The Paramedic Practitioner

In this episode I talked with Dr. Quinn Cummings (@resus_bae) about the topic of cognitive bias and some ways we can reduce the influence of biases in our practice. Quinn is an emergency physician with a special interest in this topic. During an average shift an emergency medical provider makes hundreds to thousands of decisions. To make these decisions, our brains use a combination of conscious and subconscious information. We tend to think that all our decisions are made objectively but, in fact, much of our decision making comes from knowledge or ideas that we are not even aware of. This is the concept of cognitive bias. A cognitive bias is a systematic error in thinking which can skew our ability to process information properly and accurately. This can lead to an improper diagnosis or treatment path for our patient. There are numerous examples of specific biases such as anchoring bias, confirmation bias, premature closure, etc. We discuss a few examples in the podcast but we encourage you to research more to see which ones you may be more susceptible to (see resources below). As always please feel free to share feedback, comments, or questions! Twitter: @amerelman Instagram: @paramedicpractitioner   Facebook: The Paramedic Practitioner Podcast Email: amerelman@gmail.com References and other resources: https://www.nuemblog.com/blog/cognitive-bias https://first10em.com/cognitive-errors/ https://criticalcarenow.com/criticalcarecares-25-cognitive-biases-every-doctor-needs-to-know/ Croskerry, P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Med. August 2003, 1-6. Croskerry, P et al. Patient Safety in Emergency Medicine. Lippincott Williams & Wilkins, 2009. Thomas, D. D., & Mustafa, Y. Design for cognitive bias. Jeffrey Zeldman / A Book Apart. 2020. Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med 2003;41(1):110–120. Croskerry P. The feedback sanction. Acad Emerg Med. 2000 Nov;7(11):1232-8. doi: 10.1111/j.1553-2712.2000.tb00468.x. PMID: 11073471. Caplan R.A., Posner K.L., Cheney F.W.: Effect of outcome on physician judgments of appropriateness of care. JAMA 1991; 265: pp. 1957-1960. Abraham Kaplan (1964). The Conduct of Inquiry: Methodology

On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in the management of agitation as well as sedation and airway management. Agitated patients are often challenging to treat. They require a high-level of assessment skill and a tailored treatment plan. There is a spectrum of agitation and it is important to determine where your patient falls to choose the correct management. This episode is a framework of the agitation spectrum and treatment options for the various types of patients we see. Ketamine dose continuum (all doses IV unless indicated) With ketamine the two therapeutic ranges are analgesic and dissociation. We generally avoid the two middle ranges. For agitation, the only reliable use is to target dissociation using at least 3 mg/kg IM. A Law Enforcement Approach to ExDS References and Resources

This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management. Facebook: https://www.facebook.com/paramedicpractitioner/ Instagram: @paramedicpractitioner Email: amerelman@gmail.com Twitter: @amerelman Image: PulmCrit References and Further Reading UpToDatehttps://emedicine.medscape.com/article/296301-overview https://canadiem.org/management-of-severe-asthma/ http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/ https://rebelem.com/rebelcast-crashing-asthmatic/ https://emcrit.org/ibcc/asthma/ https://asthma.net/treatment/prevention/ https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/ https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/ https://err.ersjournals.com/content/22/129/227.full https://www.ncbi.nlm.nih.gov/books/NBK430901/ https://www.ncbi.nlm.nih.gov/pubmed/11406055 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/ https://www.ncbi.nlm.nih.gov/pubmed/23235634 https://www.ncbi.nlm.nih.gov/pubmed/22479740 https://www.ncbi.nlm.nih.gov/pubmed/26033128 https://www.ncbi.nlm.nih.gov/pubmed/25447559 https://www.ncbi.nlm.nih.gov/pubmed/27289336 a

In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share. Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists. Facebook: https://www.facebook.com/paramedicpractitioner/ Instagram: @paramedicpractitioner Email: amerelman@gmail.com Twitter: @amerelman Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.

http://www.cmaj.ca/content/188/17-18/E466 Mechanism of Slow-Fast AVNRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/ AVNRT versus AVRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/ Sinus tachycardia with P waves at the end of the T-wave. Theses can be less obvious and the EKG can be mistaken for AVNRT or AVRThttp:// https://litfl.com/sinus-tachycardia-ecg-library/

This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful. Airway Checklist Examples Anything worse than grade 2a is ideally managed using a bougie. Image: nurse-anesthesia.com Grade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized. Reference: EMCrit Checklist page SALAD Airway Rich Levitan on epiglottoscopy Video discussion

This is part 1 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving basic airway skills and avoiding common errors that make airway interventions less likely to be successful. Ear-to-sternal-notch positioning Patient sitting upright with ear-to-sternal notch positioning. Known as back up, head elevated (BUHE) The ideal mask seal using a BVM. The index and middle fingers pull the mandible forward maintaining airway patency. Reference: A Modern Approach to Basic Airway Management Bougie and Positioning Simulation Scenario Resource DuCanto Suction Catheter Deep Survival Book Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Am J Emerg Med. 2017 Jul;35(7):986-992. doi: 10.1016/j.ajem.2017.02.011. Epub 2017 Feb 5. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Intern Emerg Med. 2017 Jun;12(4):

