MCHD Paramedic Podcast: Recent Episodes

Montgomery County Hospital District

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.

for the serial killer AMS patient.

We recently made some cervical spine immobilization protocol changes here at MCHD. Dr. Patrick and Dr. DePasquale discuss the history and literature that provide the foundation for rigid cervical collar use, along with the new MCHD protocol implementation. This has been a collaborative process with our local hospital partners, which has definitely involved give-and-take on both sides.REFERENCES1. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996 Nov;27(9):647-9.2. Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical hard collar on intracranial pressure after head injury. ANZ J Surg. 2002 Jun;72(6):389-91.3. Hunt K, Hallworth S, Smith M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia. 2001 Jun;56(6):511-3.4. Lerner EB, Billittier AJ 4th, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. Prehosp Emerg Care. 1998 Apr-Jun;2(2):112-6.5. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999 Oct-Dec;3(4):347-526. Mitra B, Bernard S, Yankoff C, Somesh A, Stewart C, Koolstra C, Talarico C, Nehme Z, Fitzgerald MC, Cameron PA. Change from semi-rigid to soft collars for prehospital management of trauma patients: An observational study. J Am Coll Emerg Physicians Open. 2024 Jul 17;5(4):e13239.7. Sundstrøm T, Asbjørnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma. 2014 Mar 15;31(6):531-40. 8. Millin MG, Innes JC, King GD, Abo BN, Kelly SM, Knoles CL, Vezzetti R, White CC 4th, Yee A, Gallagher JM. Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries - A NAEMSP Comprehensive Review and Analysis of the Literature. Prehosp Emerg Care. 2025 Aug 7:1-13. 9. Ramasamy A. Advanced trauma life support 2025: A brief review of updates. Injury. 2026 Apr;57(4):113079. doi: 10.1016/j.injury.2026.

Drs. Geoff Comp and Jerry Snow join the podcast to discuss their recent paper describing their experience treating undifferentiated heatstroke in Phoenix with cold water immersion. Their protocol mirrors ours here in Montgomery County. Heatstroke is a time-sensitive emergency, and the rate of cooling directly correlates with mortality reduction. Learn how to implement CWI in your service. It's the best of all worlds: inexpensive, impactful, and applies to all EMS clinician levels.REFERENCES1. Comp G, Finch C, Kupanoff K, Sandoval M, Lloyd M, Aldaco N, Kirk D, Pugsley P, Nordstrom L, Koenig BW, Narang A, Snow J, Kamer M, Foster A, Patel G, Stowell JR. Fighting Fire with Ice: A Multisite Collaboration to Evaluate the Impact of Prehospital Cold Water Immersion on Heat Stroke Patients. Prehosp Emerg Care. 2026 Mar 13:1-11.

MCHD's Spencer Lantz and Fort Bend County EMS Medical Director, Dr. Gill join the podcast to discuss the importance of allowing an open conversation around the mental health issues and strain of being an EMS clinician. We've finally started to recognize the issue, Spencer and Dr. Gill have some concrete solutions for the future.

One of our major 2026 clinical and educational focus areas here at MCHD is medication error reduction. While medication errors are complex and have no simple solution, recognizing the issue is the initial step in changing culture. We're lucky to have a special guest with a unique perspective on this episode. Kevin Mercer, an emergency department pharmacist, joins Dr. Patrick to discuss all things medication administration. This is the second episode of our two-part series!REFERENCES1. Harmer BM, Hoyle JD Jr, Edwards A, Fredericks T, Wells L, Lecznar A, Christopher K, Dunwoody S, Hong G, Rantz W, Popov V, Mahajan P, Fogarty K. Assessing the Influence of a Statewide Dosing Reference Aid on Prehospital Pediatric Medication Dosing Errors: A Mixed-Methods Simulation-Based Investigation. Prehosp Emerg Care. 2026 Mar 9:1-8.

One of our major 2026 clinical and educational focus areas here at MCHD is medication error reduction. While medication errors are complex and have no simple solution, recognizing the issue is the initial step in changing culture. We're lucky to have a special guest with a unique perspective on this episode. Kevin Mercer, an emergency department pharmacist, joins Dr. Patrick to discuss all things medication administration. The episode went so well, we had to create a two-part series!REFERENCES1. Harmer BM, Hoyle JD Jr, Edwards A, Fredericks T, Wells L, Lecznar A, Christopher K, Dunwoody S, Hong G, Rantz W, Popov V, Mahajan P, Fogarty K. Assessing the Influence of a Statewide Dosing Reference Aid on Prehospital Pediatric Medication Dosing Errors: A Mixed-Methods Simulation-Based Investigation. Prehosp Emerg Care. 2026 Mar 9:1-8.

As discussed on prior episodes, we recently overhauled our entire protocol structure here at MCHD. One of our MCHD paramedics, David Lozano, joins us to discuss the foundations of EMS protocol creation. Who writes them and how? Where are the potentially risky decisions? What should the MCHD field paramedics know about the process? Have a listen to better understand the true foundation of EMS clinical practice.

in a Suburban EMS System. Prehosp Emerg Care. 2025 May 29:1-6.2. Haussner WK, Breyre AM, Bascombe K, Barrett WJ, Camacho MA, Overton-Harris P, Williams S, Lyng JW, Martin-Gill C, Colwell C. Prehospital Trauma Compendium: Management of Geriatric Trauma Patients - A Position Statement and Resource Document of NAEMSP. Prehosp Emerg Care. 2025 Sep 25:1-10.

in Out-of-Hospital Airway Management. Ann Emerg Med. 2025 Nov;86(5):531-532. 3. Maia IWA, Besen BAMP, Silva LOJE, et al; BARCO group. Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study. Crit Care. 2025 Apr 17;29(1):155.

Recently, some paramedics, obstetricians, and EMS medical directors were locked in a room and produced some fantastic collaborative prehospital guidelines for managing post-partum hemorrhage, eclampsia, and pre-eclampsia. Have a listen, take a look at the guidelines (links below), and we'll all take better care of our pregnant/post-partum patients.REFERENCES1. https://naemsp.org/news/now-available-new-ems-obstetric-emergency-guidelines/

Yamane, D. (2025). Hyperangulated video laryngoscopy in the emergency department: An analysis of errors and factors leading to prolonged apnea time. The American journal of emergency medicine, 95, 153–158.

We're lucky to have a special guest on this podcast episode to discuss a topic that, unfortunately, all of us in emergency care encounter all too frequently: the opiate epidemic. Peter Canning is a paramedic who has lived through the epidemic while working on the ambulance in the New England epicenter. This discussion navigates Peter's progression through newer terminology like stigma and harm reduction in an effort to provide compassionate and best-practice care for our OUD patients.REFERENCES1. https://www.press.jhu.edu/books/title/12438/killing-season?srsltid=AfmBOopOX3Wpf9blJDuiJbwOCKyNCACoxU2IixIMtLg1N1a-wYTGeEmr2. https://www.press.jhu.edu/books/title/53796/friends-and-family-guide-opioid-overdose-epidemic

We're going to take our "Serial Killers" series and continue into the transition from the ambulance to the emergency department. What happens to the patient with chest pain once the ER doctor takes over? How does the workup advance? What imaging is ordered? What labs? Join us to discuss the "next 30 minutes" for the serial killer chest pain patient.

On this episode, the podcast crew discusses the recent introduction of video laryngoscopy with recording capability at MCHD. What device did you use? How did you train? What lessons have you learned? All these and more will be addressed and answered.REFERENCES:1. Zhao, Y., Zang, B., & Wang, Q. (2024). The Effectiveness of Bougie Use on First-Attempt Success in Tracheal Intubations. Annals of emergency medicine, 84(3), 331–332. 2. Weingart, S. D., Barnicle, R. N., Janke, A., Bhagwan, S. D., Tanzi, M., McKenna, P. J., Bracey, A., & Resuscitationists Research Group (2023). A taxonomy of key performance errors for emergency intubation. The American journal of emergency medicine, 73, 137–144.

The podcast crew takes on the topic of prehospital analgesia. What pain medication do we choose when facing a complex patient with all analgesics available? Are there better options for hypotensive patients? What about pregnancy and the elderly? On this episode, we'll walk through our MCHD pain medication options, take a moment for a BLS reminder, and discuss some specific situations where certain medications are the best fit.REFERENCES1. McArthur, R., Cash, R. E., Rafique, Z., Dickson, R., Crocker, K., Crowe, R. P., Wells, M., Chu, K., Nguyen, J., & Patrick, C. (2024). Intravenous Acetaminophen Versus Ketorolac for Prehospital Analgesia: A Retrospective Data Review. The Journal of emergency medicine, 67(3), e259–e267. 2. McArthur, R., Cash, R. E., Anderson, J., De La Rosa, X., Peckne, P., Hogue, D., Badawood, L., Secrist, E., Andrabi, S., & Patrick, C. (2025). Fentanyl versus nebulized ketamine for prehospital analgesia: A retrospective data review. The American journal of emergency medicine, 89, 124–128. 3. Powell, J. R., Browne, L. R., Guild, K., Shah, M. I., Crowe, R. P., Lindbeck, G., Braithwaite, S., Lang, E. S., Panchal, A. R., & Technical Expert Panel (2023). Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods. Prehospital emergency care, 27(2), 154–161. 4. Aceves, A., Crowe, R. P., Zaidi, H. Q., Gill, J., Johnson, R., Vithalani, V., Fairbrother, H., & Huebinger, R. (2023). Disparities in Prehospital Non-Traumatic Pain Management. Prehospital emergency care, 27(6), 794–799.

