Good morning,

January is a great time for a refresher on frostbite! Frostbite is most easily defined as frozen tissue. The face (cheeks, nose, ears, etc.), hands, and feet are the most involved areas. Frostbite occurs when there is exposure to very cold weather, i.e., when the temperature is well below freezing. The incidence of frostbite injury patients increases significantly when the temperature is ≤ 10 °F (-23°C). With these freezing temperatures, the tissue cools down faster than the circulation and metabolism can warm it up, and the tissue temperature drops below its freezing point. When this happens, ice crystals form within the tissue, and the local circulation decreases or stops, further exacerbating the freezing of the tissue. Clinically, it is recognized as cold, pale, waxy tissue that is firm, not soft, and pliable. As the frostbite occurs, the patient might experience numbness, burning, and pain, but often these systems don’t manifest themselves until the tissue starts to warm up and thaw out.

The risk of an individual sustaining frostbite is even greater if the weather is windy, such as during a blizzard, due both to the wind increasing convective heat losses (the wind blowing across the tissue increasing its heat loss) and by the wind decreasing the thermal insulating capability of one’s clothing.

Although you might expect to see frostbite in homeless individuals who cannot escape the cold, in those working outdoors (e.g., shoveling a driveway), in those walking to a bus or subway station, or in those stuck in a broken down car, etc., EMS personnel are also at risk for experiencing frostbite. When the weather is really cold, salt and other road deicers lose their effectiveness. Icy roads can lead to MVAs and sustained cold exposure during patient extrication activities. As the EMS personnel focuses on scene management, extrication, and patient care, they are even less likely to recognize frostbite happening to themselves. If you see your co-workers’ ears or the tip of their noses turning white, it would be good for them to take a break and warm up in the back of the squad (winter weather scene rehab).

If you see a patient with a frostbite injury a day or two after the initial freezing event, the tissue may be swollen (edematous) and erythematous (reddened). There can also be fluid-filled blisters overlying the involved area. Severe frostbite can lead to irreversible tissue death and black, necrotic tissue, but this typically happens over a period of days to weeks.

Frostbite treatment is easy. Stop the cold exposure and get the individual into a warm environment. Gently remove any wet clothing. Assess the patient for any other conditions and transport. It is generally recommended to leave rewarming the frostbitten tissue to the Emergency Department. Rewarming is usually performed rather quickly and can be quite painful. It is also critical that the frozen, frostbitten tissue isn’t partially thawed and re-frozen, as this is known to worsen the outcome significantly. Also, treat the frostbitten tissue very gently and carefully. Do not rub the area to “help warm it up.” The pressure and motion of the tissue increase the tissue injury when the tissue is frozen.

Prevention is always the best medicine! If you, your crew, or your family and friends find themselves outdoors in the very cold weather, be sure to dress appropriately and prevent your skin from being directly exposed to the cold air (wear a hat, scarf, quality gloves; and dry, waterproof, insulated boots). Limit your cold exposure and watch for the early onset of frostbite in yourself and those around you.

Winter recreational activities, such as skiing, snowboarding, skating, and ice fishing, can all be great fun. Just make sure to dress appropriately, warm up often, and stay healthy! 

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician

PDE - January 9, 2023

Good morning,

Congratulations! You have just obtained ROSC (Return of Spontaneous Circulation) while treating a patient in cardiac arrest. The patient has a palpable pulse and is starting to breathe on their own. You obtain a blood pressure and find that your patient is markedly hypotensive: 50/28 mmHg, HR 116. You already have an IV in place with NS running wide open. You have a pressure bag around the IV fluid bag to increase the flow. The patient is in cardiogenic shock with a stunned heart from their cardiac arrest. Fortunately, you have a medication and a protocol to raise their blood pressure and improve their CNS and cardiac perfusion during this critical time period.   

Push Dose Epinephrine (PDE) has been in the protocol, but like TXA discussed last week, the dosage changed with the new 2023 protocol. Previously, once mixed, one could administer 1 ml (10 mcg) per dose, repeated every 2 – 5 minutes. The new dose has been increased to 1 – 5 ml (10 – 50 mcg), slow IV / IO push every 2 to 5 minutes, as needed. As the IV epinephrine is metabolized very rapidly, there is no maximum total dosage limit. 

The goal is to titrate the medication as needed to obtain and maintain an SBP > 90 mmHg (MAP > 65 mmHg). Push the Epi slowly, and then obtain a new blood pressure reading. One might start with a 1 ml dose, and if that isn’t sufficient, administer a higher dose on the next administration.

