Office of the Chief Medical Officer of the City of Austin, Texas
Official blog of the ATCEMS System OCMO
Today I sit down with Dr. Joseph Martin, (IG: @JaTXerd) a Family Practice and Addiction Specialist who is now an EMS physician, to talk about mental health in our first responders. Spoiler alert: it has a lot to do with sleep deprivation, uncertainty, community, and organizational support.
Today I sit down with Dr. Joseph Martin, (IG: @JaTXerd) a Family Practice and Addiction Specialist who is now an EMS physician, to talk about mental health in our first responders. Spoiler alert: it has a lot to do with sleep deprivation, uncertainty, community, and organizational support.
Cold weather incoming! This is just a quick review of carbon monoxide poisoning treatment options, as well as what differentiates cold water immersion from regular drowning.
We anticipate an increase in the number of Carbon Monoxide (CO) related calls in the system as people use charcoal grills and generators for heating. Symptoms include headache, nausea, vomiting, dizziness, syncope, altered mental status, and neurologic symptoms such as weakness, numbness, or paresthesia. During these winter events we frequently have calls with multiple patients.
Anyone with RED FLAGS should be treated with 100% oxygen and transported to the hospital. These include:
Pregnancy
Cardiac history like arrhythmia, MI, CHF
Significant pulmonary history like COPD or pulmonary fibrosis
Neurological symptoms, even mild ones like paresthesias or numbness
Altered mental status
Emotional changes, which could be indicative of altered mental status
Chest pain
Difficulty breathing
Neurologic symptoms may be subtle so it is vital that you do a thorough neurologic exam and ask specifically about numbness, tingling, and weakness.
Treatment for CO poisoning is administration of 100% oxygen. For those with priority symptoms, hyperbaric treatment may be indicated.
CO >25%: Start 100% oxygen and transport to the hospital, regardless of whether or not they have red flags.
CO <25%: Start 100% oxygen. If they have red flag symptoms, transport to the hospital. If no red flags, may treat in place with oxygen until symptoms resolve and then complete a refusal.
CO <15% with no symptoms: No treatment or transport is indicated.
Consider STARFlight and direct transport to University Hospital in San Antonio for hyperbaric treatment for anyone with elevated CO level who is severely ill (unconscious, arrest with ROSC, stroke-like symptoms)
Sometimes a small dose of epinephrine or norepinephrine can keep a patient from becoming hypotensive during intubation, or may help bridge the patient to a continuous infusion. Dr. Pickett talks about simple methods for mixing and administering push doses of these pressors and how to administer the infusion. NOTE: It is ASSUMED you already know the indications, contraindications, and side effects of these drugs. This video is NOT a comprehensive review of these medications. Available on YouTube, iTunes, Google Play, and Feedburner! https://youtu.be/__PWK4P85xc
Like Starsky and Hutch, like peanut butter and jelly, like Riggs and Murtaugh, the inseparable duo is back together for Medic Mindset for an episode of the Thinking Series, this time on abdominal pain. Feast your ears, ladies and gentlemen, boys and girls. The audio is like butter. Available on YouTube, iTunes, Google Play, and Feedburner! https://youtu.be/qCpk3f3zPP8
Snakebites are a common patient encounter for #EMS here in Texas, though virtually all states have venomous snakes of one kind or another.
Dr. Spencer Greene (@ToxSpencer) walks us through some pearls and pitfalls of caring for these patients.
TL;DW:
“Dry bites” are very uncommon.
Most victims are not drunk young males that are intentionally messing with wildlife. Most are people who didn’t even know the snake was there.
Don’t mess with wildlife.
Snakes are not aggressive. They want to be left alone. Admire from a distance. If you leave them alone, they’ll leave you alone.
Do NOT bring the snake to the ER. Taking a picture of it might be helpful.
Any bruising or swelling from a snakebite indicates envenomation and should be treated aggressively.
For crotalid bites (rattlesnake, copperhead, cottonmouth), raise the affected limb to reduce pain and swelling.
For elapid (coral snake) bites, keep the limb level.
No extractors, no sucking out the venom, none of that silliness.
No tourniquets or constricting bands or pressure dressings. Applying these items may cause more tissue damage and pain.
Snakebites are painful. Treat the pain.
Watch here on YouTube:https://youtu.be/WGjy_mBsZD4
From the City of Austin, TX, this is the Austin/Travis County EMS System Office of the Medical Director channel. We will talk all things prehospital care here. It will be informative, it will be fun, it will be very poorly edited and not rehearsed.