Lindsey Ewing (IG's The Prehospitalist) joins us to discuss updates and questions surrounding the EMS management of traumatic arrest. Sure, we must address the "reversible" causes, but what about ACLS/compressions/epinephrine? Which patients are exceptions to the rules? Lindsey had a tough case, asked some hard questions, and will provide solid answers—our favorite recipe for a jam-packed educational session.REFERENCES1. Witt, C. E., Shatz, D. V., Robinson, B. R. H., Campion, E. M., Shapiro, M. L., Bui, E. H., Meizoso, J. P., & Dorlac, W. C. (2025). Epinephrine in Prehospital Traumatic Cardiac Arrest-Life Saving or False Hope?. Prehospital emergency care, 1–9.2. Breyre, A. M., George, N., Nelson, A. R., Ingram, C. J., Lardaro, T., Vanderkolk, W., & Lyng, J. W. (2025). Prehospital Trauma Compendium: Prehospital Management of Adults with Traumatic Out-of-Hospital Circulatory Arrest - A Joint Position Statement and Resource Document of NAEMSP, ACS-COT, and ACEP. Prehospital emergency care, 1–15.3. https://www.anzcor.org/assets/anzcor-guidelines/guideline-11-10-1-management-of-cardiac-arrest-due-to-trauma-253.pdf

We're joined by Dallas-area cardiac arrest management thought leaders from Best EMS and Parker County Hospital District to discuss the Resuscitation Academy. Where did this thing start? How can you and your service benefit? What RA lessons have we implemented here at MCHD? Learn how to improve your cardiac arrest survival rates without breaking the bank.REFERENCES1. https://www.resuscitationacademy.org

Orthostatic vitals are taught throughout medical training as a quick and easy way to assess patient volume status objectively. We also frequently see these documented in MCHD charts. Is there any evidence that orthostatics help our clinical decision-making? Has anyone ever evaluated their use in EMS? Could standing a patient to check their heart rate actually be harmful? Join the podcast crew as they address these questions and more. REFERENCES1. White, JL, Hollander, JE, Chang, AM, et al. (2019). Orthostatic vital signs do not predict 30-day serious outcomes in older emergency department patients with syncope: A multicenter observational study. The American journal of emergency medicine, 37(12), 2215–2223. 2. Shen W, Sheldon R, Yancy C, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of The American College Of Cardiology. August 1, 2017;70(5):e39-e110. Available from: MEDLINE, Ipswich, MA. Accessed May 1, 2018.3. Cohen E, Grossman E, Sapoznikov B, et al. Assessment of orthostatic hypotension in the emergency room. Blood Press. 2006;15(5):263-267.4. Aronow WS, Lee NH, Sales FF, Etienne F. Prevalence of postural hypotension in elderly patients in a long-term health care facility. Am J Cardiol. 1988;62(4):336.5. Ooi WL, Barrett S, Hossain M, et al. Patterns of orthostatic blood pressure change and their clinical correlates in a frail, elderly population. JAMA. 1997;277(16):1299-1304.

On today's episode, we're lucky to have a couple of special guests to discuss prehospital transcutaneous pacing. Medics turned medical students and EMS researchers, Josh Kimbrell and Judah Kreinbrook recently published a case series decsribing EMS pacing capture. Like many of our favorite topics this came from a paramedic asking a clinical question with loads of dogma and little evidence. What they found should motivate us all to be skeptical when it comes to determining if TCP is actually working. REFERENCES1. https://www.mchd-tx.org/wp-content/uploads/2025/03/TCP-Podcast-Figures.pdf2. Kimbrell, J., Kreinbrook, J., Poke, D., Kalosza, B., Geldner, J., Shekhar, A. C., Miele, A., Bouthillet, T., & Vega, J. (2024). False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series. Prehospital emergency care, 28(7), 928–936. 3. https://www.ems12lead.com/post/tcp-in-transit-part-i4. https://www.ems12lead.com/post/transcutaneous-pacing-part-25. https://www.ems12lead.com/post/transcutaneous-pacing-part-3

We often discuss "one in a million" and "once in a career" cases in emergency medicine and EMS, and do we ever have one of those for you in this episode! MCHD Captain, Jason Jones, joins Dr. Patrick to discuss an exeedingly rare STEMI/chest pain presentation with lessons that we can all apply to our daily care.REFERENCES1. https://www.mchd-tx.org/wp-content/uploads/2025/02/SITUS-Fig-1.pdf2. https://www.mchd-tx.org/wp-content/uploads/2025/02/SITUS-Fig-2.pdf3. https://montgomerycountypolicereporter.com/mchd-celebrates-survival-of-one-in-a-million-patient-first-responders-please-read/4. https://pubmed.ncbi.nlm.nih.gov/34317454/

This is a special edition of the MCHD Paramedic Podcast. Ginger Locke, of the absolutely amazing Medic Mindset podcast, invited Dr. Patrick on to discuss rate control of rapid atrial fibrillation in the prehospital setting. She was gracious enough to share the audio for a dual release. This episode has been out in the world on Medic Mindset for a couple of months, but we wanted to offer it to our MCHD Paramedic Podcast listeners as well. Also, like, subscribe to and follow Medic Mindset wherever you listen to podcasts.REFERENCES1. https://medicmindset.com2. Elam, K., & Bolar-Softich, K. L. (1997). Dilemmas in the acute pharmacologic treatment of uncontrolled atrial fibrillation. The American journal of emergency medicine, 15(4), 418–419. 3. Abarbanell, N. R., & Marcotte, M. A. (1997). Prehospital use of intravenous diltiazem (cardizem Lyo-Ject) in the treatment of rapid atrial fibrillation. The American journal of emergency medicine, 15(6), 618–619. 4. Abarbanell, N. R., Marcotte, M. A., Schaible, B. A., & Aldinger, G. E. (2001). Prehospital management of rapid atrial fibrillation: recommendations for treatment protocols. The American journal of emergency medicine, 19(1), 6–9. 5. Wang, H. E., O'connor, R. E., Megargel, R. E., Schnyder, M. E., Morrison, D. M., Barnes, T. A., & Fitzkee, A. (2001). The use of diltiazem for treating rapid atrial fibrillation in the out-of-hospital setting. Annals of emergency medicine, 37(1), 38–45. 6. Luk, J. H., Walsh, B., & Yasbin, P. (2013). Safety and efficacy of prehospital diltiazem. The western journal of emergency medicine, 14(3), 296–300. 7. Rodriguez, A., Hunter, C. L., Premuroso, C., Silvestri, S., Stone, A., Miller, S., Zuver, C., & Papa, L. (2019). Safety and Efficacy of Prehospital Diltiazem for Atrial Fibrillation with Rapid Ventricular Response. Prehospital and disaster medicine, 34(3), 297–302. 8. Fornage, L. B., O'Neil, C., Dowker, S. R., Wanta, E. R., Lewis, R. S., & Brown, L. H. (2024). Prehospital Intervention Improves Outcomes for Patients Presenting in Atrial Fibrillation with Rapid Ventricular Response. Prehospital emergency care, 28(7), 910–919.

MCHD recently rolled out Ceftriaxone for long-bone open fracture care. The podcast crew welcomes our new assistant medical director, Dr. Mike DePasquale, to discuss some background evidence and danger spots within this protocol.REFERENCES:Lack, W. D., Karunakar, M. A., Angerame, M. R., Seymour, R. B., Sims, S., Kellam, J. F., & Bosse, M. J. (2015). Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. Journal of orthopaedic trauma, 29(1), 1–6. Johnson, J. P., Oliphant, B. W., Dodd, J., Duckworth, R. L., Goodloe, J. M., Lyng, J. W., Sagraves, S. G., & Fischer, P. E. (2024). Prehospital Antibiotic Administration for Suspected Open Fractures: Joint COT/OTA/ACEP/NAEMSP/NAEMT Position Statement. Prehospital emergency care, 28(8), 1063–1067. Muniz, A. D., Gregorio, D. J., Studebaker, S. A., Peth, A. M., Camacho, C. G., Williams, B., Kupas, D. F., & Brown, L. H. (2024). Time Savings and Safety of EMS Administration of Antibiotics for Open Fractures. Prehospital emergency care, 28(8), 1046–1052.

We recently implemented a "push-dose" norepinephrine protocol at MCHD and have already learned some valuable lessons. Join us for some vasopressor pharmacology and protocol review, accompanied by some of our new teaching points that have arisen following the protocol's release into the wild.REFERENCES:1. Berkenbush, M., Singh, L., Sessa, K., & Saadi, R. (2024). Scoping Review: Is Push-Dose Norepinephrine a Better Choice? The western journal of emergency medicine, 25(5), 708–714. 2. Permpikul, C., Tongyoo, S., Viarasilpa, T., Trainarongsakul, T., Chakorn, T., & Udompanturak, S. (2019). Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. American journal of respiratory and critical care medicine, 199(9), 1097–1105.

Our final entry into the EKG Manifesto series moves into the STEMI/OMI world of acute coronary occlusion. Who do we activate and why? Where is the STEMI paradigm headed? Join Dr. Patrick and Dr. Dickson to refresh your EKG knowledge. REFERENCES 1. https://www.emdocs.net/ecg-pointers-stemi-equivalents-from-the-american-college-of-cardiology/

One of the most fear-inducing procedures in all of emergency care is the surgical cricothyrotomy. Dr. Al Lulla from Dallas Fire joins the podcast to discuss our recent collaboration on a retrospective look at MCHD's surgical airway experience over the past decade. Can paramedics successfully perform cricothyrotomies? Who needs surgical airway placement in the field? What can we learn for our next "can't oxygenate/can't ventilate" scenario? REFERENCES 1. https://youtu.be/wVQFJR7qmrQ?si=QBUfJd_7oZ3vmEpR 2. Lulla A, Dickson R, Wells M, Gilbert M, Rogers Keene K, Patrick C. Prehospital Surgical Cricothyrotomy in a Ground-Based 9-1-1 EMS System: A Retrospective Review. Prehosp Disaster Med. 2024 Apr 23:1-4.

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. In Part 2 of this series, we'll discuss bradycardias and tachycardias.REFERENCES1. https://www.youtube.com/watch?v=UXh8PS9dtmo

We've initiated a multi-pronged, system wide overhaul of our agitation management at MCHD. This included a move to fixed-dose ketamine for the severely agitated patients. Evidently we weren't the only ones thinking of this as there is exciting new data from Buffalo supporting this approach. Join the podcast crew as they review the recent literature and MCHD protocol changes.REFERENCES1. O'Brien MC, Kelleran KJ, Burnett SJ, Hausrath KA, Kneer MS, Nan N, Ma CX, McCartin RW, Clemency BM. Fixed dose ketamine for prehospital management of hyperactive delirium with severe agitation. Am J Emerg Med. 2024 Jul;81:10-15.

We've recently had several challenging, wide-complex tachycardia cases here at MCHD, so the podcast crew decided to bring forth some VT vs. SVT with aberrancy knowledge. Learn the V-Tach FACT, and you'll feel more comfortable with your next wide rhythm at a rate of 185.REFERENCES1. https://litfl.com/vt-versus-svt-ecg-library/2. https://www.youtube.com/watch?v=UXh8PS9dtmo3. Marill KA, Wolfram S, Desouza IS, Nishijima DK, Kay D, Setnik GS, Stair TO, Ellinor PT. Adenosine for wide-complex tachycardia: efficacy and safety. Crit Care Med. 2009 Sep;37(9):2512-8.

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.REFERENCES1. https://www.youtube.com/watch?v=UXh8PS9dtmo2. 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.REFERENCES1. 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.REFERENCES1.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.REFERENCES1. 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. REFERENCES1. 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? REFERENCES1. 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.REFERENCES1. 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.pdf3. 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.REFERENCES1.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.REFERENCES1. 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.

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!REFERENCES1. 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.

