This month's Medical Director messages will focus on the clinical decisions that are made every day in the care of our patients. To make an appropriate decision, you must assess the patient's situation. That's where we will begin.

In order to come to a likely diagnosis, you must start with a broad differential diagnosis of all the possible diseases that can be causing the symptoms. The differential starts with the dispatch complaint. For example, if the call is for shortness of breath, the possibilities include asthma, COPD, pneumonia, CHF, Covid, Pulmonary Embolism, anemia, pneumothorax, STEMI, etc. We start to formulate this before even seeing the patient. We must limit our differential diagnosis to the most probable 2-3 diseases to initiate appropriate treatment. This process occurs with every patient interaction, and we may not realize that we are doing it.

The assessment starts with the scene size up. Whether it’s a medical call in a home or an MVC, the scene must be safe. Once we know the scene is safe, we start to gather clues from what we see. Examples include the damage to a vehicle involved in an MVC. Things like starring of the windshield and intrusion into the passenger compartment give us information about the mechanism of injury. We can gather other types of information from the scene as well. It is important to note the living conditions of our patients. Is there heat, water, food, electricity? Are there empty pill or liquor bottles? Are there ashtrays or cigarette packets lying around? Every piece of data gives us more clues to the possible illness and we still have not assessed the patient.

I like to think about patient assessment using the SOAP note method:

• Subjective: This is information that the patient tells us: their chief complaint, history of present illness, aggravating or alleviating factors, past history, medications, etc.

• Objective: Things that we can measure: physical exam, vital signs, EKG, capnography, and blood sugar are all examples.

• Assessment: We combine the subjective and objective data to assess the likely diagnosis.

• Plan: After our assessment, we plan and initiate our treatment using the appropriate protocol.

Part of the plan will be determining the need for transport, the method of transport, and the appropriate receiving facility. We will consider these decisions in next week's message.

Tony Daher  

Clinical Decision Making - March 8, 2021

This week we will continue to think about the clinical decisions that we make every day in caring for our patients. Since last week's message referenced the clinical assessment, as a logical next step, this week is about deciding whether a patient requires transport.

The decision to transport must consider the patient assessment which includes subjective and objective data. Most of our patients have a complaint that will need evaluation at the hospital. High-risk symptoms and abnormal vital signs should prompt evaluation. 

Not to mention there is always the chance a patient will refuse transport. If the patient refuses transport, then we need to determine the capacity to refuse transport.

Capacity deals with the medical decision and must be assessed in a patient refusing care. Capacity is situation-specific, for example, a person may lack capacity when intoxicated but have capacity when they are sober.

To have capacity, a person must be alert and oriented x4. They must know who they are, where they are, and what time it is. Orientation to time does not have to be the specific date, which may be difficult, especially in the early morning hours. Knowing the month and year is sufficient. The patient must also understand the situation and the possible consequences of their decision. They must understand what they are refusing and the possible (worst case) consequences of refusing care.

It is best to document the discussion saying that the person was alert and oriented x 4 and understood by refusing _______ they may have _______, worsening symptoms up to and including death. In this situation, the person should sign a refusal of care form.

Competency, on the other hand, is a legal definition that must be determined by a court of law. Below is a key to help further clarify the two terms. If the patient and caregivers agree about the need for transport, the decision then becomes the location of transport. Next week's message will examine the possible facilities for transport. 

If the patient and caregivers agree about the need for transport, the decision then becomes the location of transport. Next week's message will examine the possible facilities for transport.

Tony Daher, MD

Emergency Medicine

Clinical Decision Making - March 15, 2021

This week we continue with the clinical decisions that are necessary to care for our patients. Last week we discussed capacity in deciding or refusing transport. For the patients who consent to transport, the question becomes where to transport the patient. To decide on the best location, we must anticipate the patient's needs. these may include admission to the hospital, cardiac catheterization, stroke care, neurosurgery, hand surgery, ophthalmologic evaluation, etc. We must be aware of patient’s immediate needs as well as within the next few hours. For example, a patient with potential pneumonia will initially need a chest x-ray, blood work, and antibiotics, but they may need admission to the hospital after their workup.

Once the patient's needs have been determined, transport to a receiving hospital with the necessary capabilities can begin. Knowing local hospital capabilities is important: which hospital has a cath lab for the STEMI patient? Where can you take a stroke patient to get TPA or mechanical thrombectomy?

Stroke Centers are a different story since they are certified under different levels.

