January 1, 2024

Good morning,

December was a great month for training cases. One of the cases presented by Dr. Jay Carter involved hypovolemic hemorrhagic shock. Many of our dedicated pre-hospital providers went to the NOTS (Northern Ohio Trauma System) symposium and heard a trauma surgeon passionately describe normal saline as “poison.” Appropriately, the pre-hospital providers are questioning why the regional protocol has normal saline for our choice of crystalloids. 

The first point is that our regional protocol is approved by all systems involved with trauma in Northeast Ohio, and this is done with NOTS approval. The second point is that pre-hospital medicine is not the same as hospital medicine. In addition, the hazards of normal saline are seen with very large volumes of normal saline. When was the last time the providers reading this Medical Director message ever gave more than a liter of any crystalloid prior to arriving at an emergency department? We have embraced permissive hypotension to avoid popping the clots, reducing oxygen-carrying capacity, and diluting clotting factors, so massive amounts of crystalloids are not beneficial to any critically ill trauma hemorrhagic shock patient.  

The use of lactated ringers is not harmless either. Hyponatremia is associated with LR, and some medicines cannot be mixed with LR. For example, Heparin can’t be mixed with LR. Controversy about infusing blood with LR has been debunked. Some metabolic errors of metabolism also can’t tolerate LR, which could be dangerous. The bottom line is that I can’t think of a perfect medicine or IV fluid. I have attached a recent up-to-date article HERE  regarding comparing crystalloids, and the article can’t demonstrate a superior choice between crystalloids. We also had an energizing discussion with our medical directors at our meeting today. Even our medical directors who favor LR agreed that normal saline is safe and effective and will remain our crystalloid of choice at this time. I want to thank the medics who raised their concerns, and I hope the following article helps answer any further questions.

Sincerely,

Don Spaner, MD

January 8, 2024

Good Morning,

It has been some time since we have reviewed the Spinal Motion Restriction (SMR) Protocol - Adult and Child. This protocol drastically changed the way we handled patients who fell, were involved in a motor vehicle accident, had penetrating trauma, and other minor injuries. This protocol virtually eliminated the routine use of a backboard in favor of less ridged devices like the vacuum mattress. It allowed providers to use a simple screening process to clear a patient’s need for a cervical collar or full immobilization. As with any change in protocol, over time, there can be confusion or misunderstanding of the protocol. It can occur in the way it is written or through word of mouth from provider to provider. In this Monday Message, I hope to clear up any confusion with the SMR protocol and help you have greater confidence in your decision on how and when to use the SMR protocol in the field.

The SMR protocol is broken down into 3 columns/boxes. Let’s start with the easiest thing to remember with the SMR protocol. If your injured patient has cervical or thoracic pain and or tenderness on examination, a cervical collar should be applied. The next question is, does my patient meet the criteria for full SMR in a required supine position? Let’s take a moment and look at the individual treatment boxes and see how the protocol guides you through your decision-making process.

Some additional considerations may require you to deviate from this protocol as it is written. Patients with extreme Kyphosis will likely need padding under the upper back and head to maintain their current spine anatomy. Never force them into a flat position. If mechanical restriction to straightening the neck or the patient reports severe pain (and resists) attempts to straighten the neck, do not straighten the neck to place in the collar. Pad neck and head to maintain current position and restrict further movement. The patient likely has a C spine injury that could be made worse by forcing the neck straight.

Lastly, documentation is very important. Your report should list the criteria your patient met based on the treatment boxes in this protocol. Note all of your exam findings. Did the patient have pain or tenderness on exam, were they A&OX4, did they have any motor or sensory findings, and were there any distracting injuries? Based on your findings, was a cervical collar applied, and why? What was the transport position? Were any other devices used? Were there any other factors that played into your decision? 

EMS is constantly changing. The staff and Medical Directors of the University Hospitals EMS Training and Disaster Preparedness Institute truly appreciate your dedication and willingness to learn and grow with those changes. Please feel free at any time to contact us with your ideas, questions, and concerns.  

Sincerely,

Dominic Silvestro EMT-P, EMS-I

EMS Coordinator 

January 16, 2024

Happy New Year!

FOAMed

The Free Open-Access Medical Education, known as FOAMed, is a collection of educational resources that emerged from the collection of ever-evolving, collaborative, and interactive open-access medical education resources distributed on the Internet. We contribute to this body of collective knowledge in several forms including email series(Medical Director Mondays and Pharmacy Phridays), the Prehospital Paradigm Podcast, and its companion, the Prehospital Paradigm website (PrehospitalParadigm.com).

