Liquid Plasma aka "Never Frozen Plasma"

/
Liquid Plasma aka "Never Frozen Plasma"

I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).

Here is what Ryan has to say…

In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)

Read More

Grand Rounds Recap - 7/23/14

/
Grand Rounds Recap - 7/23/14

n general, the best way to learn is to challenge yourself.  Teaching styles should take into account different learner types and levels

Learner levels:

  • Beginner: early 3rd year medical student
    • Can be an observer initially but transition these learners to the next stage
    • Keeps you on point as you have to really know what you are talking about
    • Incorporate them into your H+P
    • Transitional: ask them to perform supervised H+Ps as this prevents them from developing bad habits
    • Advanced:OMP (one minute preceptor) or SNAPPS model
Read More

Logistics are Critical

/
Logistics are Critical

Not much gets me as fired-up anymore as trying to optimize them. While I like to think that it’s because they are integral to our mission and are the ultimate weapon in our quest to go from “good to best”, it’s really just my borderline OCPD (just kidding…sort of).

Long story short, I spend a lot of time thinking about clinical and operational logistics in HEMS – it’s become my thing. My goal with this post is to share some of that thinking with others who might want to build off of our ideas in hopes that those colleagues (i.e. you) will share their ideas that they are really excited about with us at some point.

Read More

Grand Rounds Recap - 7/16/14

/
Grand Rounds Recap - 7/16/14

Oral Boards Case with Dr. Blomkalns

The pt is a 70 yo M who presents with AMS, weakness and nausea for 1-2 days. He complains of diffuse weakness and feeling "sick". His hx is significant for HTN, HLD, CHF and he takes digoxin. Vital signs on arrival are BP 90/60 with HR 47. There is concern for digoxin toxicity, so dig level is obtained and is 2.4

(normal is less than 1.2).

His K is 6 and Cr is 1.9. EKG shows LBBB.

Read More

Isn't that CT Enough? - Water Cooler Breakdown of CT vs CT/LP for SAH

/
Isn't that CT Enough? - Water Cooler Breakdown of CT vs CT/LP for SAH

Why Should You Care?

  • Headache approximates 2% of presenting complaints to the ED, and SAH is identified in approximately 1% of those patients with headache in the ED.
  • Overall mortality of SAH is high, estimated at 25-50% of patients dying within 6 months
  • If not fatal, SAH leaves approximately 33% of survivors with some appreciable neurological deficit affecting their ADLs.
Read More

The Glories of End Tidal CO2

/
The Glories of End Tidal CO2

If you were to choose one vital sign for your critically ill patient, what would you choose?  Blood pressure?  Pulse?  Respiratory rate?  O2 sat? Temperature? Certainly it’s nice to know if a patient’s BP is super low or sky high, but if you are evaluating someone for the presence of shock, and you are waiting on the BP cuff to cycle one more time, you are already behind in recognizing and correcting the patient’s physiologic derangements.

Read More

Grand Rounds Recap - 7/2/14

/
Grand Rounds Recap - 7/2/14

EM: Past, Present and Future with Dr. Pancioli

  • Emergency Medicine started in 1960s with first "ER group" starting out in 1961. At that time the ED was the weakest and most neglected department in the hospital and was staffed by a variety of physicians (IM, family med, surgery, derm, etc), none of them EM trained.
  • Bruce Janiak was the first EM resident with the first EM residency at UC in 1970. This was a 2 year program with only 2 dedicated ED months.
Read More

LMA FOI - You Mean You Can Intubate through that Thing?

/
LMA FOI - You Mean You Can Intubate through that Thing?

Emergency airway management is being revolutionized. Think about it…those of us who are in training now are being exposed to some very different core skills. The big culprit is the recent advent of video laryngoscopy – not much argument there.

With that said, I will argue that almost as significant as the advent of video laryngoscopy from a general “airway management revolution” perspective is the philosophical change of many pre-hospital providers in that it is becoming the norm for extra-glottic devices to be placed primarily, or at least considerably more often than in the past.

