Grand Rounds Recap - 9/3/2014

EMS Grand Rounds

EMS as a Specialty with Dr. Gerecht

"We are in the business of delivering health care to a very unique population, in a very unique environment, in a very unique way" - Dr. Edward Racht

EMS formally became a subspecialty of EM in 2006. The first board certified EMS physicians passed their exams last year (we have 3 in our EMS division).

EMS physicians train in clinical aspects of EMS medicine, medical oversight of EMS, quality management, and special operations. 

Life as an EMS fellow includes: didactics, literature review, simulation, teaching, CQI, logistics, ride time, research, scholarly project, tactical medicine, USAR, event medicine, and more. 

Protocol Review with Dr. Larrimore

Southwest Ohio EMS Protocols can be found here: http://lempert.com/protocol/2014protocols.html and on www.tamingthesru.com/prehospital-medicine. Please take some time to review them as we are expected to be experts in the protocols and provide sound advice via telemetry.

Determination of Death in CPR (Termination of CPR): we know that those who do not get ROSC in the field have very poor outcomes, CPR in a moving vehicle is poor quality and is dangerous for providers. This protocol allows providers to work the code on scene and terminate if unsuccessful. This is safer for the crew, doesn't change outcomes for the patient, and may free up the ambulance resources sooner. It requires calling the telemetry phone for a discussion with medical control (you). 

# Criteria that must be met to terminate CPR: 

  1. Good contract between medic and medical control (communication is key)
  2. Successful airway management. Any device is okay (ETT, supraglotic device, BVM) as long as they are ventilating the patient. 
  3. Minimum of 20 min of CPR in adults, 30 min in children
  4. No sustained ROSC (palpable pulse >60bpm for >5 min) at any time

*Does not apply to cardiac arrest caused by hypothermia, electrocution, lightning strike

Traumatic Cardia Arrest: If the patient is an adult (>16yo), has an obvious traumatic cause of cardiac arrest, and does not regain pulse with bilateral needle decompression and hemorrhage control the patient should be placed on a monitor. If the rhythm is Vfib, Vtach, or rapid PEA (>40bpm) the patient should be transported to the closest trauma center. If asystole of PEA <40bpm the resuscitation may be terminated. 

 http://upload.wikimedia.org/wikipedia/commons/f/f4/EMTs_loading_a_patient.jpg

http://upload.wikimedia.org/wikipedia/commons/f/f4/EMTs_loading_a_patient.jpg

Junctional Tourniquet Devices with Dr. Steuerwald

Just like the T-pod, these devices should be placed low around the greater trochanters. "Like a miniskirt, not like a heavyweight champion belt."

Several commercial devices (Junctional Emergency Treatment tool, SAM Junctional Tourniquet) designed to apply direct pressure to the femoral vessels in the femoral triangle. They each require adequately securing the device and then applying increasing pressure until hemorrhage is controlled. 


The Great Debate: CT/LP vs CT/CTA in the diagnosis of Sub-Arachnoid Hemorrhage with Dr. Stettler and Dr. Knight

 "SubarachnoidP" by James Heilman, MD - Own work. Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:SubarachnoidP.png#mediaviewer/File:SubarachnoidP.png

"SubarachnoidP" by James Heilman, MD - Own work. Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:SubarachnoidP.png#mediaviewer/File:SubarachnoidP.png

Background: 4% of ED visits (2 million annually) are for headache. Of those with "thunderclap" or "worst headache of life" 88% have non-serious causes. 80% of SAH is caused by aneurysmal bleeding. In SAH, the ruptured vessel causes blood to leak into the CSF with increases ICP, irritates the meninges, and can cause vasospasm of the cerebral vasculature in a delayed fashion. This sentinel bleed my be the predecessor to a more significant bleed. Mortality of SAH is 51% with very high morbidity. 

CT/LP "gold standard rules": LP is considered to be the gold standard in diagnosis (although this may lead to falsely high sensitivity when comparing LP to the "gold standard"). In addition to it's ability to diagnose SAH, LP can also provide additional information from opening pressure and CSF studies to help with alternative diagnoses. In an LP, the RBC should clear from Tube 1 to Tube 4 if a traumatic tap, although there is no guide for how much. There is also no clear guide of how many RBCs = SAH. By using the gold standard test, you are saying that SAH is a never-miss event, but you are probably committing to about 700 LPs for every 1 case of SAH you find. LP is most sensitive >12 hours from ictus.

CT/CTA "embrace the technology": CTA can identify aneurysms down to 3mm in size but requires reconstructions and to be read by a neuroradiologist to be most sensitive (this is not done overnight). If the CT or LP are positive, the next test is going to be a CTA anyways, so you can just skip right to it and get the information the neurosurgeon needs without the discomfort to the patient of the LP. Since we don't have standard for how to diagnose SAH when you get RBCs in your tap, it is hard to utilize this test diagnostically. Don't forget that most studies looking at imaging include data from several years ago and likely do not represent the modern generation CT scanners we have available to us now. 


CPC: Dr. Riddle and Dr. Kreitzer

16yo non-obese F who presents with chief complaint of headache for 2-3 weeks which has been progressive now with photophobia, phonophobia, blurry vision, and "seeing spots". Found to have papilledema but an otherwise normal neuro exam and no fever, no meningismus. Negative CT head. 

  • Test of choice: opening pressure on LP
  • Diagnosis: doxycycline induced intracranial hypertension

To diagnose intracranial hypertension: CSF opening pressure >20cmH20, normal CSF studies, headache, papilledema, imaging without hydrocephalus or structural abnormality. 


EBM Quick Hit: Multiple Comparisons with Dr. Betz

Standard 0.05 p-value states 5% chance of getting the observed result if the null hypothesis were true (ie false discovery or Type I error)

When you perform multiple comparisons, there is an increasing fraction of false discoveries based on the number of comparisons you perform. There are 2 common methods to correct for this:

  1. Bonferroni Method: new p-value (called p prime) = old p-value/ number of comparisons used. This works well when sample sizes are small but is too conservative with large sample sizes.
  2. False Discovery Rate: new p-value = number of subjects (old p-value)/ number of initially positive findings when stats were run with old p-value. This method works well when studying very large numbers (ie thousands of genes in genetic testing). 

Transitions of Care with Dr. McDonough

There are many obstacles to a safe hand-off: signal-to-noise ratio with the chaos of the department during turnover, conciseness vs completeness, we have no standard approach, there is an ambiguous moment of transition of care, no clear high-risk-triggers for dangerous hand-offs, cognitive bias, and economic incentives. 

Phases of turnover:

  1. Pre-turnover time the offgoing provider establishes final plans on existing patients and completes notes for turnover patients.
  2. Signout
  3. Post-turnover time where the offgoing provider wraps up last minute tasks and the oncoming provider checks labs/vitals, sees new patients, checks in on turnover patients, and performs a quick recap with the offgoing provider of tasks/expectations. 

The signout itself needs a structure to keep it uniform and complete. 

  1. Patient status and condition (is the patient admitted, an active turnover, or a new patient). If they are sick, say so to get the attention of the oncoming provider
  2. Brief HPI
  3. What's pending
  4. Dispo (if/then)
  5. Concerns
  6. Questions