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•PossibilitiesREFERENCES1. 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. REFERENCES1. 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. REFERENCES1. https://emcrit.org/pulmcrit/brash-syndrome-bradycardia-renal-failure-av-blocker-shock-hyperkalemia/2. https://www.youtube.com/watch?v=UXh8PS9dtmo&t=2s3. 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. REFERENCES1. https://podcasts.apple.com/us/podcast/episode-19-juan-lessing-and-read-pierce-teaching-more/id1603333202?i=10005602890322. 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.

MCHD medics Kelcie Adams and Rich Serra join the podcast to discuss a critically ill trauma patient they delivered to Dr. Patrick in the emergency department. Our default is so often airway, airway, airway first, but prioritizing circulation first was likely life-saving. This is an excellent "Monday Morning Quarterback" case to look back on and dissect with tons of educational pearls.

Special guest alert!! We're lucky to have superstar Aussie medic and University of Melbourne Ph.D. candidate Matt Wilkison-Stokes, on this episode to discuss his recent paper looking at the risk of hypotension with nitroglycerin administration in acute MI. Where is NTG really more likely to cause hypotension in AMI? When is it safest? How often do isolated RVMI's occur, and what are the correct diagnostic criteria? Dr. Patrick changed his practice based on Matt's work and knowledge. See if you might do the same.REFERENCES1. Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2022 Sep 30:emermed-2021-212294. 2. Ferguson JJ, Diver DJ, Boldt M, et al. Significance of nitroglycerin-induced hypotension with inferior wall acute myocardial infarction. Am J Cardiol 1989;64:311–4.3. matt.wilkinsonstokes@student.unimelb.edu.au

We have MCHD Cpt. Megan Powell to thank for this episode as she posed an excellent question about where and how to look for trusted educational information as a practicing paramedic interested in continuing clinical growth and progression. With the amazing and immense amount of free online textbook, blog, and podcast resources available, trying to keep up can be totally daunting. Join Megan and the podcast crew as they discuss tips and strategies to manage the waterfall of open-access EMS education that exists today.

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.

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.

When it comes to exciting educational topics in EMS, oftentimes, the endocrine system, specifically the adrenal glands, can be left off the list. Dr. Patrick is joined by one of our local emergency/trauma nurses, Melanie Gander, to discuss her journey as a parent of a child with congenital adrenal hyperplasia. We'll review basic adrenal physiology and discuss the caveats on how to recognize and treat adrenal crises in the field.

REFERENCES 1. https://united4rare.org/

https://caresfoundation.org/
https://www.magicfoundation.org/Growth-Disorders/Congenital-Adrenal-Hyperplasia/

Across the world of health care, everyone is wrestling with how to reduce medication errors. With the decision in the Vanderbilt case, there is now the added fear of potential prosecution for giving an incorrect medication. Join the podcast crew as they try to better define the various types of medication errors while looking at what the literature says about medication errors in EMS.

REFERENCES 1. Walker D, Moloney C, SueSee B, Sharples R, Blackman R, Long D, Hou XY. Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review. Prehosp Emerg Care. 2022 Jun 27:1-18. 2. Morrow D, North R, Wickens CD. Reducing and Mitigating Human Error in Medicine. Reviews of Human Factors and Ergonomics. 2005;1(1):254-296. 3. Hoyle JD Jr, Crowe RP, Bentley MA, Beltran G, Fales W. Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics. Prehosp Emerg Care. 2017 Mar-Apr;21(2):185-191. 4. Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther Adv Drug Saf. 2019 Jan 21 5. Reason J. Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70.

Join the Podcast Crew as they answer some recent questions submitted to podcast@mchd-tx.org. We discuss a wide range of topics including epinephrine drips, IV Tylenol for pain, Knee-BOA, whole blood in EMS, the green whistle (methoxyflurane), and an awesome "S" for our loss of airway protection teaching files. Thanks to all our listeners out there!!

REFERENCES 1. O'Dochartaigh D, Picard CT, Brindley PG, Douma MJ. Temporizing Life-Threatening Abdominal-Pelvic Hemorrhage Using Proprietary Devices, Manual Pressure, or a Single Knee: An Integrative Review of Proximal External Aortic Compression and Even "Knee BOA". J Spec Oper Med. 2020 Summer;20(2):110-114.

The Podcast Crew is joined by MCHD District Chief, Spencer Hall, to discuss a recent trauma patient that Chief Hall delivered to Dr. Patrick's ED care. This one encapsulates many of our recent podcast topics including the tenets of DSI and the importance of maintaining oxygenation and blood pressure in TBI patients.

The MCHD Paramedic Podcast would like to welcome EM/EMS physician Dr. Katherine Luu, to Montgomery County. Dr. Luu joins the podcast to discuss anchoring bias and how this impacts medics in the field. Listen and learn how to describe, recognize, and prevent anchoring bias in your practice.

REFERENCES 1. https://onlinelibrary.wiley.com/doi/epdf/10.1197/aemj.9.11.1184

https://www.amazon.com/Thinking-Fast-Slow-Daniel-Kahneman-ebook/dp/B00555X8OA/ref=sr_1_1?crid=24FYPXSEKVE8Y&keywords=thinking+fast+and+slow&qid=1662524196&sprefix=thinking%2Caps%2C104&sr=8-1

Thinking, Fast and Slow

Brief resolved unexplained what?? MCHD paramedic, Cpt. Clayton Smith, joins Dr. Dickson to discuss an EMS approach to BRUE's. These can often be falsely reassuring to prehospital providers because the event, by definition, has resolved prior to EMS arrival. But don't get too comfortable because up to 4-5% of BRUE's can have severe underlying diagnoses as the cause. We can never talk too much "sick peds" material on the podcast. This episode will make the approach to your next BRUE a breeze.

REFERENCES 1. Tieder JS, Sullivan E, et al; Brief Resolved Unexplained Event Research and Quality Improvement Network. Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study. Pediatrics. 2021 Jul;148(1)

Banerjee, P. R., Ganti, L., et al. (2019). Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival. Resuscitation, 135, 162-167.

The Podcast crew is joined by MCHD In-Charge Paramedic Brady Walding to discuss a recent difficult STEMI case that intersected with Dr. Patrick in the ED. How do we best communicate with our consultants when we disagree? What happens when a paradigm shift is occurring without our consultants (STEMI vs. OMI/NOMI)? We are excited about our new Monday Morning Quarterback Series, where Dr. Patrick and Dickson review their cases with the MCHD medics involved. Hopefully, you will enjoy it as well!!

REFERENCES 1. Meyers HP et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. Journal of Emergency Medicine 2020.

https://www.nuemblog.com/blog/dont-forget-avl
https://www.youtube.com/watch?v=dWrG8d3YXq4

The podcast crew welcomes newly transplanted Texan EMS physician, Dr. Louis Fornage, to join in on some rapid-fire mythbusting for 2022. We run the gamut from post-ROSC vasopressor evidence to whether or not saying "QUIET" affects emergency department volume.

REFERENCES 1. https://www.nremt.org/News/National-Registry-of-EMT-s-Resource-Document-on-Sp#:~:text=NREMT's%20use%20of%20the%20term,most%20trauma%20patients%20is%20unproven

https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/s12879-022-07337-y.pdf
https://www.tandfonline.com/doi/full/10.1080/10903127.2021.1992053
https://rebelem.com/using-the-word-quiet-in-the-ed/?fbclid=IwAR1yAtVPnUSJqWnGWDWy9yhgXNHSie0AgAxWctGq-zwd_xczFrsvaexwvgw
https://journalfeed.org/article-a-day/2022/battle-of-the-catecholamines-epi-vs-norepi-for-post-resuscitation-shock/

Join the podcast crew as they turn their attention from the EMS transport to the First Responders here in Montgomery County. We welcome MCHD FRO Coordinator Bryan Perry and Chief Ray Vaden from Porter Fire to discuss some recent FRO initiatives and advances. It wouldn't be the MCHD Paramedic Podcast if we also didn't slip in some recent CARES research highlighting improved OHCA outcomes when fire and police can initiate life-saving interventions.

REFERENCES 1. Salhi RA, Hammond S, Lehrich JL, O'leary M, Kamdar N, Brent C, Mendes de Leon CF, Mendel P, Nelson C, Forbush B, Neumar R, Nallamothu BK, Abir M; CARES Surveillance Group. The association of fire or police first responder initiated interventions with out-of-hospital cardiac arrest survival. Resuscitation. 2022 May;174:9-15.

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.

Join Dr. Patrick and MCHD District Chief and Bike Team lead, Scott Sanders, as they discuss the MCHD Bike Team. What does it take to be an MCHD bike team medic? How does patient care differ from the truck vs. when on the bike? Learn how the MCHD Bike Team fills multiple invaluable roles in the county.

Photo Link - https://www.mchd-tx.org/wp-content/uploads/2022/06/Bike-Team.jpg

Friend of the podcast emergency physician, addiction specialist, and toxicologist extraordinaire, Dr. Jerry Snow joins the podcast crew to discuss a scary and potentially deadly twist in the opiate crisis…xylazine. Dr. Snow will school us all about xylazine pharmacology and treatment tips and why EMS high-dose naloxone may not be ideal.

REFERENCES 1. https://www.acep.org/tacticalem/newsroom/oct-2021/xylazine-an-emerging-adulterant/

https://www.kxan.com/news/drug-responsible-for-recent-overdoses-in-austin-travis-county-identified-by-officials/
Reyes, J. C., et al. "The emerging of xylazine as a new drug of abuse and its health consequences among drug users in Puerto Rico." Journal of Urban Health 89.3 (2012): 519-526.
Ruiz-Colón, Kazandra, et al. "Xylazine intoxication in humans and its importance as an emerging adulterant in abused drugs: a comprehensive review of the literature." Forensic Science International 240 (2014): 1-8.
Nunez, Jacqueline, Maura E. DeJoseph, and James R. Gill. "Xylazine, a veterinary tranquilizer, detected in 42 accidental fentanyl intoxication deaths." The American Journal of Forensic Medicine and Pathology 42.1 (2021): 9-11.
Johnson, Jewell, et al. "Increasing presence of xylazine in heroin and/or fentanyl deaths, Philadelphia, Pennsylvania, 2010–2019." Injury prevention 27.4 (2021): 395-398.
Friedman, Joseph, et al. "Xylazine spreads across the US: A growing component of the increasingly synthetic and polysubstance overdose crisis." Drug and Alcohol Dependence (2022): 109380.

8.https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2019/Jan%202019%20ToxTidbits.pdf

https://www.deadiversion.usdoj.gov/drug_chem_info/Xylazine.pdf

There is no possible way to improve ketamine, right? Join Dr. Patrick for a discussion of exciting recent literature investigating the effectiveness and safety of nebulized ketamine for emergency department analgesia. Everyone's favorite EMS medication may be primed for an enhanced delivery option.

REFERENCES 1. Dove D, et al. Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Ann Emerg Med. 2021 Dec;78(6):779-787.