It is likely that the rate of field placement of extra-glottic devices will become more common. Thus, we will probably see many more patients present to the ED in whom EMS has placed an extra-glottic. As we recognize the power of extra-glottic devices, I think that even the most advanced airway managers will use extra-glottic devices with more frequency to facilitate rescue oxygenation and ventilation.

This begs the obvious question: should we remove these devices after they are in and working?

Read More

PEEP PEEP PEEP

/
PEEP PEEP PEEP

Ventilator management can be one of the more intimidating aspects of caring for critically ill patients both in the ED and in the prehospital setting.   There are several great #FOAMed resources out there on varying aspects of ventilator management including the well-known series by Dr. Weingart of emcrit.org (here and here).  Ventilator management can be an absolutely massive topic but for this post, and specifically for the embedded video below, I wanted to do a little deeper dive on only one of the components of ventilatory management: PEEP.

Read More

Sepsis in the Air

/
Sepsis in the Air

Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis.  However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care.  I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients.

Read More

Water Cooler Breakdown: The ProCESS Trial

/
Water Cooler Breakdown: The ProCESS Trial

In March of 2014, Derek Angus and colleagues published the ProCESS trail in the NEJM (1)(N Engl J Med 2014;370:1683-93. DOI: 10.1056/NEJMoa1401602). In ProCESS, they explore the time-honored theory in EM-resuscitation that EGDT as described by Rivers (NEJM 2001) is the dominant strategy to improve survival in severe sepsis and septic shock. Despite the marked reduction in mortality that is reported in Rivers’ study, the study itself has not been successfully reproduced in a multicenter trial.

Read More

The Myth of the Stable STEMI Transfer

/
The Myth of the Stable STEMI Transfer

We fly/transfer many patients with STEMI on Air Care and Mobile Care.  And, fortunately, a majority of these patients end up doing very well.  You accept them at the referring facility, load them in the helicopter, and transfer them to the cath lab at the receiving facility without incident.  You certainly may make some adjustments in nitro drips, maybe give some metoprolol, certainly review their outside hospital records, but usually the biggest benefit you are offering them is rapidity of transport.  Transport 20 or 30 of these patients without incident and you might get lulled into thinking that these patients are so incredibly stable that nothing bad will happen during the course of the transport.  To do so would be folly.

Read More

Running a Code (in Tight Quarters)

/
Running a Code (in Tight Quarters)

How many hands does it take to run a code?   Think about that for a bit...

In the SRU, the available hands seem essentially limitless.  There's a train of PCAs and medical students lined up to perform CPR, a nurse to run the monitor and defib, a nurse and/or pharmacist pulling up meds and mixing drips, a nurse charting, a MD dedicated to the airway, a RT to help with bagging, not to mention the MD running the whole show.  At a minimum you probably have 10 hands ready to ensure compressions are as uninterrupted as possible, to keep a check on the respiratory rate, to hook up monitors, push meds, defib, and all the other tasks that are necessary to code a patient.

Now what do you do in the back of the helicopter when a patient loses a pulse?

Read More

Prehospital TBI - Beyond the "Code"

/
Prehospital TBI - Beyond the "Code"

Of the injuries that one will care for in the pre-hospital setting, traumatic brain injury is one of the most challenging.  Quite often, more than one organ system has been injured and they require rapid, thoughtful, and precise management of their airway and hemodynamics.  In addition, TBI patients require frequent reassessment to detect progression of the primary neurologic injury.  This is easier said than done in the dynamic, unpredictable, and resource-limited prehospital environment.

To help simplify their care, the following “Code of Care” forms the core principles that characterize optimal TBI care:

  1. NO Hypoxia (SpO2 < 90%) – therefore, apneic oxygenation for all TBI patients
  2. NO Hypotension (sBP < 90 mmHg) – greatest iatrogenic risk is with induction and provision of positive pressure ventilation
  3. Blown pupil -> Hyperosmotic therapy + Hyperventilate
Read More