Hot Topics in EMS: Recent Episodes
Montgomery County EMIHS
Happy EMS Week! In this episode, Dr. Chizmar and Captain Tipton go over the July 1 protocol changes in detail.
Joint Statement on Lights & Siren Vehicle Operations
Using Red Lights and Sirens for Emergency Ambulance Response: How Often Are Potentially Life-Saving Interventions Performed?
Joint Position Statement on EMS Performance Measures Beyond Response Times
Veronica video
NEMSQA Lights and Sirens Podcasts
Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes
Paramedic Chiefs of Canada Abstract: Lights and Sirens; Is It Worth the Risk?
Written by Eric Jaeger, JD, NRP, EMS IC, July 2024
AP News and PBS Frontline Lethal Restraint Reporting
Over the last several months, the AP News and PBS Frontline have published a series of stories, linked below, on death in custody and the role of EMS sedation. In a multi-year investigation, they uncovered over 1000 deaths across the United States due to lethal restraint involving police and, in some cases, EMS. Chemical sedation by EMS was involved in nearly 100 of these deaths. I encourage you to review these stories; they demonstrate increasing attention on this issue by the public and they reveal that the scope of the issue is larger than previously realized.
PBS Frontline: Documenting Police Use of Force
(note this links to the story where it discusses EMS sedation; for the full documentary click here).
AP News: How the medical syringe became a tool of control when police restrain people
AP News: Dozens of deaths reveal risks of injecting sedatives into people restrained by police
AP News: At least 15 people died in Texas after medics injected sedatives during encounters with police
AP News: At least 16 people died in California after medics injected sedatives during encounters with police
Key Takeaways
Large Number of Deaths
This reporting expands significantly the number of individuals who are known to have died after EMS sedation. (Note: We have no reason to believe that sedation was a cause of death in all of these cases; only that the individuals received sedation prior to death.)
Criminal Charges & Civil Liability for EMS Providers
Two paramedics have been found guilty in a criminal trial involving use of ketamine. Prosecutors seem more willing to hold paramedics and police officers criminally liable for their conduct. In addition, dozens of EMS providers and agencies have been the subject of civil lawsuits arising from deaths in custody, with payouts of over $100 million.
Increased Public Attention and Scrutiny
While the AP News and PBS Frontline stories are the largest reporting project on this topic, many other reporters across the country are now focusing on issues related to death in custody and the role of sedation by EMS.
It's NOT the Ketamine; The Problem is the Overall Approach to Prehospital Sedation
While 20% of the deaths involved ketamine, nearly 50% involved midazolam. This leads to the conclusion that the problem is not ketamine per se, but rather our overall approach to prehospital sedation.
I strongly believe that to address these issues, we must radically reframe the approach to prehospital chemical sedation. Protocols for physical restraint and chemical sedation should be rewritten (not just tweaked). And all EMS providers should receive updated training that focuses on prehospital sedation as a deliberate, protocolized procedure, following the model of RSI or ED procedural sedation. While classroom training is helpful, in my experience hands-on simulations are key to helping EMS providers relearn the approach to this important topic.
I'm continuing to focus on this topic, including providing virtual and in-person training at agencies and EMS conferences across the country. Please let me know if you are aware of speaking opportunities that might be appropriate. And please reach out if I can be helpful in any way.
This is an update from our Mobile Integrated Health team including manager Avital Graves and our new MIH medics, Simon Marteli and Joseph Lee.
Dextrose
https://www.ncbi.nlm.nih.gov/pubmed/2029097
https://www.ncbi.nlm.nih.gov/pubmed/17763842
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415309/
https://www.ems1.com/cardiac-care/articles/prove-it-administering-dextrose-during-cardiac-arrest-improves-outcomes-9FP6hslyU2OFNrCX/
https://www.foamfrat.com/post/hypoglycemia-in-cardiac-arrest
Ketamine
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9014273/
https://www.sciencedirect.com/science/article/abs/pii/S0300957217300394
https://pubmed.ncbi.nlm.nih.gov/35586308/
https://www.cfp.ca/content/64/7/514.short
https://pubmed.ncbi.nlm.nih.gov/15928464/
https://www.webmd.com/heart-disease/what-to-know-agonal-breathing
https://www.mdpi.com/1660-4601/20/4/3654
It's not as rare as you might think. We are joined by Camie Bruhweiler from Shady Grove who discusses a profound increase in incidence of this life threatening process that includes symptoms often written off by new moms.