Rhodes AJ, et al. Nebulized ketamine for managing acute pain in the pediatric emergency department: A case series. Turk J Emerg Med. 2021 Apr 9;21(2):75-78.

Join the podcast crew, District Chief Kevin Mifflin and In-Charge Payden Seals as they discuss our MCHD Case of The Quarter for Q1 2022. This case is a prime example why field providers must keep wide differentials with a keen awareness of the initial scene situational factors.

REFERENCES 1. https://coreem.net/core/hypothermia/

https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-environmental/hypothermia

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.

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.

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.
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.
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.
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.
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.
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.

Join Dr. Dickson and the podcast crew as they dive into the MCHD approach to mass casualty incidents. We're lucky to be joined by MCHD Safety and Preparedness Officer, Sean Simmonds and MCHD District Chief Ryan Davenport. These are field medics talking about actual logical field pearls for MCI management.

Episode 127 - Airway Patency Vs. Protection by Montgomery County Hospital District

On Episode 126, the podcast crew was able to catch up with the one and only Dr. Jeff Jarvis at Texas EMS in Austin. Dr. Jarvis is a longtime fan of droperidol for multiple uses in the prehospital setting ranging from acute headache treatment to sedation and as an anti-emetic. Let this be a warning, we're all droperidol zealots in this discussion. Listen and learn practical ways to implement droperidol into your EMS practice.

Texas has been the epicenter of the ground-based EMS integration of whole blood programs for hemorrhagic shock in the prehospital setting. The MCHD clinical staff have been watching the evidence closely and feeling the push from our own medics. Join Dr. Dickson and Dr. Patrick as they discuss the "why" behind no whole blood at MCHD (yet...). Send any requests, questions or ideas to podcast@mchd-tx.org

REFERENCES - https://bit.ly/3M6De5N

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.

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

Wherever you turn in the world today, social media is present with constantly expanding visibility and influence. Join MCHD's Chief of EMS James Campbell and Public Information Officer Misti Willingham as they discuss some lessons and ground rules on how to successfully integrate an active social media program into your EMS service.

It’s time to review some recent cardiac arrest literature. Both of today’s articles come from Resuscitation and address predictors of OHCA survival. Should we take a third attempt at intubating an OHCA patient, should we intubate OHCA at all? What about PEA arrest, can ETCO2 help identify pseudo-PEA? Listen to get some hot off the press OHCA literature updates.

REFERENCES 1. Murphy DL et al. Fewer tracheal intubation attempts are associated with improved neurologically intact survival following out-of-hospital cardiac arrest. Resuscitation. 2021 Oct;167:289-296.

Crickmer M, et al. The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity. Resuscitation. 2021 Oct;167:76-81.
Bergum D, et al. ECG patterns in early pulseless electrical activity-Associations with aetiology and survival of in-hospital cardiac arrest. Resuscitation. 2016 Jul;104:34-9.

We sure do love myth busting on the MCHD Paramedic Podcast and there are definitely some persistent myths surrounding burn care in EMS. Join the podcast crew as they provide updates on burn staging, fluid resuscitation and the basics of burn wound care. This episode will keep you from getting burned during your next burn transport.

REFERENCES 1. Parvizi D, Kamolz LP, et al. The potential impact of wrong TBSA estimations on fluid resuscitation in patients suffering from burns: things to keep in mind. Burns. 2014 Mar;40(2):241-5.

Swords DS, Hadley ED, Swett KR, Pranikoff T. Total body surface area overestimation at referring institutions in children transferred to a burn center. Am Surg. 2015 Jan;81(1):56-63.

Join the podcast crew and Dr. Taylor Ratcliff as they discuss the dangers of the "Lift Assist" calls in EMS. These responses can be under-appreciated with hidden diagnoses such as sepsis, GI bleeding and even fractures. How can we better create checklists to better assess these calls? What are the warning signs in these patients? Do lift assists even require an ALS evaluation? Listen and get these answers and more!

REFERENCES 1. Leggatt L, Van Aarsen K, Columbus M, et al. Morbidity and mortality associated with pre-hospital “Lift-Assist.” Prehosp Emerg Care. 2017;21(5):556-562.

On this episode, we’re lucky have a special guest from Texas Children's Hospital, pediatric sedation and pain management expert, Dr. Corrie Chumpitazi. Nitrous oxide has been in our protocols here at MCHD for some time, but probably doesn’t get the recognition and appreciation that it deserves. We’ll discuss NO history, dosing, indications, contraindications, and side-effects. Listen to learn why we all should be incorporating more Nitrous Oxide into our daily EMS practice.

https://www.acep.org/patient-care/map/map-nitrous-oxide-tool/

REFERENCES 1. Ducassé JL et al (2013). Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial. Acad Emerg Med. 2013 Feb;20(2):178-84. 2. Annequin D and Carbajal R, et al; Fixed 50% Nitrous Oxide Oxygen Mixture for Painful Procedures: A French Survey. Pediatrics. 2000; 105; e47. 3. Collado V, Emmanuel N, et al; Expert Opinion: a Review of the Safety of 50% Nitrous Oxide/Oxygen in Conscious Sedation. Drug Safety. 2007, 6(5): 559-571. 4. Sanders R, Weimann J, Maze M; Biologic Effects of Nitrous Oxide. Anesthesiology. 2008, 109: 707-722 5. Gall O, Annequin D, et al; Adverse Events of Premixed Nitrous Oxide and Oxygen for Procedural Sedation in Children. Lancet. 2001; 358: 1514-15. 6. Tobias, JD, Review Article: Applications of Nitrous Oxide for Procedural Sedation in the Pediatric Population. Pediatric Emergency Care. 2013; 29: 245-265. 7. Onody P, Gil P, Hennequin M. Safety of Inhalation of a 50% Nitrous Oxide/Oxygen Premix: A Prospective Study of 35,828 Administrations. Drug Safety. 2006; 29(7):633-640. 8. American Academy of Pediatric Dentistry. (2013). Guideline on use of nitrous oxide for pediatric dental patients. Retrieved September 3, 2013, from www.aapd.org: http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf 9. Heinrich M, Menzel C, Hoffmann F, et al. Self-administered procedural analgesia using nitrous oxide/oxygen (50:50) in the pediatric surgery emergency room: effectiveness and limitations. Eur J Pediatr Surg. 2015;25(3):250-6. 10. 28. Pasaron R, Burnweit C, Zerpa J, et al. Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients. Pediatr Surg Int. 2015;31(2):173-80. 11. 29. Zier JL, Liu M. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care. 2011;27(12):1107-12. 12. 30. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med. 1989;18(2):177-81. 13. 31. Martin HA, Noble M, Wodo N. The Benefits of Introducing the Use of Nitrous Oxide in the Pediatric Emergency Department for Painful Procedures. J Emerg Nurs. 2018;44(4):331-5.

Within EMS, significant time is spent learning high risk, low frequency procedures and the pharmacology and physiology surround these events. In most EMS services consultations or checklist verifications are required in some fashion surrounding these events. Often times, though, we tend to overlook and fail to provide a structure for best practices in how to complete a clear and concise clinical consultation. MCHD District Chief, Ashley Fillmore, joins the podcast to discuss a framework for successful EMS consultations.

REFERENCES 1. https://bit.ly/3HEhJXJ

With the recent transition of IV acetaminophen from patent to generic, it's a good time to discuss MCHD's 2021 NAEMSP abstract describing our prehospital experience with IV tylenol for pain. If you've not looked into bringing this tool into your service, listen today to be convinced why IV Tylenol is an option worth considering across EMS.

REFERENCES 1. Mahshidfar B, Rezai M, et al. Intravenous Acetaminophen vs. Ketorolac in Terms of Pain Management in Prehospital Emergency Services: A Randomized Clinical Trial. Adv J Emerg Med. 2019 May 8;3(4):e37

2.Bijur PE, Friedman BW, et al. Randomized Clinical Trial of Intravenous (IV) Acetaminophen as an Adjunct to IV Hydromorphone for Acute Severe Pain in Emergency Department Patients. Acad Emerg Med. 2020 Aug;27(8):717-724.

Everything occlusion MI isn't always STEMI. After a recent discussion of "STEMI equivalents" during MCHD continuing education, Dr. Patrick cared for a textbook hyperacute T wave patient in his emergency department practice. On this episode, we review some hyperacute T wave tips, in addition to addressing how to deal with resistant consultants.

REFERENCES: 1. https://tinyurl.com/3aser4j5

Tzimas, Georgios et al. “Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention.” The American journal of cardiology 124.8 (2019): 1305–1314
Aslanger EK, ET AL. DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study). Int J Cardiol Heart Vasc. (2020) Jul 30;30:100603
Pendell Meyers H, ET AL. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. Int J Cardiol Heart Vasc. (2021) Apr 12;33:100767

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.

It seems as though each week brings some crazy and bizarre COVID-19 related news. MCHD Cpt. Megan Powell joins the podcast to spread the word about a harrowing COVID related case that made us all stop and do a literature search. Listen and in and learn yet another clinical consideration when caring for complex COVID-19 patients.

REFERENCES 1. Wang Y, Wang Z, Tse G, Zhang L, Wan EY, Guo Y, Lip GYH, Li G, Lu Z, Liu T. Cardiac arrhythmias in patients with COVID-19. J Arrhythm. 2020 Jul 26;36(5):827-836. doi: 10.1002/joa3.12405.

https://www.tandfonline.com/doi/full/10.1080/10903127.2021.1924325

NOTE - THIS EPISODE WAS RECORDED PRIOR TO THE DELTA SURGE The MCHD clinical crew (Pre-Delta, obviously)attended an actual in-person EMS meeting – EAGLES 2021. One of the most interesting talks was by friend of the podcast/EMS research superstar, Dr. Remle Crowe. Join Dr. Patrick and Dr. Crowe as they discuss the “AHORA” stroke tool and how it has the potential to positively impact prehospital stroke care.

REFERENCES 1. Keenan KJ, Kircher C, McMullan JT. Prehospital Prediction of Large Vessel Occlusion in Suspected Stroke Patients. Curr Atheroscler Rep. 2018 May 21;20(7):34.

https://www.ems1.com/stroke-care/articles/the-time-for-spanish-language-stroke-community-outreach-efforts-is-ahora-xxJdr9dKClRMXJn5/
https://www.mchd-tx.org/blog-post/mchd-ems-joins-campaign-to-bring-stroke-education-to-the-spanish-speaking-community/

Join the podcast crew as they discuss a recent study investigating the risk of being awake while paralyzed when intubated in the emergency department setting. This is definitely an under-discussed topic in the EMS world, especially considering the recent swing from succinylcholine to rocuronium for prehospital medication assisted intubation. This conversation should make us all a bit nervous and better focused the next time we intubate.