Do you remember how to mix PDE? It’s easy. There are many different approaches, but the underlying concept is the same. Epinephrine is provided in the drug boxes in small vials with 1 mg in 1 ml of solution (1:1,000); and in larger pre-filled syringes with 1 mg in 10 ml of solution (1:10,000). BOTH provide 1 mg of the Epinephrine. The small vial is more concentrated and used for IM injections and for administration via a nebulizer. The syringe is a more dilute form of the medication and is typically administered IV/IO when treating a patient in cardiac arrest. Remember, they both contain the same 1 mg amount.

PDE is administered in a more dilute form than both of the above concentrations, so the administrator has to mix it themselves before administering it. PDE is prepared by adding Epinephrine 1 mg to the small 100 ml D5W piggyback IV bag that is provided within the drug box. Typically, one would use the small, concentrated Epi 1 mg in 1 ml vial for this, but it really doesn’t matter. Using the Epi 1 mg in 10 ml (“cardiac”) Epi for this is acceptable, as they BOTH provide 1 mg of the Epinephrine. The purest will realize that the Epi concentration in the D5W piggyback bag will be slightly different, depending upon which approach is taken, but this difference is completely immaterial when one realizes that the dose to be administered is 1 to 5 ml of the solution.

Do NOT bother to take 1 or 10 ml out of the 100 ml piggyback bag before adding the Epi to it. PDE is typically used on high acuity patients, and that extra step will slow you down and isn’t necessary.

Remember to put a label on the 100 ml D5W piggyback bag once you have added the Epi to it! Ideally, there is a page of PDE, Amiodarone, and TXA stickers in the drug box. You can also print out your own on an Avery® type sticker sheet. The next to last page of the protocol has a pre-formatted page just for this purpose. In a pinch, one can label the IV bag with a piece of tape.

As with all our medications and interventions, there are both indications and contra-indications in their use. PDE is aimed at improving the blood pressure and perfusion in patients experiencing cardiogenic, anaphylactic, and septic shock, along with the administration of IV fluids. It is not indicated in the treatment of hemorrhagic (traumatic) shock where the goal is IV fluids (no PDE) to maintain an SBP of 90 mmHg until blood and blood products can be administered, and ultimately the source of the bleeding can be controlled. Remember that when treating hemorrhagic shock, the goal is an SBP ≥ 90 mmHg. A higher blood pressure is NOT better in hemorrhagic shock patients.          

PDE is summarized nicely within the 2023 protocol at the end of both Adult and Pediatric: Hypovolemic, Neurogenic, Cardiogenic, and Septic Shock protocols. For adult patients, PDE is a standing order within the protocol. For pediatric patients, remember that On-Line-Medical-Control needs to be contacted for authorization to administer PDE.

Sustained hypotension is detrimental to our patients’ outcomes. Please remember you have the tools to intervene in this regard and improve their outcome! PDE is truly easy to utilize and can be a true game changer in caring for these high-acuity individuals.

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS physician

Errors - January 16, 2023

Good morning,

Have you ever made an error? 

I know I have, and I suspect most of us have. In 2000 the Institute of Medicine (US) Committee on Quality of Health Care in America published their report: To Err is Human: Building a Safer Health System. This committee investigated medical errors in great detail and estimated that 98,000 people die every year from medical errors that occur in hospitals. That number should shake everyone up, as presumably those deaths could have been prevented had no error been committed.

Although the IOM’s investigation and report focused on hospital health care, there is no reason to believe that those who practice in the out-of-hospital setting are immune from making such mistakes. Indeed, EMS research in this area has shown that, like their hospital counterparts, EMS personnel make mistakes and are often oblivious to the fact that an error was even made.

One of the key take-home messages from the IOM report, and from subsequent research into the area of medical errors, is that most errors are made by good people, acting with good intentions within a system that sets them up for failure instead of setting them up for success. 

By studying our system, processes, and approaches to care, it is possible to identify weaknesses within our system that make it easy for an error to be committed. Once such weaknesses are identified, one can change the system to guide the practitioner down the desired path and set up hurdles to make it more difficult to make an error.

Medication administration often requires full attention, careful thinking, and cross-checking. Ketamine, for example, has four indications in the protocol: 

1. The treatment of violent, behavioral health patients (250 mg/dose)

2. Pain management (10 mg/dose)

3. Pharmacologic sedation for the placement of an advanced airway (1 mg/kg)

4. Rapid Sequence Intubation, [For those specifically trained and authorized], (1 – 2 mg/kg). In addition to having four different doses for this medication, depending upon its availability, it can be provided in either 500mg/5ml (100 mg/ml) or 200 mg/20 ml (10 mg/ml), concentrations (which differ by a factor of 10!). Additionally, when used for pain management, the EMS provider has to first dilute the Ketamine medication to a concentration of 10 mg/ml.  