Video – how to fill out an operational support report
TSR - to request an MDC key
What I read:
Dr. Maia Dorsett - NAEMSP
PEC article
JEMS article
SCTEMS blog
Protocol
Abstract: Exploring Competencies For the Family Facilitator During Resuscitation
Know the Risks - Opioids
General Order 22-04 - Leave-Behind Naloxone
Leave behind naloxone program details
https://www.emra.org/emresident/article/naloxone-in-cardiac-arrest/
https://criticalcarenow.com/naloxone-in-opioid-associated-cardiac-arrest-2/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4982449/
https://emergencymed.arizona.edu/faq/why-shouldn’t-i-just-give-all-cardiac-arrests-narcan-it’s-not-going-hurt-them-right
https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958
http://www.emdocs.net/sodium-bicarbonate-therapy-does-not-work-in-cardiac-arrest/
https://emergencymedicine.wustl.edu/items/sodium-bicarbonate-administration-in-cardiac-arrest/
https://rebelem.com/sodium-bicarbonate-in-cardiac-arrest-management/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780490/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864130/
https://litfl.com/sodium-bicarbonate-use/
https://www.sciencedirect.com/science/article/abs/pii/S0300957217303337
https://www.sciencedirect.com/science/article/abs/pii/S0735675705003141
https://www.sciencedirect.com/science/article/abs/pii/S0300957221000939
https://pubmed.ncbi.nlm.nih.gov/33662526/
https://pubmed.ncbi.nlm.nih.gov/36403820/
https://rebelem.com/rebel-cast-ep106-the-coca-trial-calcium-in-cardiac-arrest/
This is just the beginning... we're only looking at the rabbit hole. Grab some coffee. Start at the top.
Summary of research
NAEMSP Position Statement - Cardiac Arrest
NAEMSP Position Statement - Supraglottic Airways
PART Trial
Airways-2 Trial
CAAM Trial
Fewer intubation attempts is associated with improved outcomes
Here are several education resources targeting community clinicians / first responders:
- This is the link to the current PDF version of the EMS field guide document: https://www.mylvad.com/sites/default/files/EMS%20Field%20Guides/2021%20Field%20Guides/ICCAC_Emergency_Guides_20_21-1.pdf
- The Emergency care of a HM3 is a pamphlet created by the manufacturer.
- The MedStar ED LVAD Job Aid has the on call coordinator pager number. It is a challenge to use in the field if the scene is noisy. The call is “answered” by a computer that says, “enter your numeric message”. The action required is that the responder uses the phone key pad to put in the 10 digit phone number you want the vad coordinator to call. Turn around time is 2 – 3 minutes. We have patients and caregivers practice paging. If you or someone on your team would like to practice so the first time using the system is not during an emergency, please do so but say quickly when we answer that it is just a test.
We are joined by Paramedic Robert Gold to tell us about his first time using telehealth
We are joined by BC Dave Sabat and Dr. Matt Levy from Howard County to discuss cardiac arrest care during the Covid era.
Link to the field resource guide
These two videos show me connecting to telehealth with a Sonim phone. The connection method is up to doctor and depends on the device she/he is using:
Text method video
Input method video
And... we got music!
This podcast provides an overview of the MCFRS MIH team and the great work they are doing through innovative programs.
In this episode BC Kaufman and MFP Touzeau review troubleshooting measures to improve first pass success when using the Airtraq video laryngoscope.
Process checklist
Here's the 5 minutes airway article- really cool videos and it won't take long, we promise.
Here's a glimpse at some of the great work that's being done.
Video 1 - Midline insertion, great view of the hyoepiglottic ligament, great view of the glottis, successful tube placement. This would have been even better if a tube introducer had been used.
Video 2 - Look how easy the bougie makes it! The Coude tip affords so much flexibility and forgiveness if blade placement isn't absolutely perfect.
We discuss the ALS to BLS downgrade process in the context of Fire Chief's General Order 20-07.
In this episode BC Kaufman and MFP Touzeau review techniques to improve first pass success when using the Airtraq video laryngoscope.
Check out the Airtraq training module prior to listening to the podcast, if possible.
Here's the 5 minutes airway article - really cool videos and it won't take long, we promise.
Here's a glimpse at some of the great work that's being done.
Video 1 - Midline insertion, great view of the hyoepiglottic ligament, great view of the glottis, successful tube placement. This would have been even better if a tube introducer had been used.
Video 2 - Look how easy the bougie makes it! The Coude tip affords so much flexibility and forgiveness if blade placement isn't absolutely perfect.
In this episode BC Kaufman and MFP Touzeau review techniques to improve first pass success when using the Airtraq video laryngoscope.
Check out the Airtraq training module prior to listening to the podcast, if possible.
Here's the 5 minutes airway article - really cool videos and it won't take long, we promise.
You'll find a READ-DO checklist on page three of the training file.
Check out the Appendix and infographic!
IRP Appendix U – Cardiac Arrest Management
SPASM Infographic
This is reposted from the original distribution back in July 2020 right before we added Toradol.
Obtain 0.75 hours of ALS continuing education by taking this quiz.
Click here to view completed podcost con ed.
This is reposted from the original distribution back in July 2020 right after we added ketamine.
Obtain 0.5 hours of ALS continuing education by taking this quiz.
Click here to view completed podcost con ed.