EMS Clinical Brief

What does it really take to administer pediatric medications safely in EMS—and what can go wrong even when clinicians use cognitive aids? Host Maia Dorsett interviews Bryan Harmer, a paramedic researcher and expert in pediatric medication safety who has used simulation to directly observe and characterize medication errors. Together, they unpack the often-overlooked microskills involved in pediatric medication administration, from determining weight and calculating doses to preparing, administering, and documenting medications. Drawing on Bryan’s research, they explore how seemingly small errors—including incorrect use of length-based tapes, air in syringes, and bedside dilution—can lead to discrepancies between the dose intended, the dose administered, and the dose documented. They also discuss why cognitive aids alone aren't enough and share practical strategies EMS systems can use to identify hidden risks and improve medication safety through simulation, equipment selection, and medication cross-checks.

References:

1. Hoyle Jr, J. D., Davis, A. T., Putman, K. K., Trytko, J. A., & Fales, W. D. (2012). Medication dosing errors in pediatric patients treated by emergency medical services. Prehospital emergency care, 16(1), 59-66.
2. Hoyle Jr, J. D., Ekblad, G., Hover, T., Woodwyk, A., Brandt, R., Fales, B., & Lammers, R. L. (2020). Dosing errors made by paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference. Prehospital Emergency Care, 24(2), 204-213.
3. Harmer, B. M., Hoyle Jr, J. D., Edwards, A., Fredericks, T., Wells, L., Lecznar, A., ... & Fogarty, K. (2026). Assessing the influence of a statewide dosing reference aid on prehospital pediatric medication dosing errors: a mixed-methods simulation-based investigation. Prehospital emergency care, 30(6), 848-855.
4. Harmer, B. M., Hoyle Jr, J. D., Wells, L., Fredericks, T., Edwards, A., Lecznar, A., ... & Fogarty, K. (2026). A Simulation-Based Root Cause Analysis of Pediatric Medication Dosing Errors in Emergency Medical Services. Prehospital emergency care, 1-9.
5. Dorsett, M., O’Donnell, S., Strickland, W., Cheng, W., Sensenbach, B., Cannuli, M., ... & Cushman, J. T. (2026). Improving pediatric medication safety through implementation of evidence-based guidelines. Prehospital Emergency Care, 1-8.

Hospital pre-notification can directly influence how quickly patients receive time-sensitive care. In this episode of the EMS Clinical Brief, host Maia Dorsett is joined by Tyler LeMay and Jennifer McLymond to explore pre-notification as a clinical intervention, focusing on patients whose next critical treatment requires resources beyond the ambulance—including those with suspected occlusion myocardial infarction, stroke, and major trauma. Through practical examples, they discuss when notification should take priority over other prehospital tasks, how early notification enables parallel processing at the receiving hospital, and how to communicate essential information using a concise, structured framework.

References:

1. Nam J, Caners K, Bowen JM, Welsford M, O'Reilly D. Systematic review and meta-analysis of the benefits of out-of-hospital 12-lead ECG and advance notification in ST-segment elevation myocardial infarction patients. Annals of Emergency Medicine. 2014;64(2):176-186.
2. Shavadia JS, Roe MT, Chen AY, Lucas J, Fanaroff AC, Kochar A, et al. Association between cardiac catheterization laboratory pre-activation and reperfusion timing metrics and outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A report from the ACTION Registry. JACC: Cardiovascular Interventions. 2018;11(18):1837-1847.
3. Nielsen VM, Song G, DeJoie-Stanton C, Zachrison KS. Emergency medical services prenotification is associated with reduced odds of in-hospital mortality in stroke patients. Prehospital Emergency Care. 2023;27(5):639-645.
4. Durr K, Ho M, Lebreton M, Goltz D, Nemnom MJ, Perry J. Evaluating the impact of pre-hospital trauma team activation criteria. Canadian Journal of Emergency Medicine. 2023;25(12):976-983.
5. Deeb AP, Guyette FX, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, et al. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. Journal of Trauma and Acute Care Surgery. 2023;94(4):504-512.
6. Ahmed OZ, Yang S, Farneth RA, Sarcevic A, Marsic I, Burd RS. Association between prearrival notification time and Advanced Trauma Life Support protocol adherence. Journal of Surgical Research. 2019;242:231-238.

