Season’s Greetings Providers,

I thought an introduction to our disposable CPAP unit would be a nice transition from last week’s heart failure topic. We had been resistant to move to the disposable CPAP units because we were not seeing the reliable flow and oxygenation required to stave off intubation of our severe heart failure patients. Our Emergent CPAP systems seemed excellent and very reliable. What we noted, however, was that the use of nitro, which is an integral part of our prehospital protocol for our CHF exacerbation patients, was dropping off with the emergent. Simply put, Emergent was hard to remove, and our critical patients were not receiving the much-needed nitroglycerin. The disposable CPAP units have been out long enough now to show significant improvements and especially show reliability for FiO2 pressure and simple mask flips that allow for rapid- lift, nitro administration, and flip right back on. In addition, aerosolization can be done inline.  

We will be training departments over the next couple of months as we will continue to collect data on a few of our departments who will start using the O2-MAX Pulmodyne disposable CPAP. If this is what folks who have been using this product have said, which is an excellent disposable CPAP product, we will be moving to this system-wide over the next year. There will be training programs in January, and we plan to have the first product wave into a few departments in February. Thanks again for always being ready for safe, easy, and patient-centered advances in Prehospital care.

Sincerely,

Don Spaner, MD

EMS Medical Director

UH EMS Institute President

Capacity - December 13, 2021

We often talk about the competence of a patient to make decisions but infrequently do we run into patients who have been declared incompetent. Competency is determined by a court of law. While we may run across someone who has been declared legally incompetent, we mostly are stuck in situations determining if a patient can make educated decisions for themselves. It is an assessment of their decision-making capacity. 

Capacity can be a tricky and multifactorial thing to decide. In the 2022 EMS protocols, we have added a small matrix of questions that you can use to help determine capacity. Our protocol definition of capacity is patient is lucid and capable of making an informed decision and is alert to person, place, time, and event. EMS is familiar with determining orientation to person, place, time, and event.

To help determine capacity, and the ability to make an informed decision, the following can help make that case for your documentation:

• Expressing a choice: It is the ability to state a decision. This may be best understood by asking “Based on what we just talked about, what would you choose?”

• Understanding: This is the ability to state the meaning of relevant information regarding risk, diagnosis, and options. This could be determined by asking “Tell me in your own words what may happen if we don’t take you to the hospital?”

• Appreciation: It is the ability to explain how the information applies to oneself or situation. An example of how to determine this may be “Tell me in your own words what you see as your medical problem?”

• Reasoning: It is the ability to compare information and infer the consequences of choices. This may be ascertained by asking “How could not seeking treatment affect you in the long run?”

Some of these items are similar, and several may be answered in properly asked questions. Documenting the patients’ responses verbatim helps to reduce liability in cases where the patient is refusing care or treatment. It may seem lengthy to document all these responses in your narrative, but it’s much easier than trying to explain it to the court. 

Some of these cases are difficult even for our physician colleagues. Engage medical control in cases where the answers you get from your patient do not help form an image of a patient who has appropriate capacity. Patients who have been determined to have the capacity to appropriately answer the questions above are allowed to make decisions we disagree with. Despite our disagreement, the patient still has the right to make dumb decisions even if they threaten their own lively hood. 

Patients that have been deemed without the capacity to make sound decisions. These cases may be AMS cases due to head trauma, drugs, alcohol, hypotension, hypoxia, metabolic disturbances, and potentially psychiatric illnesses. In these cases, on-scene law enforcement may be able to help with proper legal custody issues as well as provide great witnesses to your attempts to determine their capacity. Remember, they have body cameras in most cases. Ask them to record the interaction for a most durable record. 

Sincerely,

Scott Wildenheim, Paramedic, EMSI

EMS Educator, University Hospitals

RASS Score - December 20, 2021

RASS SCORE

Over the last several years, we have seen several changes to our Behavioral / Psychiatric Emergencies Protocol. There are specific criteria for restraint use, specific criteria for how to safely restrain a patient, and guidelines for treatment based on how agitated or violent the patient may be. We have also added medications specific to the patient’s level of agitation. While Haloperidol (Haldol) has been the mainstay in these cases, providers now have other options. Olanzapine (Zyprexa) 10mg oral disintegrating tablet is an option for a patient with agitation that is not combative. On the other end, there is Ketamine (Ketalar) 250mg IM that can be used in the combative – violent patient that is a significant threat to providers. 

One of the most important things for the EMS Provider to remember in these types of emergencies is the need for proper documentation. You must be able to accurately document and justify the restraint method and/or pharmacological intervention you chose to use and why.