REFERENCES 1. https://www.annemergmed.com/article/S0196-0644(20)31314-7/fulltext

Like the rest of the country and world, our Montgomery County hospital partners and ED's have been under severe strain due to a myriad of factors related to the COVID-19 pandemic. This had led to a significant increase in EMS wall times which, in turn, places that severe strain back on the prehospital system. The podcast crew takes an operational turn with MCHD Chief of Operations, Jacob Shaw, to discuss some of our operational adaptations to try and combat our ED delays. We'd love for this episode to open up discussions on how listeners are approaching these problems with their services.

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.

The best clinical discussions always stem from real-life cases. MCHD paramedic Jarrett Kenning had a run of recent bradycardia patients and developed the idea for a bradycardia breakdown with the podcast crew. Bradycardia treatment can vary wildly depending on the underlying cause(s). Joint Jarrett and Dr. Patrick as they discuss several bradycardia cases and present a framework for creating your differential the next time you run on a patient with a pulse in the 30's.

Join Dr. Dickson as he discusses all things French emergency medicine, EMS and prehospital care with Dr. Eric Revue - Emergency Department and EMS Chief - Louis Pasteur Hospital. Docs on ambulances...what???

We’re going to attempt a new recurring podcast series based around the amazing pathology seen on a daily basis by MCHD medics. Cpt. Travis Clay joins the podcast to discuss the current MCHD “Case of the Quarter”. Listen in and learn how to approach the patient with acute, bilateral lower extremity paraplegia and pain.

REFERENCES 1. https://www.ems1.com/patient-assessment/articles/i-cant-feel-or-move-my-legs-mchd-critical-case-report-eVk3jFR1l6DPbwGS/

There may not be any hotter topic in EMS right now than whole blood administration for patients with hemorrhagic shock. Dr. Patrick is joined on today’s episode by Joe Cuthbertson from St. John Ambulance Service in western Australia. St. John's serves the largest land mass of any EMS service worldwide and they are on the forefront of international prehospital whole-blood administration.

REFERENCES 1. https://clinical.stjohnwa.com.au/medications/packed-red-blood-cells

There has been significant development and change surrounding which patients are best served by immediate revascularization post-ROSC over the past 12-18 months. On that note, we discussed the COACT study previously on the podcast, but uncertainty still exists. OHCA and post-ROSC patients are wildly heterogenous and one size will never fit all. What if we could simply change the timing of our post-ROSC ECG and better select those with true acute coronary occlusions that warrant emergent catheterization? That’s the topic of our journal review on this episode. A simple, logical idea that has potentially powerful ramifications, listen in for the details…

REFERENCES 1. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774740

May is Mental Health Awareness Month, so the podcast crew decided to dedicate an entire episode to discussing EMS provider mental health issues and resources. Dr. Patrick and Sean Simmonds are joined by Justin Farris from Cypress Creek Behavioral Health Hospital. Topics range from recognizing mental health warning signs in your partner, to accessing proper mental health resources through programs such as "Honor Strong" at Cypress Creek Hospital.

REFERENCES: https://www.cypresscreekhospital.com/behavioral-health-programs/honor-strong-program/

We have all been guilty of caring for labeling and judging “pseudoseizures.” First of all, this term is outdated, and this episode looks at a study examining the mortality in psychogenic seizure patients. This is a debilitating disease that needs more attention and improved treatment options. Come, have your prior assumptions shattered, and leave a better and more empathetic provider.

REFERENCES: 1. https://n.neurology.org/content/95/6/e643

This episode was directly drawn from a recent MCHD educational need surrounding ventilator management and a summary of our approach to using the vent in the EMS setting. We've touched on aspects of many of these topics before, but this is our first effort at providing a true "MCHD ventilator overview." Join Dr. Patrick and Dr. Dickson as they discuss a stepwise approach to EMS ventilator management and how to first and foremost prevent patient harm.

Is there a more daunting time than those first few shifts as a new paramedic? Yes, clinical knowledge and operational knowledge are key, but how are new medics supposed to synthesize this mountain of information? Dr. Patrick is joined by Cpt. Michael Wells-Whitworth to discuss some "Rules of the Road" for new paramedics.

TOP TEN RULES OF THE ROAD FOR NEW MEDICS 1. Be on time 2. Failing to prepare, is preparing to fail 3. Know your protocols 4. Pour a solid BLS foundation 5. Be like a lamprey - latch on to sharks 6. You need patience - be realistic with your goal pathway 7. Lots of patients - patient contacts are absolutely key 8. Treat other providers with respect 9. Think about what happens next 10. Value handoff communication and scripting

Dr. Dickson and Patrick are joined on this special episode by EMS Medical Directors from across Texas to discuss the recent winter storm that ravaged the state. We discuss the varying ways the disaster impacted each service, multiple lessons learned statewide, several unexpected operational and clinical developments, and steps everyone plans to make to improve moving forward. Thanks to Jeff Jarvis, Jason Pickett, and Veer Vithalani for helping arrange this last-minute recording.

REFERENCES 1. https://www.dallasnews.com/news/weather/2021/02/11/winter-weather-causes-hazardous-conditions-on-north-texas-roads/

https://www.amazon.com/Grips-4-Ice-Winter-Traction-Over-Shoe-Cleats/dp/B07D9128TD/ref=asc_df_B07D9128TD/?tag=hyprod-20&linkCode=df0&hvadid=312131909651&hvpos=&hvnetw=g&hvrand=18032707165061169024&hvpone=&hvptwo=&hvqmt=&hvdev=c&hvdvcmdl=&hvlocint=&hvlocphy=9027681&hvtargid=pla-589843109945&psc=1
https://www.mayoclinicproceedings.org/article/S0025-6196(19)30486-0/fulltext

Hugo Grips-4-Ice Winter Traction, Over-Shoe Snow Cleats, One Size Fits Most

Nothing scares an emergency provider quite as much as the “sick infant.” During today’s episode, Dr. Patrick and Dr. Dickson walk through the pediatric general assessment triangle and discuss the finer points that make up each side. They’ll also discuss the singular/#1 Law of the Pediatric Exam. Your next pediatric run will be a breeze after this review.

REFERENCES: 1. Leeper, Christine M. MD, MS; McKenna, Christine MSN; Gaines, Barbara A. MD Too little too late: Hypotension and blood transfusion in the trauma bay are independent predictors of death in injured children, Journal of Trauma and Acute Care Surgery: October 2018 - Volume 85 - Issue 4 - p 674-678

Balamuth F, Alpern ER, Abbadessa MK, et al. Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign-Based Electronic Alert and Bedside Clinician Identification. Ann Emerg Med. 2017;70(6):759-768.
Mottled Skin - http://empem.org/wp-content/uploads/2011/12/EMPEM-mottled-legs.jpg
Startle Reflex - https://www.youtube.com/watch?v=PhOleckx1-Y
Moro Reflex - https://www.youtube.com/watch?v=PTz-iVI2mf4

After 100 episodes and almost 3 years, the podcast crew decided to celebrate a little bit and look back on our successes and failures thus far. Why did we start the podcast in the first place? How has MCHD used the Paramedic Podcast within the EMS service? What have been the most successful episodes and what are the "Take home Points?" Join Dr. Dickson and Dr. Patrick as they discuss the MCHD Paramedic Podcast past, present, and future.

Emergency medical providers are comfortable in the chaos of a crashing medical or trauma patient. We know how to systematically address dangerous medical conditions like hypotension, hypoxia and bradycardia. However, when asked to dip our toes into the legal realm, we are often paralyzed with fear. On this episode, the podcast crew is joined by local legal expert, Andrew James. Mr. James is the vehicular crimes chief with the Montgomery County DA's office, and he has extensive experience working with medics and first responders in the courtroom. Listen and learn some of the basics of what happens when you're called to court as witness.

Anytime we arrive on scene with blaring sirens and flashing lights, this can be exceedingly stressful on patients and families. This is especially true for our patients with autism. We're lucky to have Jennifer Dantzler on the podcast today to discuss autism basics along with some tools that we can use in the prehospital setting to better care for and communicate with our autistic patients. Jennifer is the director of the Including Kids Autism Center and a true expert in the field of autism spectrum disorder.

REFERENCES 1. https://www.includingkids.org/our-story/helpful-resources/ 2. https://www.autismspeaks.org

Around the MCHD Clincial Department we’ve had some recurrent themes pop up over the past few months that always make the medical directors shake their heads. During this episode, Dr. Dickson and Dr. Patrick take a shot at dispelling some “medical director myths."

Electrical storm has dismal outcomes. It is most frustrating because we know the cause is very likely coronary occlusion (~75%)! We have added esmolol to our tool belt here at MCHD to try and improve refractory VF outcomes. Others are trying early ECMO in this patient population. Prior eCPR studies have all been retrospective. Join the podcast crew as they discuss a recent Lancet article looking at eCPR vs. standard ACLS in refractory VF. Randomized, prospective, and quite amazing.

REFERENCES https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32338-2/fulltext

Freestanding emergency departments are becoming more and more common across the United States. Here at MCHD, we feel that EMS transport to these sites can be beneficial to both our system and the community as well. During today's episode, Dr. Patrick is joined by multiple hospital partners for some enlightening FSED myth-busting.

Thankfully, we finally have some positive COVID-19 news to discuss. Join the medical directors for a discussion of vaccine basics and some of the specific issues EMS and public health will likely encounter with COVID-19 vaccine administration.

REFERENCES 1. https://podcasts.apple.com/us/podcast/stimulus/id1501107371?i=1000494006283 2. https://www.chop.edu/centers-programs/vaccine-education-center/making-vaccines/prevent-covid 3. https://www.cdc.gov/vaccines/imz-managers/downloads/COVID-19-Vaccination-Program-Interim_Playbook.pdf

We’ve discussed burnout on the podcast in the past. When thinking about ways to combat burnout, a word that often comes up is resilience. Emergency care was stressful enough, then 2020 decided to add COVID to the mix. Join the podcast crew and special guest Kris Kaull as we talk about ways to foster resilience as an EMS provider which will hopefully extinguish burnout before it spreads.

REFERENCES 1. https://www.kevinmd.com/blog/2020/08/7-habits-of-highly-resilient-physicians.html

https://www.amazon.com/When-Breath-Becomes-Paul-Kalanithi/dp/081298840X/ref=sr_1_1?crid=2O1RTLPJFYHVE&dchild=1&keywords=breath+becomes+air&qid=1604872706&sprefix=breath+be%2Caps%2C191&sr=8-1
https://podcasts.apple.com/us/podcast/the-accumulation-of-marginal-gains-with-salim-rezaie/id1501107371?i=1000487654581

When Breath Becomes Air

Sometimes in medicine, we do things just because they’ve always been done that way, which is terrible reasoning. Valsalva maneuver followed by the two-syringe technique for adenosine administration has been standard practice in PSVT management for decades. Recent data suggests that both of these approaches may have better alternatives. Join Dr. Patrick and Brad Ward as they provide updates on both non-pharmacologic and pharmacologic management of PSVT.