In this episode of the EMS Clinical Brief, host Maia Dorsett interviews Amelia Breyre, an emergency physician, EMS physician, and EMS Medical Director for the City and County of San Francisco who is nationally recognized for her expertise in prehospital palliative care and advance care planning. Together they explore how EMS clinicians can provide goal-concordant care by understanding advance care planning documents, including advance directives, health care proxies, and POLST/MOLST forms. They discuss how to interpret these documents, distinguish legal documents from actionable medical orders, navigate challenging situations involving limited interventions, and develop practical communication skills to clarify patient goals before initiating invasive treatments. The episode emphasizes that one of EMS's most important roles is not simply delivering medical interventions, but ensuring that the care provided aligns with what the patient would have wanted.

CAPCE-accredited CME Available @Prodigy EMS: https://frontend.prodigyems.com/class/511A0F86-3B25-4A57-8D2E-91F1B9F26F76?tab=overview

References:

1.Breyre, A. M., Sporer, K. A., Davenport, G., Isaacs, E., & Glomb, N. W. (2022). Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions. BMC Emergency Medicine, 22(1), 145.

2. Breyre, A. M., Merkle-Scotland, E. J., Yang, D. H., Hanson, K., Jagani, S., Tolkoff, A., & Gunaga, S. (2025). Do not resuscitate (DNR) emergency medical services (EMS) protocol variation in the United States. The American journal of emergency medicine.

3.Breyre, Amelia M., Haley Vertelney, Karl A. Sporer, Glen Davenport, Eric D. Issacs, and Nicolaus W. Glomb. "Emergency medical service interpretation of Physician Orders for Life‐Sustaining Treatment (POLST) in cardiopulmonary arrest." Journal of the American College of Emergency Physicians Open 3, no. 2 (2022): e12705.

Dispatch systems are designed to get the right resources to the scene based on limited information, but the dispatch determinant is only the beginning of the patient assessment. Because dispatch decisions must be made before EMS arrives, some patients receive ALS resources that ultimately are not needed, while others may require a higher level of care than initially recognized. As a result, determining the appropriate level of transport depends on the assessment performed at the patient's side—not the dispatch determinant alone. In this episode, Maia Dorsett is joined by Roger Stone, Ben Kaufman, and Jeremy Cushman to discuss how EMS clinicians and systems can determine whether a patient requires ALS transport or can be safely transported by a BLS crew. Drawing on Montgomery County's pioneering work in developing and validating an ALS downgrade process, the panel explores common pitfalls, the importance of thorough assessment, strategies to avoid missed diagnoses, and the role of structured decision-making in improving patient safety while making the best use of limited ALS resources. Whether you are an EMT, paramedic, educator, quality leader, or medical director, this conversation offers practical insights into building systems that support consistent, patient-centered transport decisions.

Resources:

Montgomery County Resources: Checklist, posters, presentations

Monroe-Livingston policy on Determining the Appropriate Level of EMS Clinician for Patient Transport

CAPCE accredited CME available @ Prodigy EMS: https://frontend.prodigyems.com/class/CDB94B9A-6A2F-4DFD-A91F-C6F270700826?tab=overview

What happens when we fail to treat pain early in older adults? What unique considerations arise when managing pain in geriatric patients in the prehospital setting? In this episode of EMS Clinical Brief, Dr. Maia Dorsett is joined by Dr. Tony Rosen, Dr. Aaron Farney, and paramedic Kevin Gustina for a thoughtful conversation about prehospital pain management in older adults, particularly after falls and hip fractures. The discussion explores how untreated pain contributes to delirium, physiologic stress, and downstream complications, while also examining the cultural and operational barriers that often lead to under-treatment in EMS. Through practical examples and a discussion of a regional quality improvement initiative, the episode highlights how small changes in assessment and treatment can meaningfully improve patient outcomes. This is a clinically grounded and deeply human conversation about one of the most common yet overlooked aspects of EMS care.

Learning Objectives:

By the end of this episode, listeners should be able to:

1. Describe the physiologic and clinical consequences of untreated acute pain in older adults, including the relationship between pain and delirium.
2. Discuss unique considerations in geriatric pain management, including altered pharmacology, dementia, multimodal analgesia, and age-adjusted opioid dosing.
3. Identify operational, cultural, and systems-based barriers to effective prehospital pain management and strategies to improve care for older adults with suspected hip fractures.