The Email Series

This series was designed to provide a continual information stream of EMS Medical Education specific to the UH EMS System. 

The Medical Director Mondays are written by the Medical Directors themselves, and we hope that it is used as additional insight into prehospital care expectations from them. This also allows a means of information conveyance when there are sentinel events that need to be brought to light by all providers to prevent re-occurrence.  

The Pharmacy Phridays is a review series on each medication within the EMS protocol to keep providers sharp on the pharmaceuticals. Many of the errors we deal with regarding protocol compliance and potential patient harm revolve around medications. We hope all providers take the time to keep on medications for safety. There is no reason a provider who cannot administer a particular agent, cannot have knowledge of them. This team knowledge can be imperative in helping prevent medication errors when everyone understands what the medications do and their indications. 

The Prehospital Paradigm Podcast

This is our flagship FOAMed product featuring our regular EMSI team with rotating guest lineups from differing specialties. This podcast series is available as both a video product on YouTube and an audio-only product available on almost every podcast streaming service. 

The vision for this series is to provide medical education in a conversational and laid-back format. The series is published every Monday on all platforms. The first three Mondays are pre-recorded, while the fourth Monday features a live broadcast simulcast on YouTube and Facebook. The live show allows the audience to message in with questions or comments during the show for interaction. 

Beginning this year, the live show will be later, hopefully, to catch more live viewers at 1900 on the fourth Monday of each week. Also, in keeping with UH’s commitment to its Medical Control departments, and taking education to the departments, the live show will be hosted at various Medical Control departments throughout the year. It will also allow in-person conversation with the department audience, as well as the Facebook and YouTube audience. View upcoming episodes HERE.

The Prehospital Paradigm Website (PrehospitalParadigm.com)

It was originally intended to be the podcast internet home, but it has expanded to much more in the FOAMed space. This site has become the repository for all FOAMed provided by UH EMSI. Here, you will not only find current and archived copies of all the Medical Director Mondays, Pharmacy Phridays, and previous CE offerings, but you will also find other original content. As a companion to every podcast video and audio posting, there are complete show notes and a collection of information from the tactical medical division, as well as our data and documentation team. 

One of the more recent additions was the great cases section, which are actual de-identified cases from our EMS departments. These are written as short reads to either highlight model care or teaching cases. 

Your feedback and questions can help us continue to form these versatile media offerings. Here is the link for the “Ask a Podcast Question” form to give us an idea of what we should cover on all the various FOAMed outlets we sponsor. 

Scott Wildenheim, Paramedic, EMSI

Operations Manager

University Hospitals

Critical Care Transport LLC.

January 22, 2024

2024 Protocol Changes

Thanks for tuning in to this week’s message. In the next couple of installments, we will examine some of the changes to the 2024 EMS protocol. Let’s start this week with changes to Adenosine as well as the changes to the cardiotox protocol.

Adenosine

Two changes have been made in the space of Adenosine administration this year. As we examined previous protocol compliance data, it was apparent we had some issues here revolving around the proper selection of this agent. As we dug further, we also realized that the protocol presentation could be contributory to the improper selection, warranting these changes. 

1. Narrow complex tachycardia

In the narrow complex tachycardia stable column, verbiage was added regarding looking for the absence of “P” waves. It is because classical EMS teachings focus too much on heart rates greater than 150 being automatically SVT. While SVT is almost always greater than 150 beats per minute, it is not the sole determinant of the rhythm. The presence/absence of P waves in a heart rate USUALLY greater than 150 with NARROW complexes should be the broader focus of the diagnosis.

It becomes dangerous in situations when people NEED the heart rate higher than 150 to compensate for something (PE, shock, etc.). Using only the heart rate determinant may lead a provider to administer adenosine to someone who is in a compensatory sinus tachycardia, often with disastrous results. Look deeper and understand the story before administering this medication. The P waves tell a lot of the story here. 

2. Wide Complex tachycardia

Previous iterations of ACLS have suggested that Adenosine may be considered in situations where there is a wide complex tachycardia that is believed to actually be a narrow complex origin rhythm with some sort of aberrancy, making it wide and ugly. It was very specific to MONOMORPHIC and REGULAR rhythms fitting this bill. It was one of the first things in the stable regular column in the wide complex tachycardia protocol in previous iterations. In review, our placement MAY have made it seem like this was the starting point for all wide complex tachycardias when the verbiage was trying to have it used in very specific situations. 