YES I KNOW THE THUMBNAIL HAS EPISODE 4 and it’s episode 49. But we have a YouTube channel now so that’s why we have different episode numbers. It’s less confusing than renumbering everything.
ANYwhomst, this is our takedown of the week long winter weather event that crippled the region starting around Valentine’s Day. The impacts to EMS were many and required a lot of creative thinking by responders. We are so proud of the bravery, ingenuity, and dedication that they showed during this event. Got some time? This is the story.
Vaccines are finally available. I’m getting mine, and you should too. How do they work? Are they safe? What are the side effects? What are the particulars of administration?
Bamlanivimab is a monoclonal antibody for treating mild to moderate COVID-19. You’ve probably heard of it as it has rolled out here in Texas in force. What does it do and how is it given?
Operation Warp Speed is a public-private partnership that has helped speed development of vaccines and treatments for COVID-19. But what does that mean for safety of these treatments? TL;DR: The program does not cut safety corners. It supports industry to rapidly develop capability without the financial risk usually associated with experimental therapies.
This study looks at an intriguing concept: What happens when you give an acutely suicidal patient ketamine in the ED? This study intrigued me so I thought I’d cover it. This study will not change your practice but will hopefully interest you in participating in research on the topic.
TL;DR/TL;DL: DON’T START DOING THIS YET. IT NEEDS MORE STUDY. But it is promising.
Citation: Domany Y, Shelton RC, McCullumsmith CB. Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial. Depress Anxiety. 2020 Mar;37(3):224-233. doi: 10.1002/da.22975. Epub 2019 Nov 16. PMID: 31733088.
Strengths: Randomized placebo controlled design. Disposition and care for patients was determined before randomization, so study drug not likely to affect care delivered. Close assessment at multiple points. Administration protocol was over 5 min, so very conducive to the ED environment.
Weaknesses: Too small to really tell us how effective this treatment is, though there is a body of literature that supports it in other settings. Evaluation of patients was thorough, more than what could be expected of a prehospital provider without substantial training. Study setting was an ED, not EMS. Does not answer the question of whether patients can be safely discharged to outpatient mental health treatment after receiving this drug.
The Health Data Exchange allows the flow of information between EMS charts and the hospital chart, helping us to easily look at outcomes and how EMS care has affected the patient. The best way to check your own knowledge and understanding of prehospital care is to know how the patient turned out. Was your diagnosis right? Did they decompensate after transport? Scan the patient’s sticker into our electronic patient care record and you can find this out. In this episode I sit down with 4 very special guests: Travis Baker, PA-C, our own Paramedic Practitioner; Remle Crowe, PhD, Data Scientist for ESO Solutions; Jason Gilliam, LP, Designated Medical Officer and Captain at ATCEMS; and Bill Leggio, EdD, our Clinical Standards and Practice Coordinator to talk about what we gain from this.
“What if” can be anxiety provoking and can send you down a rabbit hole of undesirable futures. But it can also be a powerful tool for the clinical preceptor and the clinician who is looking to improve their performance.
SUPER short one today about COVID and ACE inhibitors (-pril) and Angiotenstin Receptors Antagonists, like Angio Recept Antag. Maybe ang rec ant. Or artan. Artans yeah, that’s it.
We talk about some of the things you’ve seen in the news lately about treatments that might help COVID. AND WHAT DO THEY MEAN I CAN’T TAKE IBUPROFEN? *sad Army Doc noises*
So, you caught the COVID. You have endured the fever, cough, sore throat, diarrhea, and abject boredom of being home. When can you be let out of this prison? In this micro episode we talk about the return to work criteria. BLUF: No, you don’t have to be in quarantine forever.
Covid is now a pandemic, the real kind, the not-the-zombie-kind. In this episode we talk about what the Office of the Medical Director, Austin Public Health, and Austin/Travis County EMS is doing to respond to what is now a declared disaster.
Buy in from the workforce is necessary to bring any useful change to an organization. While unions and leadership are often set against each other, the things they can accomplish when they work together far exceed those they can accomplish when moving in different directions. The union can give the MD valuable feedback on wants and barriers to implementation, and the MD can get an idea of how to effectively introduce change to the department with wide support. I’m fortunate to get to work with Selena Xie, who is smart, politically savvy, collaborative, and has an eye for the immediate future and years down the line.
Some causes of headache are benign, but the EMS provider would be wise to consider carefully some “bad actors” that cause headache. Here we will talk too about how to manage these patients in the prehospital setting.