Resources:

MLREMS Suspected Isolated Hip Fracture Care Bundle: https://www.mlrems.org/wp-content/uploads/2026/04/Care-Bundle-Suspected-Isolated-Geriatric-Hip-Fracture.pdf

CAPCE credit for this episode available for members of Prodigy EMS: https://frontend.prodigyems.com/class/E95419B8-E766-4FF2-B6AE-587EA3C2927C?tab=overview

References:

1. Thompson, C., Brienza, V. J., Sandre, A., Caine, S., Borgundvaag, B., & McLeod, S. (2018). Risk factors associated with acute in-hospital delirium for patients diagnosed with a hip fracture in the emergency department. Canadian Journal of Emergency Medicine, 20(6), 911-919.
2. Morrison, R. S., Magaziner, J., Gilbert, M., Koval, K. J., McLaughlin, M. A., Orosz, G., ... & Siu, A. L. (2003). Relationship between pain and opioid analgesics on the development of delirium following hip fracture. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 58(1), M76-M81.
3. De Simone, B., Chouillard, E., Podda, M., Pararas, N., de Carvalho Duarte, G., Fugazzola, P., ... & Catena, F. (2024). The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World journal of emergency surgery, 19(1), 18.
4. McGuire, S. S., Brown, C. S., Palmer, A. K., Jeffery, M. M., Mullan, A. F., Stanich, J. A., ... & Bellolio, F. (2026). The Downstream Effects of Prehospital Opioid Dosing in Older Adults: A Retrospective Cohort Study. Academic Emergency Medicine, 33(4), e70294.
5. Hughes, J. A., Alexander, K. E., Spencer, L., & Yates, P. (2021). Factors associated with time to first analgesic medication in the emergency department. Journal of Clinical Nursing, 30(13-14), 1973-1989.

In the inaugural episode of EMS Clinical Brief, Maia Dorsett and Shane O'Donnell are joined by Jeff Jarvis for a candid, high-level conversation on patient-centered airway management. Framed by lessons from the NEMSQA Airway Collaborative, the discussion challenges long-held assumptions about airway success—moving beyond “getting the tube” to asking what actually improves patient outcomes. Through real-world examples, debate, and reflection on past missteps, the group explores how EMS culture, training, and system design have historically prioritized procedures over physiology. They unpack the tension between clinician identity and patient need, examine the risks of hypoxia and hypotension during airway interventions, and highlight how thoughtful metrics and policies can reshape practice. 

CAPCE-accredited CE for this episode is available via Prodigy EMS at https://www.prodigyems.com/

References discussed:

1. Dorsett, M., Cooper, R. J., Taira, B. R., Wilkes, E., & Hoffman, J. R. (2020). Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emergency Medicine Journal, 37(4), 240-245.
2. Jarvis, J. L., Panchal, A. R., Lyng, J. W., Bosson, N., Donofrio-Odmann, J. J., Braude, D. A., ... & Sholl, J. M. (2024).Evidenced Based Guidelines for Prehospital Airway Management Prehospital Emergency Care, 28(4), 545-557.
3. Spaite, D. W., Hu, C., Bobrow, B. J., Chikani, V., Gaither, J. B., Barnhart, B., ... & Keim, S. M. (2017). Effect of Prehospital Hypoxia “Depth-Duration Dose” on Mortality in Major Traumatic Brain Injury. Journal of Emergency Medicine, 53(3), 443.
4. Vithalani, V. D., Vlk, S., Davis, S. Q., & Richmond, N. J. (2017). Unrecognized failed airway management using a supraglottic airway device. Resuscitation, 119, 1-4.
5. Jarvis, J. L., Jarvis, S. E., & Kennel, J. (2025). The association between out-of-hospital drug-assisted airway management approach and intubation first-pass success. Annals of Emergency Medicine.
6. Robinson, A. E., Knack, S. K., Driver, B. E., Prekker, M. E., Perlmutter, M. C., Bunting, A. J., ... & Puskarich, M. A. (2025). Trends in Prehospital First-Attempt Use of Supraglottic Airways in Non-Cardiac Arrest Patients: A Descriptive Study. Prehospital Emergency Care, 1-8.
7. Jabre, P., Penaloza, A., Pinero, D., Duchateau, F. X., Borron, S. W., Javaudin, F., ... & Adnet, F. (2018). Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiorespiratory arrest: a randomized clinical trial. Jama, 319(8), 779-787.
8. Do it For Drew Foundation: https://www.doitfordrew.org/