The protocol also lists three different narcotic analgesics: fentanyl (I mcg/kg/dose), hydromorphone (0.5 – 1 mg/dose), and morphine (2.5 – 5 mg/dose). Within our EMS drug box, there are also three different forms of epinephrine (1mg/ml, 1 mg/10ml, & autoinjectors), which also have multiple indications, each with their own specific dosing regimen. Is it any wonder that a tired medic working an extra shift on a high-acuity scene might make an unintentional medication error?

If an error is made (medication or otherwise), it is common to feel embarrassed and to want to hide it! Often the provider feels guilty and depressed over having made a mistake. The prospect of one’s partner, supervisor, medical director, State EMS Board, or the courts punitively penalizing one for one’s mistake is a far too real concern. Transitioning from old-school practices to a “Just Culture” mentality can be a slow process. Unfortunately, however, if one fails to report an error, it becomes very challenging for all of us, as a group, to collectively learn from one’s mistake. 

It is also imperative to know that if one makes a particular mistake, they are likely not alone. It is very likely that another individual has also made the same exact mistake! We, as medical directors, can’t modify our systems and processes, or provide extra training on high-risk areas, if we are unaware of the weaknesses and errors within our system.

How do we get better at our jobs, perform our patient care in a safer manner, and reduce the occurrence of errors within our system? The first step is reporting errors, or “near misses” (I almost made an error when I …). Ideally, one reports errors to both the Emergency Department physician who will be caring for the patient and to one’s medical director. Realizing that some errors and near misses go unreported, however, we have created an anonymous online App for reporting such events. 

The last page of the protocol, where it will always be easy to locate, is a scannable QR Code to direct one to our Serious Incident Report (SIR) App. One can complete a totally anonymous report via their smartphone, tablet, or computer. Note that the first time one uses the QR Code to access the system, it might instruct one to “tap here” to download the free signNow App for completing electronic pdf documents.

The SIR App will then allow one to explain what happened, the mistake that they either made or almost made, and any other details about the case that the individual wishes to include. 

 It is optional to include their name and contact information.

Reportable events include medication errors, treatment errors, equipment failures, dropping a patient, missing a diagnosis, and going down the “wrong” protocol, etc. The SIR App provides a new avenue to communicate anonymously with the medical directors. 

The SIR App is a tremendous addition to the University Hospitals EMS Institute, and it will allow one to easily report, anonymously, any medical errors or near misses that occur. Through such reporting, we can help root out system-level causes that set our personnel up to make an error and then work to improve our system to prevent their re-occurrence. 

If an error or near miss occurs while caring for your patient, please let us know anonymously or otherwise! By making us aware of these events, we can make our healthcare system safer for our patients and better for our personnel.

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician

Positive Interactions - January 23, 2023

Good morning,

The Million Dollar Question…

We’ve all been there. You are on the scene, and the patient is giving you some pushback regarding going to the hospital! The patient clearly has a medical condition warranting transport, and THEY called 911, and now here they are, throwing a wrench in the gears and refusing to go! As your frustration, blood pressure, and anger rise, your pleasant demeanor and customer service attitude plummet. As things escalate, you finally get in the patient’s face and ask: “So, do you want to go to the hospital or not?!”

This scenario occurs far too often within our industry. It undermines the positive, beneficial, good relationship that a care provider is attempting to build with their patient and leaves both the patient and the provider with a feeling of resentment.  But we can do better!

Remember that HOW a question is asked is as important as the question itself. The wording, the tone of voice, and the accompanying body language all set the stage for the interaction. In the above scenario, it is all too easy for the patient to perceive that you are upset with them and that you don’t want to care for them or transport them. The underlying hostility makes it even less likely that the patient will agree to further care and transport with YOU, with whom their interaction isn’t going well. You may be doing your best, but at the end of the day, the patient’s perception and interpretation of your demeanor impact their ultimate decision.

The care provider can often set an entirely different spin on the interaction by making a positive statement that guides the patient down the desired path. Instead of asking the patient the question, (Do you want to go the hospital, (or NOT!), said with a snarling frown and your hands on your hips), say: “I’m glad that you called EMS today! You clearly are having some difficulty with your breathing (a fever, pain in your hip from your fall, etc.) and need further care in the ER. Let’s get you in the squad so we can take care of you and get you to the ER.”