Jessica Sasser, RN, is one of the amazing staff at our public safety wellness division which supports the physical and mental health of Austin/Travis County EMS and Austin Fire Department. In this episode she discusses meditation and how it can be useful to the first responder. Hint: it doesn’t just make you feel better, it makes you better. Please don’t meditate while driving.
Resources for ATCEMS and AFD employees can be found at: atxpublicsafetywellness.com
Insight Timer can be downloaded from the Apple app store.
Combat medic, paramedic, PA, and now medical student Andy Fisher talks about his journey. If you’ve thought about making the leap from #EMS, don’t miss this episode.
In patients with hemorrhage, nothing else can take the place of #blood. Andy Fisher talks about why, and how, you can bring #blood to your #EMS system.
Syncope, or fainting, is an incredibly common complaint seen by #EMS providers. This short episode discusses some of the exam findings and considerations.
The Epsilon wave: https://litfl.com/epsilon-wave-ecg-library/
Wolff Parkinson White syndrome: https://www.youtube.com/watch?v=K098rnvqRE0
Lown Ganong Levine syndrome: https://ecglibrary.com/lgl.html
If you are not using #EtCO2 during airway management and monitoring, then you are wrong. Fix yourself. Dr. Pickett tells you why. #EMS #Prehospital #Paramedic #maybeifIsqueezethisbagashardandfastasIcanthepatientwillgetbetter #morewavylines #butIjustlearnedEKGs #Isawthetubegothroughthecords #sodideveryonewhoevermisplacedanETtube
Do you get nervous when you are faced with a patient with a tracheostomy tube? This short episode covers common problems and how to troubleshoot them. Be nervous no more. Â #paramedic #EMS #prehospital #criticalcare
In this episode, I make reference to a couple of great YouTube videos on the subject. One is from RT Clinic on the ins and outs of tracheostomy devices. The other is from The Crashing Patient Series from the University of Maryland and goes into greater depth on care of the crashing tracheostomy patient.
We undertook the unenviable task of revising our clinical operating guidelines to make them more usable, more manageable, and easier to read. We want to foster a clinician mindset and embrace the clinical flexibility medics need to take care of our patients in a very fluid environment. We also created new credentialing levels for medics to expand their current horizons.
Today we are covering some of the flight rules for those studying for their #FP-C exam. Â #paramedic #EMS #prehospital #HEMS
Today we are covering a bit of #flight physiology for those studying for their #FP-C exam. We broke this episode into 3 parts to make it a bit more manageable. #paramedic #EMS #prehospital #HEMS
Today we are covering a bit of #flight physiology for those studying for their #FP-C exam. We broke this episode into 3 parts to make it a bit more manageable. #paramedic #EMS #prehospital #HEMS
Today we are covering a bit of #flight physiology for those studying for their #FP-C exam. We broke this episode into 3 parts to make it a bit more manageable. #paramedic #EMS #prehospital #HEMS
Heat illness ranges from the benign and temporary to the life-threatening. We dive into management of heat cramps, heat syncope, heat exhaustion, and heat stroke. Rule #1: Stay on scene to cool them down.
In person and on the radio, make the most of your concise patient report. Â
If you felt the need to put a #cardiac monitor on at any point in the patient interaction, it should stay on as you walk into the ED. #EMS #paramedic #prehospital
We dug into our QA data and the literature to bring you some pearls on #prehospital #airway management. #EMS #paramedic
750,000 Americans will suffer from sepsis this year. Early recognition and treatment are key. Here we go into the field recognition of sepsis and treatment priorities.
For patients with #stroke outside of 4.5 hr #tPA window, they may benefit from thrombectomy up to 24 hours since last seen well. Take to comprehensive stroke center and perform MRI safety screen. #EMS #paramedic
Quick and dirty estimation of weight for #pediatric #resuscitation:
Birth: 5kg.
Age 1: 10kg.
Age 3: 15kg.
Age 5: 20kg.
Age 7: 25kg.
Age 9: 30kg.
#PALS #APLS
This is a short episode on the response to and care for bombing victims for #EMS, #Firedepartement and #Police. A longer episode will follow that covers #prehospital care in detail, but this is the initial response and considerations. #packagebombmurders #austinbombings @ATCEMS @Austin_police @austinfiredepartment @TxDPS @TravisCoSheriff @CommitteeTECC @CommitteeonTCCC @NTOATEMS Find us on @iTunes and @GooglePlay and @feedburner
From the National #Counterterrorism Center, this chart gives #evacuation distances for #explosives of different sizes. Time, distance, shielding. Minimize the TIME you are in a threat zone, increase DISTANCE between you and the device, and seek SHIELDING in the form of cover from hard buildings or terrain. #packagebombmurders #austinbombings #EMS #prehospital #paramedic #firedepartment
Neither rare nor mysterious, Cannabis Hyperemesis Syndrome causes pain and vomiting that can be difficult to treat.