In this revision, the drug adenosine has been completely removed from the wide complex tachycardia column so as not to inadvertently cause someone who may be referencing it in a hurry to cause a medication error. The ability to use it in the aforementioned situation has not been removed; it’s just been put at the bottom of the column and gives permission to use the narrow complex tachycardia protocol in these situations. Adenosine should be used early in these wide tachycardias to “rule out” an ugly narrow complex rhythm. Again, much like the concerns in the first part of this paper, inappropriate use of Adenosine in wide complex tachycardia that truly may have disastrous outcomes. 

3. Cardio tox protocol

Last year, with the introduction of the cardiotox protocol, the individual columns teased out the various types of common cardio toxicology agents, then the presenting rhythms associated with the agent listed below. In our own training, we found ourselves simplifying the training to “follow the EKG”, as this is tied to the agent. So, we re-crafted the protocol to utilize this mindset. Now, the presenting rhythm is listed first for simplified decision-making. Although understanding the agent at play is important, treating the presenting rhythm initially makes for fast work for stabilization. 

In addition to the “follow the EKG” rework, the calcium channel blocker and the beta blocker treatment columns are almost the same. In discussion with the medical directors, it was decided that we could safely make the treatment the same for both agents for simplicity. In addition, the presenting rhythm will be the same for both, so this was all combined into one column.

We hope this helps with some of the back story with a few larger changes for 2024. 

Thanks,



Scott Wildenheim, Paramedic, EMSI

Operations Manager

University Hospitals

Critical Care Transport LLC.

January 29, 2024

2024 Protocol Changes Part 2

In the second installment of this protocol update note, we look at the changes to the cardiac sections. This year, three big changes were made in the cardiac section:

• The addition of a chest pain protocol

• The removal of the post-resuscitation targeted temperature management

• The addition of a refractory/recurrent V-Fib / V-Tach protocol

Chest Pain

In previous versions, the only chest pain treatments revolved around treatment and management of the patient having a coronary event. It may have made the impression that the ACS protocol was the landing spot for all chest pain patients when it was really for patients with a specific cause of chest pain. The simple overview  is that “not all chest pain is cardiac in nature.”

The new addition of a chest pain protocol now spells out various causes of chest pain, such as trauma, pulmonary etiologies, musculoskeletal pain, or gastrointestinal pain. This differential diagnosis page helps the provider think about potential causes and gets them started in the right direction. In its simplest form, patients with classic cardiac chest pain symptoms get treated by the ACS protocol, and everyone else gets treated by the pain management protocols unless there is another treatable cause. 

Targeted Temperature Management

In previous versions, it was stressed to cool patients after ROSC for the neuroprotective benefits of mild hypothermia. While this is clinically beneficial, the ability of EMS to do this procedure correctly to therapeutic targets is limited. For this procedure to yield the desired results, patients must be cooled deeply, and that cooling must be maintained. 

Our traditional methods of using chemical cold packs in strategic locations do not cool deep enough, and worse yet, may cause a transient decrease in temp only to have it trend back up. It is known to actually be more detrimental than not cooling the patient prehospital. While it’s an effective therapy, it needs to be done in the hospital at this point to get to the target temperature and maintain it safely. For this reason, references to targeted temperature management have been removed for 2024.

While cooling for neuroprotection is not currently in the protocol, points are made to allow the providers to treat a fever with passive cooling techniques if present during / post-arrest. Fever can be detrimental to the outcome and should be treated if identified post-arrest. 

Refractory / Recurrent V-Fib / V-Tach

Previous iterations of the protocols have suggested a few items to try if a patient refuses to respond to traditional V-Fib / Tach therapies, such as CPR, defibrillation, vasopressors, and antiarrhythmics. These may include electrical vector changes by trying differing pad placements for defibrillation or potentially double sequential defibrillation.

The addition of a new refectory V-Fib / V-Tach protocol allowed us the space to recommend trying other medications when traditional ACLS medications fail. While this seemingly departs from AHA standards, there is no firm recommendation on what to do in these cases when the textbook response fails. The medical directors have authorized this protocol as the best option available when nothing else works. It essentially authorizes the use of other medications not already used in addition to the defibrillation above techniques since these patients may still be salvageable. 

Thanks,



Scott Wildenheim, Paramedic, EMSI

Operations Manager

University Hospitals

Critical Care Transport LLC.