With this phrasing, you, as the medical expert on the scene, are making it clear (nicely!) that the patient’s call to 911 was appropriate and that your goal is to provide further care and transport. You have, subtly and not confrontationally, made it clear that they need to go to the ER. You have also raised the bar for them to refuse and to elect a non-transport outcome. You have actively set the expectation that they need to go to the ER, and refusing at this point will require them to go against your medical expertise and recommendation.  

With this positively worded statement, instead of a question to the patient, you are not leaving the decision as the appropriateness of their calling 911, or the need for transport, up to the patient. You have answered any doubts about that in the patient’s mind and set expectations for the next part of your interaction. Additionally, you haven’t sent any mixed messages through your comments or body language about your desire to be there caring for them. The entire interaction has been framed differently, with you taking charge and directing their decision rather than putting that decision in the patient’s hands.

It is challenging to salvage the relationship with the patient once it has turned for the worse. As you care for your patient and move towards a disposition decision, please keep the above approach in mind. Reaffirming the appropriateness of the patient’s calling you and setting the expectation for your providing further care and transport can strengthen your relationship with your patient and guide their decisions and actions. Strive to build a positive relationship with your patients, not an adversarial one, and start down that path from the very beginning of your interaction with them.

Remember, in EMS, we often encounter patients on their worst day ever, not their best. Let your caring and compassion dominate your interaction and brighten your patient’s day.

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician

Positive Interactions - January 30, 2023

Good morning,

January is a great time for a refresher on frostbite! Frostbite is most easily defined as frozen tissue. The face (cheeks, nose, ears, etc.), hands, and feet are the most involved areas. Frostbite occurs when there is exposure to very cold weather, i.e., when the temperature is well below freezing. The incidence of frostbite injury patients increases significantly when the temperature is ≤ 10 °F (-23°C). With these freezing temperatures, the tissue cools down faster than the circulation and metabolism can warm it up, and the tissue temperature drops below its freezing point. When this happens, ice crystals form within the tissue, and the local circulation decreases or stops, further exacerbating the freezing of the tissue. Clinically, it is recognized as cold, pale, waxy tissue that is firm, not soft, and pliable. As the frostbite occurs, the patient might experience numbness, burning, and pain, but often these systems don’t manifest themselves until the tissue starts to warm up and thaw out.

The risk of an individual sustaining frostbite is even greater if the weather is windy, such as during a blizzard, due both to the wind increasing convective heat losses (the wind blowing across the tissue increasing its heat loss) and by the wind decreasing the thermal insulating capability of one’s clothing.

Although you might expect to see frostbite in homeless individuals who cannot escape the cold, in those working outdoors (e.g., shoveling a driveway), in those walking to a bus or subway station, or in those stuck in a broken down car, etc., EMS personnel are also at risk for experiencing frostbite. When the weather is really cold, salt and other road deicers lose their effectiveness. Icy roads can lead to MVAs and sustained cold exposure during patient extrication activities. As the EMS personnel focuses on scene management, extrication, and patient care, they are even less likely to recognize frostbite happening to themselves. If you see your co-workers’ ears or the tip of their noses turning white, it would be good for them to take a break and warm up in the back of the squad (winter weather scene rehab).

If you see a patient with a frostbite injury a day or two after the initial freezing event, the tissue may be swollen (edematous) and erythematous (reddened). There can also be fluid-filled blisters overlying the involved area. Severe frostbite can lead to irreversible tissue death and black, necrotic tissue, but this typically happens over a period of days to weeks.

Frostbite treatment is easy. Stop the cold exposure and get the individual into a warm environment. Gently remove any wet clothing. Assess the patient for any other conditions and transport. It is generally recommended to leave rewarming the frostbitten tissue to the Emergency Department. Rewarming is usually performed rather quickly and can be quite painful. It is also critical that the frozen, frostbitten tissue isn’t partially thawed and re-frozen, as this is known to worsen the outcome significantly. Also, treat the frostbitten tissue very gently and carefully. Do not rub the area to “help warm it up.” The pressure and motion of the tissue increase the tissue injury when the tissue is frozen.

Prevention is always the best medicine! If you, your crew, or your family and friends find themselves outdoors in the very cold weather, be sure to dress appropriately and prevent your skin from being directly exposed to the cold air (wear a hat, scarf, quality gloves; and dry, waterproof, insulated boots). Limit your cold exposure and watch for the early onset of frostbite in yourself and those around you.

Winter recreational activities, such as skiing, snowboarding, skating, and ice fishing, can all be great fun. Just make sure to dress appropriately, warm up often, and stay healthy! 

Jay Carter, MSEE, MD, FACEP, FAEMS

Emergency Medicine and EMS Physician