine Featuring Dr. Peter Antevy

It's Memorial Hermann Ironman Texas time here in Montgomery County, and our MCHD crews are preparing to staff the 140.6 mile triathlon.  After fielding multiple questions about hyponatremia and hypothermia in ultra-endurance athletes, we decided that a podcast discussion was in order.  The MCHD Paramedic Podcast crew were lucky enough to have Dr. Kevin Schulz, Medical Director for Memorial Hermann Ironman Texas, join us to talk Ironman medicine.  Sit back, relax and enjoy the ride...we promise it won't hurt as bad as 112 miles on a bike!

References:
Hew-Butler T, Rosner MH, et al. Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med. 2015 Jul;25(4):303-20.

Episode 6 - MCHD Ironman Medicine 2018 Featuring Dr. Kevin Schulz

Join Dr. Casey Patrick and Brad Ward as they discuss a county wide initiative to expedite ROSC patients to definitive care in the cardiac cath lab.  They will be discussing the literature and science on why these patients have better outcomes when they are quickly taken to the cath lab.  They will also be addressing how MCHD has partnered with our hospitals to implement our new ROSC Cath Lab Activation.

References

AHA Updates
http://circ.ahajournals.org/content/132/18_suppl_2/S465

Tanveer Rab, Karl B. Kern, Jacqueline E. Tamis-Holland, Timothy D. Henry, Michael McDaniel, Neal W. Dickert, Joaquin E. Cigarroa, Matthew Keadey, Stephen Ramee,
Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient,
Journal of the American College of Cardiology,
Volume 66, Issue 1,
2015,
Pages 62-73,
ISSN 0735-1097,
https://doi.org/10.1016/j.jacc.2015.05.009.

Episode 7 - ROSC To Cath Lab Activations

Anaphylaxis is a common life threatening disease that prehospital providers encounter on a regular basis.  These patients are in need of early treatment with Epinephrine.  In today’s episode Dr. Casey Patrick, along with Kevin Crocker and Ashton Herring, will be discussing MCHD’s deployment of Epinephrine to the Fire Departments within Montgomery County.  This discussion will cover basic information on what anaphylaxis is and how to best treat it.  We will also discuss how MCHD built Epi kits and how we trained the fire departments in how to safely and effectively manage these anaphylactic patients.

References
https://www.ems1.com/epinephrine/articles/381400048-Anaphylaxis-kits-Easy-epinephrine-deployment-for-first-on-scene/

https://www.dovepress.com/cr_data/article_fulltext/s121000/121733/img/DHPS_121733_F001.jpg

Episode 8 - Anaphylaxis Kits For EMT's - MCHD Back To Basics Series

In the past 24 months, stroke care has evolved in the way we evaluate strokes in the pre-hospital space and how they are worked up and treated in the hospital. Large vessel Occlusion (LVO) stoke is a large caliber vessel clot causing stroke symptoms. New techniques and devices in endovascular retrieval of these clots along with intravenous Tpa has shown great success in five randomized trials published in 2015.(1) The number we need to treat for one improved neurologic outcome at 90 days according to data from these trials is 2.6 patients. This is a massive breakthrough in the way we approach acute stroke care. Improved outcomes in these trials are directly associated with times to reperfusion therapy and EMS must change the way we diagnose and rank stroke patients in order to get them an endovascular capable facility when appropriate. In the first podcast our team will review all of the pertinent data from these trials and suggest how EMS should approach this LVO stroke diagnosis. In the second part of our stroke awareness series we talk with Dr. Peter Antevy, an EMS medical director from Florida who is an expert of developing regional systems of care for these LVO stroke patients. He will discuss development of their system and exciting new data that demonstrates a treatment benefit up to 24 hours after onset of symptoms in some subsets of these stroke patients. (2, 3)

References

1.Hermes Collaboration: Lancet 2016
 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00163-X/abstract
2. Dawn Trial: NEJM 2018
http://www.nejm.org/doi/full/10.1056/NEJMoa1706442
3. DEFUSE 3 Trial: NEJM 2018
http://www.nejm.org/doi/full/10.1056/NEJMoa1713973

Episode 9 - The State Of EMS Stroke Care In 2018

Episode 10 - Stroke Systems Of Care Featuring Dr. Peter Antevy

With the blazing Texas summer just around the corner, we thought it would be appropriate to discuss heat related emergencies.  Dr. Patrick leads a discussion of the various terminology, physical exam findings, differential diagnoses and pre-hospital treatments for heat-illness.

Episode 11 - Summer Series 1: Heat Emergencies

Dr. Jerry Snow, a medical toxicologist and emergency medicine physician from Phoenix joins the show for a fact-filled and often hilarious talk on prehospital management of snakebites.  This episode involves copperheads, water moccasins and even unsuccessful car battery therapy (yep, you read that correctly).  Stay until the end - you won’t be sorry you did!

Episode 12 - Summer Series 2: Snake Bites

Join Dr. Patrick and Ashton Herring our community outreach coordinator as we discuss adult and pediatric drowning emergencies and best practices in prevention.

Episode 13 - Summer Series 3: Drowning (Adult and Pediatric)

Today’s show is all about the changes in how we approach intubation in EMS. Dr. Jeff Jarvis will relate how he got interested in the topic of airway management and specifically the process of delayed sequence intubation. Dr. Jarvis is the EMS medical director for Williamson County Texas EMS.  He will present data from the recent Annals of Emergency Medicine paper his group authored on the topic. MCHD quality lead, Kevin Crocker, will present our data following DSI Implementation in Montgomery County. 

Weingart Emcrit podcast and Annals of EM article
https://emcrit.org/dsi/
http://dx.doi.org/10.1016/j.annemergmed.2014.09.025

Jarvis Annals paper
http://www.annemergmed.com/article/S0196-0644(18)30071-4/abstract

Wilco EMS: https://www.wilco.org/Departments/EMS
2017 SOCs 
DSI protocol
DSI checklist for both WCEMS and Marble Falls Area EMS

Episode 14 - Delayed Sequence Intubation (DSI) With Dr. Jeff Jarvis

CHF exacerbations are bread and butter emergency medicine.  Casey Patrick and Brad Ward begin with some background physiology and review of CHF.  They then move on to describing a more detailed framework than the typical “CHF exacerbation” that is commonly taught.  You’ll finish this podcast and think you’re a plumber as opposed to a paramedic.


References

https://coreem.net/core/ape/

Episode 15 - Congestive Heart Failure Part 1 - The Basics

Patients with acute pulmonary edema need rapid preload and afterload reduction and often their volume status is difficult to ascertain.  Casey Patrick and Brad Ward discuss a novel approach to using our old friend nitroglycerin in these patients along with the other cornerstones of their care.


References

	1.	Cotter G, Metzkor E, Kaluski E, et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998;351(9100):389-93.
	2.	Levy P, Compton S, Welch R, et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007;50(2):144-52.
	3.	Wilson SS, Kwiatkowski GM, Millis SR, et al. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-31.
	4.	Peacock WF et al. Morphine and Outcomes in Acute Decompensated Heart Failure: An ADHERE Analysis. Emerg Med J 2008; 25: 205 – 209.

Episode 16 - Congestive Heart Failure Part 2 - Nitro, Nitro, Nitro

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

MHCD Medic

Mark