Flights - A Blow to the Head

Flights - A Blow to the Head

You’re working as the Pod-Doc, having just taken the radio from the off-going UH-doc, you just finish admitting the patient in C40 for NSTEMI when the tones go off.

“Air Care 1 and Pod Doc respond to a scene for motorcycle crash, Northern Kentucky”

You call the B-Pod attending, sign out the pod, grab the blood from the blood cooler and head to the helipad.  Flying over the river, landing at a local firehouse’s parking lot you hop out of the back of the helicopter and head to the awaiting squad.

Your patient is a 29 year-old male who was riding his motorcycle (without a helmet) on a local country road.  Coming around a blind corner he unexpectedly found a car stopped in the middle of the road.  Striking the car from behind at ~35mph, he flew over the handlebars and impacted the back of the car.

On EMS’s arrival he was initially unconscious, but since their arrival has become increasingly combative

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Grand Rounds Recap - 3/25/15

Grand Rounds Recap - 3/25/15

Mortality & Morbidity Conference with Dr. Bohanske

Remember that sometimes the thing a patient needs most is a specialist (i.e surgeon), especially trauma patients

  • Sharps in hectic situations, such as any resuscitation, are dangerous not just for the patient but also for providers as this is one of the most common situations leading to bloodborne pathogen exposures
  • Remove sharps from the field anytime you do not need them and always be responsible for your own sharps to keep your team safe
  • Keep in mind that early predicators of hemorrhagic shock are pulse and mental status/anxiety as BP changes are later indicators
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Laryngoscopy - A Definition of Terms

Laryngoscopy - A Definition of Terms

There can be some confusion with regards to the terminology surrounding laryngoscopy.  The term "video laryngoscopy" can be used imprecisely without specific attention paid to the geometry of the blade containing the video camera.  The geometry of the blade, however, is crucially important as the biomechanics of laryngoscopy differ substantially depending on whether a standard geometry (Macintosh or Miller) blade or a hyperangulated blade is used.  Below you will find specific definition of terms with regards to laryngoscopy and a video demonstrating the differences between direct laryngoscopy, standard geometry video laryngoscopy, and hyperangulated video laryngoscopy.

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Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Flights - A Stab in the Dark - Curated Comments and Expert Commentary

Thanks to everybody who contributed to an excellent discussion of the care of the patient on our second “flight.”  If you didn’t get a chance to check out the case and the discussion, check it out here.  Below is the curated comments from the community and a podcast from Dr. Hinckley and Flight Nurse Practitioner Jason Peng

Q1 - Walk through your initial assessment of this patient.  What are the critical aspects of the assessment of this patient?

In response to this question, most everybody wanted to first act on the bleeding wound in the patient’s right antecubital fossa.  As explained by Dr. Renne, “I would want to be systematic but efficient, probably using a C-ABCD approach to these kind of critical patients, with the first C being any sort of life-threatening but "C"ontrollable hemorrhage.”  Dr. Renne also had a fine point with regards to checking for other potential, as of yet unseen, injuries.  This is a patient with multiple stab wounds, it is crucial to conduct a quick, but thorough search for stab wounds to the back, axilla, groin, and/or other locations where significant blood loss could be caused by a stab wound.

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Grand Rounds Recap - 3/18/15

Grand Rounds Recap - 3/18/15

Evidence-Based Emergency Medicine: Vent Management with Drs. Axelson & Scupp

The term Acute Lung Injury (ALI) is being phased out and instead Acute Respiratory Distress Syndrome (ARDS) is now graded mild, moderate, and severe depending on the PaO2:FiO2 ratio

The median onset of ARDS after presentation to the ED was 2 day but could be anywhere from 5 hours to 5 days

ARDS Net was a foundational trial in ventilator management and was a triall of tidal volume and plateau pressures.  The primary end point, mortality, was reduced by >20% when folks were on a low TV (6cc/kg) and lower PP (25-30 mm Hg).

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Grand Rounds Recap - 3/11/15

Grand Rounds Recap - 3/11/15

Health Care Disparities with Dr. Ford

There is a well established distrust of the medical system by minorities, especially African Americans. The historic causes of this distrust are widespread and seen in nearly all stages of American Healthcare. A great resource is Medical Apartheid by Harriet Washington. Some key examples of the use of AA in medical advances: 

1800s: Slaves referred to as "clinical material" in medical schools and journal publications. Slave bought and used for experiments and experimental surgeries including the first successful vesicovaginal fistula repair (caused by forcep deliveries) which was done without anesthesia. 

1900-1930: "malaria therapy" with fatal falciparum used to try and treat syphilis. Tuskeegee experiments- subjects recruited under false pretense of "free testing and medical treatment" for syphilis experiment with no intention to treat despite PCN being widely available. "The future of the negro lies in the research laboratory..." Patients were offered a free burial when they died from the disease so that an autopsy may be performed. "as I see it, we have no further interest in these patients until they die..."