In this episode I discuss prehospital management of traumatic cardiac arrest, broken into penetrating and blunt. In recent years the pendulum has swung away from a nihilistic approach towards one that maximizes outcomes in the highest number of patients. This requires taking a standardized, aggressive approach when treating viable patients with traumatic arrest. In penetrating traumatic arrest, addressing reversible causes based on the location of the injury is essential. This primarily means hemorrhage control and volume restoration (ideally with blood products). It may also mean chest decompression (ideally with finger thoracostomy) for treatment of pneumothorax or hemothorax. In blunt arrest it is more difficult to determine an underlying cause of arrest so a rehearsed, pre-planned “bundle” of care directed at reversible causes should be delivered early. Chest compressions should not be expected to be effective until volume is restored or tension physiology is reversed. This approach is attributed by most people to Dr. John Hinds. Primary interventions include: Aggressive control of external hemorrhage.Maintenance of airway and ensuring oxygenation, ideally with intubationDecompression of both sides of the chest, ideally with finger thoracostomy but needle thoracostomy at minimumApplication of a pelvic binderReduction of all long bone fractures References Scott Weingart. EMCrit Podcast 135 – Trauma Thoughts with John Hinds. EMCrit Blog. Published on October 19, 2014. Accessed on May 24th 2019. Available at [https://emcrit.org/emcrit/trauma-thoughts-john-hinds/ ]. Traumatic cardiac arrest: a unique approach. Harris T, Masud S, Lamond A, Abu-Habsa M. Eur J Emerg Med. 2015 Apr;22(2):72-8. doi: 10.1097/MEJ.0000000000000180. Review. Konesky KL, Guo WA. Eur J Trauma Emerg Surg. 2018 Dec;44(6):903-908. doi: 10.1007/s00068-017-0875-6. Epub 2017 Nov 25. Escutnaire J, Genin M, Babykina E, Dumont C, Javaudin F, Baert V, Mols P, Gräsner JT, Wiel E, Gueugniaud PY, Tazarourte K, Hubert H; on behalf GR-RéAC. Resuscitation. 2018 Oct;131:48-54. doi: 10.1016/j.resuscitation.2018.07.032. Epub 2018 Jul 27. Evans CC, Petersen A, Meier EN, et al. Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. J Trauma Acute Care Surg. 2016;81(2):285–293. doi:10.1097/TA.0000000000001070

On this quick episode I discuss hyperkalemia, a life-threatening condition commonly missed by out-of-hospital providers. It is essential to recognize the signs and symptoms of hyperkalemia as these patients may require prompt treatment to prevent fatal dysrhythmias. References: http://hqmeded-ecg.blogspot.com/search/label/hyperkalemia https://emcrit.org/ibcc/hyperkalemia/ Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963–971. doi:10.5811/westjem.2017.6.33033 Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–384. doi:10.1007/s00467-010-1699-3 Ryuge A, Nomura A, Shimizu H, Fujita Y. Warning: The ECG May Be Normal in Severe Hyperkalemia. Intern Med. 2017;56(16):2243–2244. doi:10.2169/internalmedicine.6895-15 (ECGs from Smith’s ECG Blog http://hqmeded-ecg.blogspot.com) Subtle hyperkalemia indicated by peaked T-waves and ST segment flattening in V3-V5 Hyperkalemia indicated primarily by peaked T-waves in V2-V4 Wide QRS and significantly peaked T-waves indicating hyperkalemia

Severe Crashing Acute Pulmonary Edema (SCAPE) is a life threatening complication of heart failure. In this episode, I discuss the pathophysiology and modern treatment modalities with flight paramedic and medical student Michael Perlmutter. References Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719–723. doi:10.4103/0972-5229.195710 Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36. Published 2018 Feb 2. doi:10.1016/j.tjem.2018.01.004 Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23 Paone S, Clarkson L, Sin B, Punnapuzha S. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10. Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on July 10th 2019. Available at https://emcrit.org/emcrit/scape/ IMAGE 2 – Pathophysiology of heart failure, Image from CORE EM IMAGE 3 – Spiral of death in heart failure, Image from CrashingPatient.net

In this episode, I discuss the use of ketamine for pain in the prehospital setting. There are many subtleties to ensuring that you get the effect you want from the drug and minimize adverse effects. Image: EMUpdates.com References: https://emupdates.com/the-ketamine-brain-continuum/ Vadivelu N, Schermer E, Kodumudi V, Belani K, Urman RD, Kaye AD. Role of ketamine for analgesia in adults and children. J Anaesthesiol Clin Pharmacol. 2016;32(3):298–306. doi:10.4103/0970-9185.168149 Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014;8(3):283–290. doi:10.4103/0259-1162.143110 Subdissociative-Dose Ketamine for Analgesia Annals of Emergency Medicine , Volume 71 , Issue 3 , e35 Images Image: EMUpdates.com