REFERENCES 1. McDowell M et al. Single-Syringe Administration of Diluted Adenosine. Acad Emerg Med 2020, Jan;1:62-63.

Choi SC et al. A Convenient Method of Adenosine Administration for Paroxysmal Supraventricular Tachycardia. J Korean Soc Emerg Med 2003, Aug;14(3):224-227.
Weberding NT, Saladino RA, Minnigh MB, et al. Adenosine administration with a stopcock technique delivers lower-than-intended drug doses. Ann Emerg Med 2018;71:220–4.
https://www.youtube.com/watch?v=8DIRiOA_OsA

If there is one topic that we love at MCHD, it’s discussing bolus dose nitroglycerin in acute pulmonary edema patients. We’re lucky to have more positive evidence supporting it’s use thanks to Mike Perlmutter and his colleagues from North Memorial in Minneapolis. Join Dr. Patrick and Mike as they geek out over high dose nitrate use in EMS.

REFERENCES 1. https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/prehospital-treatment-of-acute-pulmonary-edema-with-intravenous-bolus-and-infusion-nitroglycerin/B7B78C8CC0A32A2E0048AECCC177DF69/share/3b38ce9a134027bde58af415173c72b9f3fe8ac4

https://www.tandfonline.com/doi/full/10.1080/10903127.2020.1711834

When thinking of what strikes fear in paramedics, most would think of answers like pediatric arrests, precipitous deliveries, and unstable bradycardias. A hidden source of misery here at MCHD is the fear of the oral scenario exams for advancement. Yes, these are artificial and do not always reflect reality, but they are a necessary evil. Join Dr. Dickson and Dr. Patrick as they try and provide some framework for attacking and succeeding when taking oral scenario exams.

REFERENCES https://www.mchd-tx.org/wp-content/uploads/2020/09/MCHD-Oral-Board-Prep-Sheet.pdf

The capnography tracing is an excellent tool that gives us insight into cellular metabolism, perfusion, and ventilation. This can yield vital information in multiple critical patient care decision processes. Join Dr. Patrick and Dr. Dickson as they walk through some ETCO2 interpretation basics. We are limited on the amount of objective information available during prehospital care, don’t ignore this vital piece of our puzzle.

REFERENCES 1. https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/utilizing-endtidal-carbon-dioxide-to-diagnose-diabetic-ketoacidosis-in-prehospital-patients-with-hyperglycemia/DE85722FCDD5C24D7949C2FCCBC58E99

http://www.emdocs.net/interpreting-waveform-capnography-pearls-and-pitfalls/

Join Dr. Dickson and our esteemed colleagues from across the globe to hear how their systems have responded to the COVID-19 pandemic and what they have learned from the experience thus far. Dr. Colin Graham is an EM specialist from Hong Kong who practiced there for the first SARS outbreak and is now tackling Corona Part 2. Additionally, we’ll be joined by Dr. Al Meyer, an EM specialist in Melbourne, Australia. This episode truly gives us a worldwide COVID-19 perspective.

Colin Graham qualified from the University of Glasgow in 1994 and completed basic surgical training and then specialist training in emergency medicine in Scotland. He came to the Accident and Emergency Medicine Academic Unit at the Chinese University of Hong Kong in 2004; he was promoted to Professor in 2007 and was appointed Director in 2015. He has broad research interests within emergency medicine and has published widely. Dr. Graham is an active clinical teacher and he co-authors the Oxford Handbook of Emergency Medicine. He is also currently Editor-in-Chief of the European Journal of Emergency Medicine (since 2009) and has served on the Executive and Council of the European Society for Emergency Medicine. Dr. Graham was elected to the Council of the Hong Kong College of Emergency Medicine in 2013 and 2016 and has served as Dean of Students at Morningside College in CUHK since 2016.

Dr. Alastair Meyer completed his specialist training in emergency medicine in Scotland and has worked in academic emergency medicine in Melbourne Australia. He is currently the emergency department director at Casey Hospital in Melbourne. He has numerous peer reviewed publications and has lectured both with AU and internationally. Dr. Meyer is an avid cyclist and word traveler in his spare time.

We're joined by a special guest, Dr. Jeff Jarvis, to talk about his recent PEC manuscript investigating potential life-saving interventions in the prehospital setting and their association with "lights and sirens" usage. Be prepared for some dogma challenging discussion!

REFERENCES: https://www.tandfonline.com/doi/abs/10.1080/10903127.2020.1797963

The firehose of information that is COVID-19 has slowed somewhat since we last discussed the pandemic, but the first wave has obviously persisted. On this episode, Dr. Patrick and Dr. Dickson address some of the recent COVID developments in treatment, return-to-work policy updates from the CDC and crazy complications seen in pediatric patients.

REFERENCES 1. https://www.cebm.net/covid-19/what-is-the-effectiveness-of-protective-gowns-and-aprons-against-covid-19-in-primary-care-settings/ 2. https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html 3. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/infographic-mis-c.html 4. https://www.nejm.org/doi/full/10.1056/NEJMoa2021436 5. https://www.nejm.org/doi/full/10.1056/NEJMoa2007764

We’ve discussed TXA, both for trauma and for epistaxis, on the podcast previously. Medics often ask about TXA in the acute GI bleed patients who are in hemorrhagic shock...“What can it hurt? It’s worth a try, right?” While TXA may seem like a harmless hail Mary, on this episode, Dr. Patrick reviews the HALT-IT study and discusses why TXA for acute GI bleeds is likely harmful and probably dead in the water as a treatment option.

REFERENCES: 1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30848-5/fulltext

This episode tackles the definition of "stupidity" and how this relates to prehospital medical care. Dr. Patrick is joined by Kris Kaull to discuss the definition of stupid, risk factors for making stupid moves and how to possibly prevent these in the EMS setting.

REFERENCES 1. Episode inspiration - https://fs.blog/2019/01/how-not-to-be-stupid/

Checklist Manifesto - http://atulgawande.com/book/the-checklist-manifesto/ https://www.amazon.com/gp/product/0312430000/
Avalanche TedX talk - https://www.youtube.com/watch?v=kWOgyyDUD2w

The Checklist Manifesto

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.

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.

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

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/

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

For the last couple months, we've been talking COVID-19 exclusively here at the MCHD Paramedic Podcast. On this episode, ops takes center stage with a discussion of our PPE/COVID-19 experience. We share our lessons learned and wish list for the future. Take a listen and please hit us up at podcast@mchd-tx.org if you have questions or experiences you'd like to share!

REFERENCES: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html

Unless you live under a rock, you've heard discussions of the pros and cons of using hydroxychloroquine (HCQ) when treating COVID-19 patients. On this episode, Dr. Patrick is joined by our favorite toxicologist, Dr. Jerry Snow, to talk about what happens in a HCQ ingestion situation. With the increased publicity of this drug, we must be on high alert in the prehospital setting for potential accidental and intentional overdoses. Listen and learn what to expect and how to treat someone who's taken too much HCQ...beware, these folks can tank quickly!!

We've had continued rapid local and national developments surrounding COVID-19. On this special release, the podcast crew reconvenes to update our listeners on the MCHD specific airway algorithm in the era of COVID-19.

REFERENCES: https://www.mchd-tx.org/wp-content/uploads/2020/04/MCHD-COVID-19-FINAL-AIRWAY-.pdf

We've had continued rapid local and national developments over the past week surrounding COVID-19. On this special release, the podcast crew reconvenes to update our listeners on the most current evidence surrounding airway management in the era of COVID-19.

REFERENCES 1. https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://emcrit.org/emcrit/some-additional-covid-airway-management-thoughts/
https://www.safeairwaysociety.org/covid19/
VALLEY, T ET AL. ASSOCIATION BETWEEN NONINVASIVE VENTILATION AND MORTALITY AMONG OLDER PATIENTS WITH PNEUMONIA. CRIT CARE MED. 2017 MARCH; 45(3): E246–E254.
NEWMAN KB, ET AL. A COMPARISON OF ALBUTEROL ADMINISTERED BY MDI AND SPACER WITH ALBUTEROL BY NEBULIZER IN ADULTS PRESENTING TO AN URBAN ED WITH ACUTE ASTHMA. CHEST. APRIL 2002;121:1036–41.

We've had rapid local and national developments over the past week surrounding COVID-19. On this special release, the podcast crew reconvenes to update our listeners on the most current evidence.

REFERENCES 1. https://www.cdc.gov/coronavirus/2019-ncov/index.html

Choking babies, seizing kids, and floppy infants turning blue...all of these events are significantly anxiety inducing for both emergency providers and families alike. On this episode, Dr. Patrick is joined by Dr. Manish Shah, a pediatric emergency medicine physician and research expert from Texas Children's Hospital. The discussion will begin with the finer points of febrile seizures and then branch off into the "artist formerly known as ALTE" - the BRUE. Follwing this episode you'll be much better prepared to deal with these patients along with their parents and families.

REFERENCES

https://www.aap.org/en-us/Documents/echo_session%201_seizures_overview.pdf
https://pediatrics.aappublications.org/content/pediatrics/127/2/389.full.pdf
https://pediatrics.aappublications.org/content/pediatrics/137/5/e20160590.full.pdf

We all love cardiac arrest with VF as the presenting rhythm. These are the ones that walk out of the hospital. But, what happens when you shock, shock, shock and still VF? Today the podcast team addresses refractory ventricular fibrillation/electrical storm and specifically the role of esmolol in this condition. Esmolol is an emerging treatment for refractory VF that makes absolute physiologic sense, however the data is limited. Dr. Patrick addresses the pathophysiology, evidence and MCHD’s approach this in episode 72.

REFERENCES 1. Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;32(8):111-21.

Lee YH, et al. Refractory ventricular fibrillation treated with esmolol. Resuscitation. 2016;107:150-155.
Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular brillation. Resuscitation. 2014;85(10):1337-41.

A proper sleeping environment is vital for infant safety. On this episode Dr. Patrick is joined by two "safe sleep" experts - MCHD's own, Aston Herring and Dr. Lisa Owens from Texas Children's Hospital. After listening, you'll know how to recognize what exactly constitutes unsafe sleep and more importantly understand the impact that sleep environment can have on otherwise healthy infants. Join us as we attempt to shine a light on a potentially deadly problem with surprisingly simple solutions.

REFERENCES 1. https://cribsforkids.org

https://pediatrics.aappublications.org/content/138/5/e20162938

3.https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/Safe-Sleep-for-Babies.aspx

Over the past week we’ve had several local false alarms with possible patients presenting with the 2019 Novel Coronovirus. On this special release, the podcast crew will discuss the impact of this worrisome viral infection on EMS providers.