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Soft Tissue Neck Radiographs

Soft Tissue Neck Radiographs

The soft-tissue neck radiograph can be an extremely useful tool in a variety of clinical situations. These include: epiglottitis, croup, retropharyngeal abscesses, and localization of airway foreign bodies. 

However, like any diagnostic tool, the soft tissue neck x-ray’s usefulness depends on knowledge of the relevant anatomy — particularly the normal size and appearance of various airway structures — as well as a systematic approach to each radiograph. We will discuss both the anatomy and radiographic approach in this blog post.

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EMS Recertification Requirements

EMS Recertification Requirements

Often times during the EMS continuing education courses we teach, we get questions about recertification requirements for both our state and National Registry certifications.  This podcast is designed to summarize the various recertification requirements as well as discuss the National Registry Transition from EMT-Paramedic to Paramedic.  While much of the discussion focuses on these issues relating to Paramedic certifications, the same principles can be applied to recertification requirements for other levels of pre-hospital providers.  For a complete set of recertification requirements we refer Ohio providers to the Ohio EMS website: ems.ohio.gov.  For details about the National Registry’s requirements for re-certification, we refer everyone to their website: nremt.org.   

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Flights - A Stab in the Dark

Flights - A Stab in the Dark

You are working overnight as the H2 doc based at Butler County Regional Airport.  It’s bitter cold out (for Ohio that is).  Its only 11 PM and already the temperature has dropped to 9 degrees fahrenheit on its way to a low of 0.  You are in the lounge refamiliarizing yourself with the contents of the critical care cells when the tones go off: “Scene: stab wound – Hamilton Ohio”

You and the nurse grab your equipment, the blood cooler, and head to the helicopter.  You put the critical care cells back in their spot in the rear of the helicopter and then buckle in for the short flight to the scene.

Your patient is a 23 year-old female who was in an argument with her boyfriend earlier in the evening.  The verbal argument quickly escalated, her boyfrienf pulling a knife and stabbing her multiple times in the right arm and right chest.  He fled the scene and she managed to call 911.  The first responders found the patient with significant active bleeding from her arm as well as chest.  She was initially responsive, but is now only awake to painful stimuli.

You meet the EMS crew in the back of the squad truck and assess the patient from the head of the bed.

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Grand Rounds Recap - 3/4/2014

Grand Rounds Recap - 3/4/2014

IABP With Dr. Wojciechowski

  • What is it? It's a ~10cm long intravascular balloon that inflates with 25-50ml of helium gas during diastole to increase the coronary perfusion pressure and decrease the afterload on the heart (coronary perfusion pressure = diastolic blood pressure - left ventricular end diastolic blood pressure). The catheter itself has a pressure transducer and a catheter that shuttles the helium gas.
  • Why helium? it is low density, metabolically inactive, and dissolves in blood in case the balloon were to rupture.
  • Who gets one? In general they are reserved for hemodynamically unstable patients as salvage therapy (STEMI with cardiogenic shock, acute MI that can't be reperfused, high risk CABG, failed maximal medical therapy).
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Flights - One Road too Far - Curated Comments & Expert Commentary

Flights - One Road too Far - Curated Comments & Expert Commentary

Thanks to everyone who chimed in for our first ever "Flight"!!  If you didn't get a chance to read the case, take a look here.  There was some excellent discussion on how best to care for the blunt polytrauma patient.  Below is the curated comments from the community and Dr. Hinckley's take on the questions posed to the community.

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Hemoptysis

Hemoptysis

What is it?  Bleeding below the cords

More specifically, it may be subdivided into Massive and Non-Massive hemoptysis.  And while the definitions of massive vary from paper to paper, it is generally agreed that increasing volume over 24 hours is associated with increased mortality.  However, the literature consistently concludes that patients and providers are poor, at best, at estimating volume.  Thus, the simplest and most effective definition for massive hemoptysis is as such: expectoration of blood causing hemodynamic instability or abnormal gas exchange / airway obstruction.

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Grand Rounds Recap - 2/18/2015

Grand Rounds Recap - 2/18/2015

Hyperthyroidism: 1.3% of the US population has hyperthyroid. Thyrotoxicosis = too much thyroid hormone activity. Remember, T4 is a prohormone and T3 is the bioactive form. Causes of hyperthyroidism are broad and include: inappropriate thyroid stimulation, autonomous release of excess thyroid hormone, excessive release of thyroid stores, extra-thyroid sources of hormone. Hyperthyroidism increases risk of all-cause cardiovascular mortality and incidence of Afib. Diagnosis of hyperthyroid made by TSH <0.1 and high free T4. Iodine uptake test helps to find nodules and differentiate from thyroiditis. 

