MCHD Paramedic Podcast

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.

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

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.

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.

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

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.

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.

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

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

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

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.

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.

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?

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.

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.

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.

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.

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.

This may seem like a curveball-type episode upon your initial listen, but this topic should be core material for all emergency medical clinicians. Too much time and emphasis within paramedic education are placed on rare presentations. Dr. Dickson and Dr. Patrick expand on a recent medical podcast/article (see links below), stressing the need to embrace learning and teaching the most common conditions we care for. REFERENCES 1. https://podcasts.apple.com/us/podcast/episode-19-juan-lessing-and-read-pierce-teaching-more/id1603333202?i=1000560289032 2. https://www.amjmed.com/article/S0002-9343(22)00134-6/fulltext

The podcast crew is joined, live at Texas EMS 2022, by Dr. Gerad Troutman to discuss the world of alternate destination EMS transports, EMS-facilitated telehealth, nurse navigation, and "hospital at home." Dr. Troutman leads the ET3 initiative and is the National Medical Director for Innovative Practice at GMR, so this episode is full of successes, road bumps, and shared experiences with the implementation and execution of each of these leading-edge concepts within prehospital care.