Stroke Centers:

•   Stroke Ready - Initial stabilization and TPA but then transfer for admission

•   Primary Stroke Center - Administration of TPA and admission but transfer for complex cases

•  Comprehensive Stroke Center - Complete care with all available treatments

The Ohio Revised Code defines trauma and requires the transport of trauma patients to trauma centers. Other transport is mandated by law and trauma centers are certified by the American College of Surgeons and are separated into adult and pediatric trauma centers; designated Level 1, 2, or 3.

There are five exceptions to trauma transport and they must be documented.



Trauma exceptions:

1. Needing immediate stabilization.

2. Inability to travel to a trauma center due to weather.

3. Limited resources to leave your jurisdiction.

4. The trauma center is on diversion.

5. Prior to transport, a patient with capacity refuses transport to a trauma center.

Other transport considerations include distance to receiving facility, patient preference, and insurance networks. While many things impact our decision on where to transport a patient, the most important factor is getting a patient to the right place to receive the care needed.

Next week we will review the appropriate transport methods.

Tony Daher, MD

Emergency Medicine

Clinical Decision Making - March 22, 2021

We will continue our review of clinical decisions made in the care of our patients by assessing the mode of transport to the receiving facility. The options are by ground (BLS or ALS including ALS intercept) or air.

BLS ground transport:

This is the cheapest mode of transport with average costs of around $500. Also, according to the Ontario Prehospital Advanced Life Support (OPALS) study, there was no increase in survival to hospital discharge for patients treated with ALS care vs. BLS care in out-of-hospital cardiac arrest and severe trauma. The study showed that concentrating on good BLS care with high quality CPR and rapid transport had equal survival to ALS care.

ALS ground transport:

There are patients who would benefit from ALS care. For example, patients who require fluid resuscitation or dysrhythmia treatment. This advanced care comes at a cost, as average ALS transport costs $500-1000. ALS intercept involves transferring care from a BLS squad to an ALS squad, or picking up a paramedic to provide care. If using ALS intercept, there might be increased transport time to consider and weigh against the benefit of ALS care.  

Air Medical transport:

Air medical is the most expensive transport option. According to an article in JEMS, the median cost of helicopter transport is $10,200 with costs sometimes exceeding $25,000. The benefit of helicopter transport is the advance capabilities of the helicopter team including initiating blood products.

Another benefit is decreased transport time if the receiving facility is assistance. A study in the Journal of Trauma showed that transport by ground was faster if the hospital was less than 10 miles away. It was always faster by air if the hospital was greater than 45 miles away. For transport between 10 - 45 miles, other factors must be considered including dispatch times, arrival times, and transfers of care. Air medical should be considered if you are far away from the receiving hospital or if there is extended on scene time due to prolonged extrication for example.

In conclusion, we need to get the patient to the right place by the most appropriate method. The decision of the most appropriate method includes consideration of cost, time and capabilities.

Tony Daher, MD

Emergency Medicine

MAP - March 29, 2021

The Mean Arterial Pressure (MAP) is the average blood pressure felt in the artery during a cardiac cycle. MAP is now recorded by most monitors. 

As you can see from the picture, a BP of 120/80 gives you a MAP of 93. It can also be calculated using the formula:   

2x diastolic BP + systolic BP

3

The MAP is heavily weighted towards the diastolic BP. The formula uses 2/3 diastolic BP and 1/3 systolic BP because diastole is longer. The average cardiac cycle takes 0.8 seconds. Diastole averages about 0.5 seconds of the cycle. So, the artery feels the diastolic BP longer than it feels the systolic pressure. The average is probably a better indicator of the pressure delivered to the cell. This is important because we worry about perfusion to the cells.

If you recall, the cell is in shock when it is not getting normal perfusion. When a cell is in shock, it does not obtain normal blood flow and oxygen and changes to anaerobic metabolism. During anaerobic metabolism, the cell only produces two molecules of ATP and no longer releases CO2. Also, a byproduct of anaerobic metabolism, Lactic Acid, is produced. Therefore, low capnography and elevated lactic acid levels are a sign of hypoperfusion and shock. You can easily measure capnography and studies are promoting measuring levels of lactate in the pre-hospital setting as an indicator of shock. The most common type of shock is septic shock.

We aim for a MAP of 65 to ensure adequate perfusion of the cells and avoiding anaerobic metabolism. Treatment of hypoperfusion and shock is dependent on the cause but typically involves fluid resuscitation. If fluid resuscitation alone is not enough, then push dose epinephrine is appropriate. Remember 1mg of epinephrine mixed in 100 ml of D5 and dosed at 1ml every 2-5 minutes until a MAP of 65 is achieved. Resuscitating patients to a MAP of 65 will keep patients out of shock and save lives.

Tony Daher, MD

Emergency Medicine