Thyroid Storm: an exacerbation of thyrotoxicosis leading to multi-organ failure. Mortality is high at 10-30%. Precipitating factors include: thyroid surgery, radioiodine treatment, medication and medication adjustment. Symptoms: febrile, tachycardic, agitation, seizures, psychosis, delirium, transaminitis. Diagnostic scoring system based upon signs and symptoms, not lab values. Treatment: propylthiouricil is available but not commonly recommended due to hepatic toxicity. Methimazole is preferred, but takes several hours to work. In the mean-time, use propanolol to decrease the effects of the hormone (the only beta blocker that crosses the BBB so is ideal at treating CNS symptoms). 1 hour after giving methimazole, can give iodine. 

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Flights - One Road too Far

Flights - One Road too Far

You are working as the UH-doc.  Driving into your shift with the windows down and music playing, you figured the first warm day of the year would result in a busy day for you and the rest of the Air Care 1 crew.  You arrive for your shift, grabbing the radio from the Pod doc when the tones go off for your first flight of the day.  You grab the blood cooler head to helipad, checking your pager you find you’ll be responding to Southeastern Indiana for a “MVC rollover, entraped.”

You strap into the helicopter and fly over the city and to the rolling hills of Southeastern Indiana.  Landing on the 4 lane divided state road, you unstrap and head to your patient who is waiting with the BLS squad.

You open the side door of the EMS truck and head to the head of the bed to assess your patient...

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The Approach to the Foot X-ray

The Approach to the Foot X-ray

Any way you slice it, foot x-rays are a pain to read.  Complicated by a number of overlapping bones, joints, the presence of multiple sesamoid bones, and multiple radiographic views, it's easy to get lost in the weeds trying to sort out normal variant from pathology.  Take a look at this short Blendspace module by PGY-1 Lauren Titone, MD and get a better understanding of the normal anatomy and a systematic approach to reading foot x-rays.

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Grand Rounds Recap - 2/11/15

Grand Rounds Recap - 2/11/15

Repeat 6 Hour Head CT in Mild TBI Patients with Dr. Kreitzer

Mild TBI = GCS > or = 13

  • Incidence of NSG intervention 0.9%
  • Mortality 0.1%

Why Consider a 6 hour CT scan?

  • Pros: quicker disposition, avoidance of unnecessary admission
  • Cons: extra radiation, does not address post concussive symptoms

ACEP policy: mild TBI patients with normal head CT and normal mental status can be discharged home

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Grand Rounds Recap: Critical Care Symposium - 2/4/15

Grand Rounds Recap: Critical Care Symposium - 2/4/15

Pressor Primer with Dr. Hebbeler-Clark

  • Norepinephrine seems to be on top in terms of vasopressor of choice currently (consider it your "easy button")
  • Per Surviving Sepsis Guidelines, Norepi has level 1B evidence as a first line pressor, while Epi is your second line with level 2B evidence and Vasopressin is currently ungraded in terms of evidence level
  • There have been 4 RCT's confirming that Norepi has no mortality difference from Epi and given it's safer side effect profile, use it regularly
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Ketamine Fight Club: Ketamine in TBI

Ketamine Fight Club: Ketamine in TBI

There has long been a concern for increases in ICP with administration of ketamine primarily stemming from reports of increased ICP in the Neurosurgery and Neuroanesthesia literature.  These increases were described primarily in patients usually with CSF outflow obstruction undergoing elective neurosurgical procedures.  In the time since these articles were published, the use of ketamine in a wide variety of patients with neurologic compromise has been reported.  In fact, there have been a couple of recent systematic reviews and meta-analyses on this topic.  These systematic reviews and meta-analyses have essentially analyzing all the same existing literature (which is generally poor in quality).  

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Grand Rounds Recap - 1/28/15

Grand Rounds Recap - 1/28/15

Mortality & Morbidity Conference with Dr. Bohanske

When volumes are high, remember the patient experience can be improved by acknowledging wait times when entering the room and apologizing for their wait.

Transverse myelitis is a result of partial inflammation of the spinal cord that can sometimes lead to necrosis.

  • The disease process is often progressive and function does not always return after treatment.
  • Most commonly this is idiopathic in nature but it is often attributed to a post-infectious inflammatory state.
  • Differential diagnosis should always include cord ischemia versus compression, and diagnosis hinges on a T2-weighted MRI.
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Annals of B Pod: Winter 2015 Issue!

B Pod and the land of clinical uncertainty

This season's issue of Annals of B Pod we highlight clinical cases from our ED's B Pod to feature some complex cases starting with simple chief complaints, emphasizing the point that the sickest patients evolve from the mundane. Flu season continues to plague us and every day we face the question of how far to take the clinical evaluation when we see generic complaints. The decision comes partly from objective data, partly clinical decision rules, and mostly from a non-quantifiable summation that is clinical gestalt.