REFERENCES 1. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

https://jamanetwork.com/journals/jama/pages/jama-author-interviews

Tracheostomy patients can be intimidating and confusing with complex recent medical histories and unfamiliar terminology surrounding the surgical hole placed in their neck. Join Dr. Patrick as he attempts to demystify the tracheostomy tube and provide a framework to utilize when approaching the crashing trached patient.

REFERENCES 1. http://www.tracheostomy.org.uk/storage/files/Patent%20Airway%20Algorith m.pdf

http://www.tracheostomy.org.uk
Mcgrath BA et al. Guidelines Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. N Anaesthesia 2012; 67 (9), 1025–1041.

While attending the 2019 Texas EMS Conference, Dr. Dickson and Chief Crocker were lucky enough to sit down with Dr. Jeff Jarvis from Williamson County EMS to discuss the background and evolution of the Texas CARES registry. We'll introduce the purpose of Texas CARES along with the ways in which it can benefit your service.

REFERENCES 1. https://tx-cares.com

Continuing with the dizziness theme for the 2019 holiday season, Dr. Dickson is joined on episode 67 by Dr. Jeremiah Johnson. Dr. Johnson is a neurosurgeon here in Montgomery County where he's the Director of the Comprehensive Stroke program at CHI-St. Luke's Hospital in The Woodlands. We all recognize the combination of aphasia with face and extremity weakness that occurs in anterior circulation strokes. But, how do posterior strokes present? How common are they? Are posterior strokes time sensitive and amenable to TPA and/or clot retrieval in the same manner as anterior strokes? For answers to all these questions and many more, take a listen and hear from a true expert in the rapidly advancing field of endovascular treatment for acute stroke.

Join Dr. Dickson as he takes a trip down under to talk with Dr. Alastair Meyer about the often dreaded chief complaint of dizziness. Dr. Meyer is the Director of Emergency Medicine for Monash Health in Melbourne. The differential diagnosis for the commonly encountered dizzy patient is broad and consists of many non-emergent conditions along with deadly pathology as well. This combination can be a recipe for disaster. This episode will leave listeners with the deadly dizzy diseases and a framework to approach your next dizzy run.

Our population is aging, and heart failure is only going to increase. This will inevitably lead to an increase of patients with left ventricular assist devices. New technology can be intimidating and confusing with complex recent medical histories and unfamiliar terminology surrounding the various LVAD brands. Join the podcast crew as we attempt to simply an EMS approach to the LVAD patient.

REFERENCES: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123099/pdf/wjem-19-834.pdf

https://emj.bmj.com/content/34/12/842.long
Goebel et al. (2019) An Urban 9-1-1 System’s Experience with Left Ventricular Assist Device Patients, Prehospital Emergency Care, 23:4, 560-565
Shinar et al. Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation. 2014;85(5):702-704

MCHD is excited for the county wide roll out of the PulsePoint app. Community Outreach Coordinator, Ashton Herring, joins Dr. Patrick to discuss the importance of bystander CPR in increasing survival in cardiac arrest patients. After listening, download PulsePoint and let’s get hands on chest as quickly as possible which we know is a recipe for saving lives.

REFERENCES 1. https://apps.apple.com/us/app/pulsepoint-respond/id500772134

On this episode, Dr. Patrick and MCHD Paramedic Podcast toxicologist extraordinaire, Dr. Jerry Snow, pick up where they left off in our recent discussion of the classic toxidromes. We'll branch out into some topics that veer from the textbook such as the Alpha 2 agonists that can mimic opiate toxicity and why toxicologists fear methadone ingestions. We'll also touch on some "tox" current events such as vaping associated pulmonary injury, imodium overdoses and why this is an increasing phenomenon, and finally a brief discussion of kratom chemistry and overdose findings.

REFERENCES: 1. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

Dr. Patrick is joined by two medics on the MCHD recruitment committee, Megan Steely and Russell Carter, to discuss the components of the "next generation" medic. We also dive in to the nuts and bolts of the EMS service of the future as well. Schedule options, compensation issues, service offerings and atmosphere are all addressed during this wide ranging conversation. Only the surface is skimmed here, so please drop a line to the podcast email if you have additional similar/related topics you'd like us to expound on in future podcasts.

We're excited to announce a new educational offering - MCHD Paramedic Podcast 360. There are many topics in paramedic/EMT education better taught with visual adjuncts that the podcast format cannot provide with audio alone. Podcast 360 will be hosted on the MCHD YouTube channel (see link below) and contain brief, high yield content similar to what you get here at the MCHD Paramedic Podcast. Please subscribe to the channel and check out our initial episode - STEMI Diagnosis.

MCHD YouTube Channel: https://www.youtube.com/channel/UC8BURiknprMC92a4mw7Krkw/videos

We’ve recently rolled out a new epistaxis treatment protocol here at MCHD. Join the podcast team as we discuss some nosebleed background information along with the classic and emerging treatment options. Did somebody say TXA?? Yep, we have TXA and this is a perfect opportunity introduce the MCHD epistaxis/TXA treatment protocol. It’s simple, cheap and minimally invasive. With rapidly accumulating evidence that we will improve patient centered outcomes using this treatment, this is an episode that you don’t want to miss.

REFERENCES: 1. Klepfish A, Berrebi A, Schattner A. Intranasal tranexamic acid treatment for severe epistaxis in hereditary hemorrhagic telangi- ectasia. Arch Intern Med 2001; 161: 767. 2. Gaillard S, Dupuis-Girod S, Boutitie F, Rivi ere S, Morini ere S, Hatron PY, Manfredi G, Kaminsky P, Capitaine AL, Roy P, Gueyffier F, Plauchu H, for the ATERO Study Group. Tranexamic acid for epistaxis in hereditary hemorrhagic telangiectasia patients: a European cross-over controlled trial in a rare disease. J Thromb Haemost 2014; 12: 1494–502. 3. Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med 2013;31:1389–92. 4. Birmingham AR, Mah ND, Ran R, et al. Topical tranexamic acid for the treatment of acute epistaxis in the emergency department. Am J Emerg Med. 2018;36:1242-1245. 5. Zahed R, Mousavi, Jazayeri MH,Nader iA,et al.Topical tranexamic acid compared with anterior nasal packing for treatment of epistaxis in patients taking antiplatelet drugs: randomized controlled trial. Acad Emerg Med. 2018;25:261-266. 6. Akkan, Sedat et al. Evaluating Effectiveness of Nasal Compression With Tranexamic Acid Compared With Simple Nasal Compression and Merocel Packing: A Randomized Controlled Trial. Annals of Emergency Medicine, Volume 74, Issue 1, 72 - 78 7. Min, H. J., Kang, H., Choi, G. J., & Kim, K. S. (2017). Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis. Otolaryngology–Head and Neck Surgery, 157(6), 921–927. 8. Kikidis D, Tsioufis K, Papanikolaou V, Zerva K, Hantzakos A. Is epistaxis associated with arterial hypertension? A systemic review of the literature. Eur Arch Otorhinolaryngol. 2014; 271(2):237-243

This episode takes us back to the basics of toxic ingestions and poisonings to review the topic of toxidromes. Why do we look for specific patterns in poisonings and what are we looking for? Dr. Patrick and podcast toxicology expert, Dr. Jerry Snow, will take us through the major toxidrome groups and you’ll come out on the other side ready to sort through your next undifferentiated overdose patient.

REFERENCES: 1. http://www.emdocs.net/the-approach-to-the-poisoned-patient/ 2. https://litfl.com/high-dose-insulin-euglycaemic-therapy/ 3. Toxidromes. Holstege CP, Borek HA. Crit Care Clin. 2012 Oct;28(4):479-98.

On this episode, the medical directors are joined by the MCHD car seat guru, Ashton Herring. The leading cause of death in children is motor vehicle related trauma. We’ll start with some background of the car seat laws that exist here in Texas and how MCHD works in the local community to increase car seat awareness. Ashton will also educate us on some common errors that parents make when installing car seats. In closing, we’ll discuss several excellent resources for car seat education.

REFERENCES: 1. https://safekids.org

https://www.chop.edu/centers-programs/car-seat-safety-kids
https://pediatrics.aappublications.org/content/142/5/e20182460
https://csftl.org

REBOA is a hot topic in the world of emergency medicine and prehospital trauma care. Join the medical directors for a review of “resuscitative endovascular balloon occlusion of the aorta.” We’ll discuss the basics, the anatomy, the complications and the evidence. Who is doing this in the EMS world and what are their results? We’ll answer that question along with looking to future possibilities as well.

References: 1. Brenner M, Inaba K, Aiol A, et al. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry. J Am Coll Surg. 2018;226(5): 730–740. 2. Lendrum, Robbie et al. Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation. 2019. Volume 135, 6 – 13. 3. Osborn LA, Brenner ML, Prater SJ, Moore LJ. Resuscitative endovascular balloon occlusion of the aorta: current evidence. Open Access Emerg Med. 2019;11:29–38. Published 2019 Jan 14.

We’ve discussed airway management and our MCHD delayed sequence approach on past podcast episodes. On this episode, join the medical directors as they take a scenario based, deep dive into the finer points of tackling the difficult airway.

REFERENCES: 1. https://m.youtube.com/watch?v=wVQFJR7qmrQ

The evolution of emergent stroke care has rapidly evolved over the past decade. With the increased emphasis on recognizing large vessel occlusion (LVO) strokes, communication and cooperation between EMS and our receiving hospitals has become vital. On this episode, Dr. Dickson is joined by an expert group of neurointerventionalists to discuss the current literature and guidelines shaping stroke management standard of care in 2019.

REFERENCES: 1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00163-X/fulltext

https://www.nejm.org/doi/full/10.1056/nejmoa1706442
https://www.nejm.org/doi/full/10.1056/NEJMoa1713973
https://www.ahajournals.org/doi/full/10.1161/STR.0000000000000158

Last year, we rolled out the MCHD “ROSC to Cath” protocol via the podcast. Recently, some compelling data from the COACT trial has led us to reassess and reconsider this protocol. On this episode, Dr. Patrick reviews COACT and discusses the MCHD changes coming as a result.

REFERENCES: 1. https://www.nejm.org/doi/full/10.1056/NEJMoa1816897

http://clinicaltrialresults.org/Slides/ACC2019/Lemkes_COACT.pdf

During a recent continuing education session at MCHD, one of the educational points of emphasis was recognizing and reporting human trafficking as a paramedic/first responder. The podcast crew was lucky enough to have Sarah Koransky, from United Against Human Trafficking (UAHT), join us to share some of the key points when encountering this vulnerable patient group. Sarah is knowledgable and passionate about this cause and she has loads of high yield information to share on this episode.

REFERENCES 1. United Against Human Trafficking www.uaht.org 713-874-0290

National Human Trafficking Hotline www.nationalhumantraffickinghotline.org 888-373-7888
HEAL Trafficking www.healtrafficking.org
Department of Homeland Security’s Blue Campaign https://www.dhs.gov/blue-campaign

Vital signs are called vital for a reason. On this episode, Dr. Patrick takes us through a differential for the workup of sinus tachycardia. This is a finding that we see daily in our practice, but often lack a step-wise approach when managing these patients.