The 2022 Prehospital Care Protocol and Treatment Guidelines will now include a tool to help you in your documentation of the Behavioral / Psychiatric Emergency Patient. The Richmond Agitation Sedation Score (RASS) is traditionally used to score the agitation/ sedation levels of ICU patients on ventilators. This scoring tool can also be used by the prehospital provider to document their patient’s agitation / violent behavior before and after treatment interventions.  

Post-care documentation of a patient that scores a +4 RASS on patient contact indicates they were violent and an immediate danger to staff. The use of Ketamine in this patient is fully supported in the protocol guidelines. While a patient who is documented a +1 RASS is restless but not aggressive on contact should probably be managed with Zyprexa ODT. The RASS score should also be used to document the patient’s response to pharmacological interventions. E.g. patient initially a +3, and after treatment with Haldol, they are now a 0 on arrival at the Emergency Department. The RASS chart shown above can be found in the Behavioral / Psychiatric Emergencies Protocol Key Points Page in the 2022 Protocol.  

Hospital Diversions 

As you are all aware, EMS run volumes are up, and Emergency Department resources are also overtaxed. There have been times over the last several weeks where individual Emergency Departments have gone on diversion requiring EMS to, in some cases, have longer transport and out-of-service times. Below is a copy of an email from Dr. Don Spaner. This email was sent to the EMS Services in our system, and we would like to share it with all of you here.

Dear Providers,

These are unusual times. I thank each and every one of you who have stayed the course and continue to provide compassionate care to all of our emergency patients. After a discussion with Chris Myers, MD from the Cleveland Clinic, both University Hospital System and the Cleveland Clinic agree that we will avoid ED diversion at all costs. However, if a hospital which is one of the primary facilities you go to is on diversion, we ask that you comply to the best of your abilities. That being said, do NOT divert from any appropriate facility, whether they are on diversion or not, if your squad is dealing with the following:

1. Cardiac Arrest

2. Trauma

3. Respiratory Failure

4. Acute Stroke

5. Myocardial Infarction

We appreciate everyone’s efforts. Please contact your Medical Directors with any specific issues. 

Sincerely,

Don Spaner, MD

As always, thank you for all you do and the way you have adapted to the changes we have seen these last few years. Stay Safe.

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute  

December 27, 2022

Thank You 

As 2021 draws to a close, the administrative staff, medical directors, and instructors of the University Hospitals EMS Training and Disaster Preparedness Institute, would like to use this Monday Morning Medical Directors Message to thank each one of you for all you do. These last couple of years have been difficult, to say the least. COVID has changed the face of EMS forever, along with the way you do your job. The hazards you face every day are ever-changing. Your run volumes are up significantly, you are being asked to do more, and you have adjusted to every challenge with efficiency and professionalism. The care you have provided your patients is outstanding. You have consoled frightened and grieving family members, endured long hospital wait times, overcrowded emergency departments, ever-evolving treatment protocols, and countless changes in guidelines. You have proven time and time again that you are willing to do your job to the best of your ability and provide the highest standard of care to your patients no matter what the danger or challenge is.   

Be Nice

Let’s face it, stress levels are at an all-time high. Everyone is feeling the effects of the current state of affairs. It’s easy to fly off the handle at a coworker, nurse, patient, family member, etc. In the heat of the moment or the middle of a really bad shift, it’s hard to put yourself in the other person’s shoes. As an EMS provider, you have no idea what that emergency department staff has been through prior to you delivering another patient to their ED. If you’re an Emergency Department staff member, you may not know what that EMS crew has had to deal with that day. In the end, they are just trying to get their patient the best care possible and get back in service for the next run. In all these situations, we can learn a lot from the great Abraham Lincoln, from the classic movie Bill and Teds Excellent Adventure, when he said, “Be excellent to each other” or simply put just be nice. A simple “Good morning, hello, or how are you doing today?” can go a long way in building and keeping the great relationships we have, plus help get us all through this crazy time.   

Our Commitment

The University Hospitals EMS Training and Disaster Preparedness Institute is committed to providing you with the highest level of medical direction possible. We will continue to provide you with the best protocols and education. Our goal is to have a partnership with you, to offer our help and guidance so that together we can provide superior EMS services to our communities. Please feel free to contact any of our staff or medical directors at any time. We are here for you and look forward to another great year as your partner in EMS. 

Respectfully Yours,

The entire team at the University Hospitals EMS Training and Disaster Preparedness Institute