FOAMfrat Podcast

Man whats up with this podcast?!!! by Tyler Christifulli & Sam Ireland

The paramedic intercept is a skill just as any other. Commonly overlooked during initial training, effective communications used during the patient handoff plays a significant role in patient care. Actually, the Joint Commission concluded that 70% of hospital-related “sentinel events” involved communications, with 50% of those events occurring during patient care handoffs. (J Quality Patient Safety, 2010 Feb; 36(2)) Think of the last time you were giving report, just to have the accepting physician or RN ask questions that would’ve already been answered had they been listening, and not just hearing you. I constantly listen to gripes from my peers how they felt disrespected by hospital staff, only to arrive on a scene with them and they do the exact same thing to a lower-scope provider. This hypocrisy is avoidable. Check out the blog at www.FOAMfrat.com

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!

Just some end of the week topics to get out! Update on the Proposed Ventilator Strategy (Podcast 23) Interview with Chip Lange from TOTALEM http://www.totalem.org/emergency-professionals/podcast-51-a-proposed-hybrid-ventilation-strategy-with-tyler-Christifulli Lifestar Podcast has an official home on the web! Check out my collaboration project with my good friend Sam Ireland. Congrats to Adam LaChappelle for winning the EMSPOCUS book. Have a great weekend!

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!

I recently received a question from a reader regarding a recent blog post I had done on compressions. In that article I discussed the science behind why allowing full recoil is important for adequate coronary perfusion. One can assume that the reasoning behind the 2015 AHA Guidelines cap of 120 on compressions, has something to do with allowing an adequate amount of time for recoil (diastole). The question that was proposed, was my thoughts on a prospective single center observational study done in September of 2016. This study included 222 patients in cardiac arrest who received manual chest compressions while in a hospital. The results were a mean chest compression rate of 139 + or - 15. Overall 53% achieved ROSC. This study concluded by saying that “In this sample of adult IHCA patients, a chest compression rate of 121-140 compressions / min had the highest ratio of ROSC." At a first glance this seems very intriguing. However once I began to scrutinize this study, I noticed some concerns. Here is my analysis of this study. 1. My first thought was that in this multivariable logistic regression they used ROSC as an outcome rather than CPC scores. If we want to utilize ROSC as an endpoint, we need more epi! 2. The study says that the compressors did not know why they were being observed, did not use a metronome, and were rotated every two minutes. Chest compressions were measured with defibrillation electrodes, which recorded change in thoracic impedance. This technique does not allow recording of chest compression depth and recoil. I also am curious if they rotated compressors every two minutes, how they were able to blindly maintain consistent rates above 120 amongst multiple providers. 3. The participant inclusion criteria used was (1) Age > 18 years, (2) cardiac arrest, defined as a documented absence of pulse and CPR initiated, and (3) cardiac arrest witnessed in hospital. We know that witnessed cardiac arrest with immediate CPR obviously increases the likelihood of ROSC and improved CPC. It was also mentioned that "a high proportion of these participants were already intubated. I wonder what the results would be for this in OOH arrest. 4. The latter part of this study mentions a high proportion of participants received a CPC of 5 (death), resulting in not enough power to find a statistically significant difference in neurological outcome. In my blog and podcast regarding the science of compressions I refer to three contributing factors to an adequate coronary perfusion pressure (CPP). You need to have an adequate amount of aortic reserve pressure at the site of the coronary ostia during diastole, you need an adequate amount of recoil to allow a bellow effect and draw blood into the coronary arteries, and you need an end ventricular pressure low enough to not compromised coronary flow. An aspect I didn’t mention in this article is factors that contribute to adequate cerebral flow. In the Thoracic Pump Theory it is believed that the recoiling state of the decompressed chest creates a negative pressure which draws blood back into the heart. This negative pressure helps reduce ICP by optimizing cerebral drainage and reducing the flow resistance within the brain. One can assume that increased compressions per minute allows less time in diastole. This could possibly explain the low CPC score for this study. The Study From The ERC. https://www.ncbi.nlm.nih.gov/m/pubmed/27666168/

This mini episode is meant to cover the logistics of setting up your induction & post procedure sedation package. Our poison of choice is obviously Ketamine because of its panoply of sexy advantages when it comes to DSI.

In a very simplified approach to ventilation we can separate our vent strategies into either an obstructive or injury patient. Obstructive patients are known to have an increased amount of effort on the exhalation phase of the respiratory cycle. Exhalation is a passive phase of breathing and when a reduction in airway caliber occurs, there is little recruitment of muscle to assist in the process. A putative practice is to reasonably reduce the minute volume and increase the exhalation time. With the obstructive patient already having an underlying pathology that causes carbon dioxide (c02) retention, the reduction in minute volume is usually well tolerated. The injury patient is essentially for everyone else. In an attempt to reduce the frequency of barotrauma and acute lung injury, evidence suggests the routine use of lower tidal volumes (Vt). A standard practice is to start off around 6-8cc/kg of IBW. This strategy is the go-to method for patients presenting with decrease lung compliance due to infiltrates and in the worst case scenario Acute Respiratory Distress Syndrome (ARDS). The clinician usually battles the task of adequate oxygenation in this subset. Recruitment maneuvers are performed in an attempt to increase the surface area for gas exchange. These techniques are performed with inspiratory maneuvers, and maintained with PEEP. I believe we have seen vast improvement in the way we care for each of these disease processes. I don’t think we have opened up enough dialogue as to how to approach when these two pathologies collide. Before You Touch The Ventilator: There are a series of thought processes one must intuitively execute before we initiate a ventilator strategy. The first is recognizing that the sicker the patient is, the wide the pulse ox latency will be. A healthy individual will have an approx. 30 second lag from central to peripheral circulation. This increases as hemodynamics deteriorate. It is not uncommon for a septic patient to have over a 2 minute lag time. What does this mean for you? Don’t expect abrupt changes in oxygenation after each turn of the dial. A good practice is to allow two minutes between an adjustment and a response. For example, if I set my positive end expiratory pressure (PEEP) to 10, I shouldn’t briskly crank it to 15 without allowing an appropriate amount of time. Get in the habit of figuring out your PaC02/ETc02 gradient. Unless you are able to analyze blood gas values on transport, this is your time to figure out what your Knowing that the COPD patient lives off of a hypoxic drive, we can reasonably conclude that a saturation of 90% is a good goal for oxygenation. With an assumed right shift on the oxyhemoglobin disassociation curve, this would require a Pa02 of approx. 90-100 mmhg. The Strategy: To initiate this strategy we are assuming the patient is hypoxic and hypercapneic. Step 1. Start with 6cc’s /kg of IBW & Frequency of 12 bpm. Fi02 should be set at 1.0. Step 2. Auto Peep and Pplat should be assessed. Step 3. Set extrinsic PEEP to 75% of Auto Peep. This will aid in stenting open the terminal bronchiole and make up for diseased elastin. Preventing cyclic opening is a secondary benefit of this approach. Step 4. If VTE is