FOAMfrat Podcast

Lately I have received some really good questions and comments based off of my blog I did a few months ago "You're not dead until you have an airway." Here are those comments: "This seems to completely ignore the growing evidence that an airway during arrest is correlated with worse outcomes." The mere presence of an established airway is not the problem with low CPC score or achievement of ROSC. The areas of advanced airway placement that I would speculate contribute to worse outcomes are. 1. Interruption in chest compressions to allow a provider to intubate. 2. Low resources and over ambition with airway as a priority rather than chest compressions and defibrillation. 3. Two hand bagging once an advanced airway is in place (decreased dead space.. increased ITP) A OPA or NPA is an airway ADJUNCT. These should be used as a bridge in the initial stages of cardiac arrest until either an SGA or ETT can be placed. This recent study shows higher complication rates when providers ONLY used airway adjuncts and BVM during cardiac arrest... go figure. http://www.mdedge.com/ecardiologynews/article/150634/arrhythmias-ep/bag-mask-ventilation-cpr-deflates-large-rct According to AHA 2015 Guidelines, continuous chest compressions can only be initiated once an advanced airway is placed. So it would make sense to place an advanced airway in a somewhat timely manner to avoid the need to stop every 30 compressions to deliver ventilations. This doesn't necessarily need to be an ET tube. Check out the blog! https://www.foamfrat.com/single-post/2017/11/03/ApOx-Suction-and-OOHA-Airway-Management

"You can't teach an old dog new tricks" is clearly repeated by an elderly man who's family got concerned he was having a stroke when they noticed some gait ataxia. EMS does a quick Cincinnati Stroke Scale and doesn't detect any deficits, 12 lead looks normal, and blood glucose is within normal limits. Should he be evaluated in the emergency room? Should EMS be concerned about a central lesion? Does a negative Cincinnati mean the patient is not having a CVA? Check out the show notes! https://www.foamfrat.com/single-post/2017/10/15/Beef-Up-Your-Neuro-Exam-with-Chip-Lange

“When you think you’re safe is precisely when you’re most vulnerable.” – Kambei Shimada, Akira Kurosawa’s The Seven Samurai Check out the show notes! https://www.foamfrat.com/single-post/2017/10/05/Common-Pitfalls-Of-ROSC

Before Google images and digital cameras, drawing was taught as an essential skill for scientist. This was the most effective way to communicate and teach findings. In addition, this allowed scientist to enhance their observation and identify holes within the way they see structures of study. As clinicians we are commonly put in situations where we need to be able to recognize patterns, visual cues, and structures. The problem is recognition can only be as good as our initial exposure and perception to the source of interest. For example; when Paramedic students are studying the airway anatomy, the main object on their mind is the vocal cords. They commonly will bury their blade into the hypopharynx and quickly become lost in a sea of pink tissue. They aren't looking for the epiglottis, they are on a mission to find the vocal cords. Their initial perception was obscured by their procedural momentum. How Do We Fix This? A few years I incorporated something I call " Illustrative Competence" into my practice. This is the ability re-create something from scratch. All you need to test your knowledge of vital memory aided images is a blank piece of paper and pencil. Below are three experiments for you to try out. Do not become frustrated if this proves to be difficult at first. Remember you are not testing your ability to draw, but rather looking for holes in your cognitive gallery. Draw a normal 1 2 lead from scratch. Sketch out the anatomy of the airway. Illustrate the cardiac conduction cycle. Now check out the podcast!

There is just not a whole lot of exposure to infusion mixing and administering in Paramedic school. In this episode I discuss what I think to be the four "must know" infusions in my current setting. High Dose Nitro! It doesn't make sense to break the CPAP seal every time you want to give a spray of nitro. IV nitro is the best way to care for the acute sympathetic pulmonary edema patient. You need quick reduction of afterload.. and you need it now. We do an initial bolus of 400mcg over 2 minutes while an infusion of 100mcg/min is being set up on our IV pump. This has been implemented in our protocols and is not recommended unless you have done the same. A paramedic should definitely have a plan to deliver either epi or norepi in an efficient and safe matter. Our typical concentration for norepinephrine is 4 mg in 250 bag of 0.9% or D5w. This renders a concentration of 16 mcg/ml. If I want to start it off at 5mcg/min, I set my pump to 18.7ml/hr. If I decide I need more inotropic or chronotropic response I can consider epinephrine. We typically mix this as 1000mcg in 500ml (depending on how much fluid you want to give). Ask a new paramedic how he plans to deliver his 150 mg of Amio over 10 minutes! These mental steps just be premeditated and planned before you have a patient in ventricular tachycardia sitting in front of you. We place 250 mg in a 250 bag of D5w. The initial bolus is run in by placing the IV pump at an infusion rate of 900 ml/hr and a volume to be infused of 150ml. This is nice because if you need to start a maintenance Amio drip later you can just set the pump to 60ml/hr (1mg/min). Ketamine intubations are the cats ass right now, which is good! However, it only lasts fifteen to twenty minutes. You need to immediately be thinking of starting a Ketamine drip to prevent your patient from coming down the K continuum to the "disassociated and aware" stage. We throw 500 mg in a 500 bag of 0.9%. This will be ran at whatever the patient weighs in KG's. For example a 120 kg person will receive 1mg/kg/hr or 120 ml/hr. Now go practice!

My friend Rob Zoladz gave an incredible talk on why not treating abdominal pain is inhumane. He gave this talk for a new segment we are doing before each monthly training called "Breaking EMS Fallacies". This is our attempt to create a work atmosphere free from dogmatic beliefs. References: 1. Brewster GS, Herbert ME, Hoffman JR: Medical myth: analgesia should not be given to patients with an acute abdomen because it obscures the diagnose. West J Med 2000; 172:209-210 2.Kim MK, Strait RT, Sato TT, Hennes HM: A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 2002; 9:281-287

In this episode I converse with my friends Brandon Oto & Dominic Walenczak on how we can narrow the gap between our Critical Care Team and the transferring or receiving ICU. Brandon Oto's Website http://critcon.org/about Dominic Walenczak's Podcast https://www.critmedic.com/ Are the levels of sedation in the ICU adequate for our austere transport environment? What kind of logistical nightmare will it cause if we change out infusion agents during transport? What kind of equipment is useful or what is dead weight on a transport. Sedation article from Oto https://exit.sc/?url=http%3A%2F%2Fcritcon.org%2Farchives%2F322 How can we improve our relationship with local ICU's All this and more in episode 27!

In part two we discuss equipment options, deployment strategies, and acknowledging how bad we are at using a stethoscope in medicine! Also.... listen to how you can win your own copy of The Point of Care Ultrasound Handbook by EMSPOCUS. https://www.amazon.com/s/ref=nb_sb_noss/144-2034685-0941859?url=search-alias%3Dstripbooks&field-keywords=EMSPOCUS

In this two part series I sit down and chat with the EMSPOCUS guys on questions that come up when a service is looking to adopt point of care ultrasound into their service. Will it delay my scene time? How long will it take to train my staff? Will insurance reimburse for the exam? All these and more answered by some pretty gnarly dudes!