REFERENCES: 1. Bossart P, Fosnocht D, Swanson E. Changes in heart rate do not correlate with changes in pain intensity in emergency department patients. J Emerg Med. 2007;32(1):19–22.

Marco CA, Plewa MC, Buderer N, Hymel G, Cooper J. Self-reported pain scores in the emergency department: lack of association with vital signs. Acad Emerg Med. 2006;13(9):974–979.
https://www.ncbi.nlm.nih.gov/pubmed/19700579

We've addressed the ten most commonly encountered medications seen in EMS on a prior podcast. In this episode, Brad Ward joins Dr. Patrick to focus on a less common, but often more impactful group of medications, the antiplatelets and anticoagulants. The combination of complex pharmacology and some relatively new drugs in both classes, make this an area prime for discussion and review.

REFERENCES 1. https://www.ajemjournal.com/article/S0735-6757(12)00169-6/pdf

http://www.emdocs.net/emin5-noacs-novel-oral-anticoagulants/

We have been fortunate here at MCHD to develop an ongoing educational partnership with Victoria University in Melbourne, Australia. A group of 11 paramedic students and instructors just finished a three-week study-abroad program here in the Greater Houston area. The podcast crew thought this would be the perfect chance for our Aussie colleagues to discuss the differences and similarities between EMS practice and education in Australia versus the United States. Our paramedic education supervisor, Lee Gillum, joins the podcast today to talk about how this international relationship started and the ways it has benefited the teachers and students alike.

REFERENCES 1. https://www.yourconroenews.com/neighborhood/moco/news/article/Montgomery-County-Hospital-District-welcomes-13894356.php

In recognition of EMS Week 2019, the MCHD Paramedic Podcast crew decided to directly address one of the most pressing issues in current EMS practice – paramedic and EMT wellness and burnout prevention. Dr. Remle Crowe, Research Scientist and Project Manager with ESO, joins the podcast to lend her tremendous burnout expertise. Burnout is a fluid and dynamic process that varies with time and the individual. Therefore, proactive prevention techniques have to be flexible and adaptable as well. After listening to this episode, you’ll be armed with multiple tools to recognize and attack burnout within your EMS system.

REFERENCES 1. Remle P. Crowe, Julie K. Bower, Rebecca E. Cash, Ashish R. Panchal, Severo A. Rodriguez & Susan E. Olivo-Marston (2017): Association of Burnout with Workforce-Reducing Factors among EMS Professionals, Prehospital Emergency Care, DOI: 10.1080/10903127.2017.1356411

Tage S. Kristensen, Marianne Borritz, Ebbe Villadsen & Karl B. Christensen (2005) The Copenhagen Burnout Inventory: A new tool for the assessment of burnout, Work & Stress, 19:3, 192-207, DOI: 10.1080/02678370500297720

Dr. Patrick and Dr. Dickson pick up where they left off on our Back to the Basics COPD Part 1 episode. We’ll delve further into the differential diagnosis one must consider when treating patients with dyspnea and discuss some of the chameleons that can masquerade as COPD. Many of our COPD patients are far from straight forward with multiple co-morbidities. After listening, you’ll run your next dyspnea call with a clear plan and more confidence.

This episode takes us back to the basics of COPD pathophysiology and treatment. Dr. Dickson and Dr. Patrick start with the differential diagnosis of wheezing and move through the escalating COPD treatment options. We then close with a review of common abnormal breath sounds and set the stage for COPD Part 2 which will be coming soon.

References: 1. http://citeseerx.ist.psu.edu/viewdoc/download doi=10.1.1.624.2777&rep=rep1&type=pdf 2. Ram, et al. NIPPV for treatment of respiratory failure due to exacerbations of COPD. Cochrane Database Syst. Rev. 2004 3. https://www.easyauscultation.com/lung-sounds

One of the most difficult situations in prehospital care is the high-risk patient refusal of EMS transport. This topic is far from straight forward for both learners and teachers alike. Dr. Patrick introduces a brand new mnemonic that will, hopefully, alleviate your FEARS the next time you care for a complex patient that decides hospital transport just isn’t in the cards.

This episode is loaded with tactical EMS pearls. Houston Fire Department Assistant Medical Director, Dr. Kevin Schulz, joins the podcast again to lend his TEMS expertise. MCHD’s tactical leader, Patrick Langan, leads the discussion and provides a Montgomery County perspective.

Managing markedly elevated blood pressures has to be one of the most common EMS clinical dilemmas. Dr. Dickson joins Dr. Patrick to help dispel some long-standing and persistent hypertension management myths. The concept of “end organ damage” is also introduced as a framework to properly identify those patients with elevated blood pressures who DO warrant emergent treatment in the prehospital setting.

With the explosion continuing education options, how do we decide who and what to believe? Dr. Tony Seupaul, evidence based medicine expert, joins the podcast crew to discuss tips on how to best manipulate and master medical information in the social media/FOAMed era. We touch on the hierarchy of medical evidence, provide clues on how to best spot flimsy evidence, and tout some of our favorite sites and Apps to add to your educational armamentarium.

References:

Hierarchy of medical evidence - https://canberra.libguides.com/c.php?g=599346&p=4149721
www.tripdatabase.com
www.thennt.com
www.bestbets.org
www.rebelem.com
www.litfl.com
www.thesgem.com
www.emcrit.org
www.coreem.net
ACEP Toxicology App - https://itunes.apple.com/us/app/acep-toxicology-section-antidote/id959303490?mt=8
MD Calc App - https://itunes.apple.com/us/app/mdcalc-medical-calculator/id1001640662

The MCHD Podcast Crew just received word that we have a documented measles case here in Montgomery County. We decided to try and get out in front of this story and provide our listeners with some basic information on clinical presentation, transmission and prevention of the measles virus.

References: 1. https://www.cdc.gov/measles/index.html 2. https://www.cdc.gov/measles/about/signs-symptoms.html 3. https://phil.cdc.gov/details.aspx?pid=132

The MCHD Paramedic Podcast wants to help all of our listeners stay up to date. Earlier this year, we discussed TXA (Tranexamic Acid) following our MCHD TXA protocol roll-out. New TXA research just popped up on the radar, join Dr. Patrick for a quick journal club discussion of the Cal-PAT study.

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225940/pdf/wjem-19-977.pdf

Despite Dr. Patrick's fear, we're delivering the second installment of our Obstetrics series. This is a potentially frightening topic that was actually requested by several MCHD medics. Part one focused on emergencies encountered prior to delivery and part two progresses into difficult deliveries and the postpartum period.

References: http://www.emdocs.net/the-complicated-delivery-what-do-you-do/ https://coreem.net/core/shoulder-dystocia/

Join Dr. Patrick for a “phast” pharmacology update on hydromorphone/dilaudid. We’ll discuss its uses, relative strength, side-effects and the future role of dialudid at MCHD.

Continuing with our recent theme of increased fire related inhalational risks with colder weather, MCHD Paramedic Podcast toxicology guru, Dr. Jerry Snow, joins us again to discuss cyanide poisoning. We’ll discuss ways to recognize cyanide toxicity and when to empirically treat. Combining this episode with our recent carbon monoxide podcast will make you razor sharp when you run on your next house fire.

References:

Curry, Steven C., and Meghan B. Spyres. "Cyanide: hydrogen cyanide, inorganic cyanide salts, and nitriles." Critical care toxicology (2016): 1-21.
Purvis, M. V., et al. "Prehospital hydroxocobalamin for inhalation injury and cyanide toxicity in the United States-analysis of a database and survey of ems providers." Annals of burns and fire disasters 30.2 (2017): 126.
Kaita, Yasuhiko, et al. "Cyanide poisoning is a possible cause of cardiac arrest among fire victims, and empiric antidote treatment may improve outcomes." The American journal of emergency medicine 36.5 (2018): 851-853.
Parker-Cote, J. L., et al. "Challenges in the diagnosis of acute cyanide poisoning." Clinical Toxicology 56.7 (2018): 609-617.

Dr. Patrick is joined today remotely by toxicologist and friend of the podcast, Dr. Jerry Snow, to talk about the nuts and bolts of Carbon Monoxide poisoning. All of your questions are answered - from the use of portable CO devices, to the presentation and recognition of CO poisoned patients. We’ll hit on all the cold weather, carbon monoxide high yield information.

Dr. Patrick and Clinical Manager Jordan Anderson run down the 10 most commonly prescribed medications in the US. The medication list can often feel like one more task that’s always partial and incomplete. Jordan and Dr. Patrick try to take a more detective-like approach to demonstrate the utility of anticipating side-effects and potential diagnoses based on medication list clues.

References: 1. http://discovermagazine.com/2010/mar/07-dr-drank-broth-gave-ulcer-solved-medical-mystery 2. Gomes T, et al (2017) Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case–control study. PLoS Med 14(10): e1002396

Shownotes: Cardiovascular medication poisoning can produce markedly unstable patient presentations. Dr. Patrick and Brad Ward review some of the basics and more recent therapeutic developments in the treatment and management of beta-blocker and calcium channel blocker toxicity.

References:

St-Onge M, Anseeuw K, Cantrell FL, et al. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Critical Care Medicine. 2017;45(3):e306-e315.
Wax P, Erdman A, Chyka P, et al. Beta-blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005; 43(3):131-146.

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.

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.

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.

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:

Tran DT et al. Rocuronium Versus Succinylcholine for Rapid Sequence Induction Intubation. Cochrane Database Syst Rev 2015.
Shoenberger JM, Mallon WK. Rocuronium Versus Succinylcholine Revisited: Succinylcholine Remains the Best Choice. Ann Emerg Med 2018; 71(3): 398-9.
Swaminathan A, Mallemat H. Rocuronium Should Be the Default Paralytic in Rapid Sequence Intubation. Ann Emerg Med 2018; 71(3): 397-8.

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/

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.

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:

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.
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.
Ranieri VM, Rubenfeld GD, Thompson BT, et al. The ARDS definition task force. Acute respiratory distress syndrome. JAMA 2012;307:2526–2533.
(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.
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
Turner JS, et al. Feasibility of upright patient positioning and intubation success rates at two academic emergency departments, American Journal of Emergency Medicine 2017.
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.

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.

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.

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.

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

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.

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/

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

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

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.
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.
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.

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

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

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

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

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.

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/

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

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.
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.
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.
Peacock WF et al. Morphine and Outcomes in Acute Decompensated Heart Failure: An ADHERE Analysis. Emerg Med J 2008; 25: 205 – 209.

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/

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

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

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.

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!

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

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

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

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.

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.

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.

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.

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

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

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

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

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