Marijuana use is growing for medical purposes and recreational abuse. With this has come a rise in Cannabis Hyperemesis Syndrome which is marked by recurrent, severe abdominal pain and vomiting that does not respond well to the usual antiemetics. Dr. Pickett discusses the causes and treatment of this disorder which we will recognize in increasing numbers with increased marijuana availability.
Dr. Cynthia Griffin @CMGrffn wrote this great article on #CCT and how to handle orders that conflict with protocol or practice style. Doctor’s orders and intra-transfer modifications
#EMS #paramedic #flightmedic #flightnurse
Fluid resuscitation, blood, acidosis, coagulopathy, hypothermia, TXA, intubation, push dose pressors! All the greatest trauma lit for your naughty bits.
Some tips to help differentiate #SVT with aberrancy and #vtach. #EMS #prehospital #paramedic
What’s the right pressor for different types of shock? When should you pull the trigger?
http://www.emdocs.net/evidence-based-approach-pressors-shock-part/
In this episode we sat down with Dr. Steven Warach the Director of the Clinical Research Institute and Vascular Neurologist from Dell Seton Medical Center to talk about acute MRI for stroke and how we might be able to reduce the time to treatment.
3 questions comprise the safety screen:
Most asthma is pretty routine. Most. Dr. Pickett talks about tools for management of the severe asthmatic adult or child.
Some people have the natural gift of teaching. For others it does not come easily. Teaching is all about connecting with your student, finding out their abilities and weaknesses, and helping build them into stronger clinicians. Teaching is a learned skill that can be molded and honed no matter how good a teacher you are. I sat down with Ginger Locke, Associate Professor of EMS Education at Austin Community College and the producer of the Medic Mindset podcast to see what tips and tricks we can offer the field preceptor.
Ever had that patient that you just weren’t sure what pathway they fit in?
You have a 75 yo F who called 911 due to palpitations and increasing shortness of breath. She looks fairly comfortable with belies the rate of 180 seen on the monitor. She does endorse some chest discomfort. No previous drug use, no recent surgery/ Rhythm might be irregular but it’s too hard to tell at that rate. Should I cardiovert? Should I give them diltiazem? Could this tachycardia be reactive to something, and I should look for other potential issues?
NYT reconstruction of Vegas shooting
This is a very well done reconstruction of the mass shooting in Las Vegas. Several things to note here: varying reactions in the crowd (you can see some individuals standing and staring in disbelief as others run to cover), care under fire and members of the crowd organizing others to help, and the police who charged into the gunfire to end the shooting.
Decided to address some reader comments with this one. Dextrose, hemostatic agents, chest seals. Little bit of medicine, little bit of trauma.
Why did we change over from D50 to D10 for hypoglycemia? And should we be treating hypoglycemic diabetics the same way we did 30 years ago? Should I have a hemostatic gauze in my kit? And how useful are chest seals really?
When the EMS provider has to convey patient information, there are 3 distinct settings in which this should occur. You don’t want to waste time on the phone when you (and they) need to be doing other things, and you don’t want to leave out critical details when you need an order or you are handing off care to another provider.
Do you like it when your patient desaturates just as you are getting ready to intubate them? Of course not, nobody does. Here are some tricks to help keep the sat up while you secure the airway.
http://www.emdocs.net/em3am-rhabdomyolysis/
Fast facts on rhabdo.
Staging during large scale attacks has a real cost in terms of lives. We must balance the tiny theoretical risk to rescuers with the huge known risk to patients who are already bleeding and dying. Rescue Task Force programs are the way to mitigate the risk and stop the clock of life threatening hemorrhage. Vegas did it right.
This is a great blog about all things emergency medicine. Great evidenced based articles. This episode they talk about epi dosing for anaphylaxis in patients on beta blockers. Academic Life in EM- Epinephrine
BLUF: Epi in patients with beta blockers does not cause seem to cause unopposed vasoconstriction and hypertensive crisis. Use standard doses of 0.3-0.5mg IM.
ETA: If the patient isn’t responding to epinephrine, give them IV Glucagon. It activates the same cGMP pathway in the cell. BUT you have to give higher doses than the 1mg you might have. 4-6mg, even 10 mg. And you can always go up on the epi dose!
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Office of the Chief Medical Officer of the City of Austin, Texas 