Grand Rounds Recap 5.3.23

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APRIL Morbidity & Mortality Report - R4 Capstone: CASES OF Near misses - R1 clinical knowledge: TBI’s - air care ground rounds

MORBIDITY AND MORTALITY REPORT WITH DR. BROADSTOCK

Suicidal Ideation & Behavior with Concomitant Substance-Use

  • Difficult to distinguish suicidal ideation/behavior from primary decompensated psychiatric disease versus substance-induced in the ED

  • Statement of Belief

    • Aka pink slip, 72 hour hold, involuntary civil commitment, etc. 

    • Allows for the patient to be held for a psychiatric evaluation

    • Varies greatly based on state laws

      • In OH, this means patient can be held for 24h prior to being evaluation by a psychiatrist & may be held for additional 72h after that initial evaluation is performed

      • In OH, can be signed by physician, psychologist, mental health NP, mental health clinical nurse specialist, health officer, parole officer, police officer or sheriff

      • In other states, such as CA and WA, physicians can not sign a psychiatric hold 

    • Criteria for an Ohio Statement of Belief 

      • Risk of physical harm to self

        • Evidenced by threats of, or attempts at, suicide or self harm

      • Risk of physical harm to others

        • Evidenced by threats of, or recent homicidal or violent behavior, geared towards others 

      • Person is unable to provide for one’s basic physical needs because of underlying mental illness

      • Would benefit from treatment in a hospital for mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or himself 

    • Typical hospital resources deployed with a statement of belief 

      • Sitter at bedside 

      • Physical restraints 

        • Need to be conscious of the restraints ordered

        • nonviolent restraints require provider orders every 24 hours and nursing reassessment every 2 hours

        • violent restraints require provider order every 4 hours, and nursing reassessment every 15 minutes with documentation every hour

      • Suicide precautions 

  • Statement of belief is different from a medical hold 

    • Useful in preventing departure and preserving health while making attempts to determine capacity and contact the appropriate decision makers

    • This is most appropriate for patients without capacity intending to leave prior to completion of medical care

    • Not appropriate for patients who need constant supervision

Acute Angle Closure Glaucoma

  • 2nd most common cause of vision loss worldwide 

  • Risk factors

    • FHx

    • Age >60yo

    • Female

    • Far-sightedness

    • Certain medications (including HCTZ, albuterol, SSRI, TMP-SMX)

    • Inuit or Asian ethnicity 

  • Pathophysiology

    • Ciliary body makes the aqueous humor

    • Absorbed by the trabecular meshwork (between iris and cornea)

    • Acute Angle Closure Glaucoma occurs when the angle between the iris and cornea becomes narrowed

  • Presentation (cause of painful vision loss)

    • Symptoms 

      • Decreased vision 

        • Halos around eyes

        • Usually starts in dim light

      • Headache

        • Rare cause of headaches

      • Eye pain

      • Nausea, vomiting 

    • Physical exam 

      • Conjunctival injection

      • Poorly reactive pupil

      • Mid-dilated pupil 

      • Elevated IOP

      • Shallow anterior chamber 

  • Diagnosis 

    • Unfortunately, high rate of misdiagnosis 

    • Low threshold to measure IOP whenever there is a concern

  • Treatment 

    • PASTA mnemonic

      • Pilocarpine 2%, 1 drop 

        • Cholinergic agent causes pupil constriction

        • This opens the trabecular meshwork & promotes aqueous humor drainage 

      • Apraclonidine 1%, 1 drop (or brimonidine)

        • Alpha-2 agonist

        • Reduces aqueous humor production

      • Sit-up 

        • Reduces IOP by 2-4mmHg

      • Timolol 0.5%, 1 drop (or cosopt- which is a combination of timolol and dorzolamide [a carbonic anhydrase inhibitor])

        • Beta-blocker

        • Reduces aqueous humor production

      • Acetazolamide, 500mg PO or IV 

        • Carbonic anhydrase inhibitor 

        • Reduces aqueous humor production

    • Monitor IOP closely 

      • Recheck q30mins

      • Redose medications every 30-60mins if no improvement

Fall with Multiple Injuries

  • 70% of sentinel medical errors occur due to miscommunication

    • 50% of those occur during the signout process 

  • Common errors stem from errors and/or emission of important physical exam findings, test results, imaging studies, etc. 

    • Typically leads to increase LOS in the ED

    • Can potentially be mitigated with oncoming provider typing notes or reviewing the EMR during actual signout process 

    • Additionally, can implement a checklist to ensure all HPI, exam findings, testing results, etc are addressed during signout process

  • Be mindful of common pitfalls during the signout process:

    • Movement of patient to a different location in the ED

    • Imaging/labs that result near or at the time of signout 

    • Lack of access to computer to view results in real-time during the signout 

    • Distractions & interruptions that occur during signout 

Atypical ACS

  • Not all patients with ACS present with typical chest pain, making the diagnosis rather difficult in the ED

    • 43% of  patients with a NSTEMI, as well as 27% of those with a STEMI, will present without chest pain

    • In these patients presented without chest pain, ACS was not properly diagnosed in about 23% of patients 

  • This leads to an increase in mortality, as well as decrease typical ACS treatments, in these patients presenting with atypical chest pain

    • STEMI patients presenting without typical chest pain had higher in-hospital mortality compared to those presenting with chest pain (OR 1.38)

    • NSTEMI patient presenting without typical chest pain had higher in-hospital mortality compared to those presenting with chest pain (OR 1.31)

    • Additionally, those with atypical chest pain who are ultimately diagnosed with ACS are less likely to receive PCI, tPA, ASA within 24h, BB at discharge, etc.

    • Highlights the importance of diagnostic momentum in the ED

  • Risk factors for atypical presentation of ACS include

    • Female sex

    • Older age

    • Underlying DM

    • Pre-existing heart failure 

  • This case was especially difficult because of a concurrent bundle branch block

    • Makes EKG interpretation of a STEMI even more difficult 

  • This case also highlights the importance of involving palliative care team when possible

    • Patient had a poor understanding of proposed procedures, which led to initial refusal of care in the ICU

    • Palliative care team was essential in discussing procedures and treatment plan with patient in CVICU

Penetrating Lower Extremity Injury

  • Traumatic penetrating vascular injuries carry high rates of morbidity & mortality 

    • Such as formation of DVT’s & infections, as well as need for fasciotomy, & amputation

  • EAST trauma guidelines 

    • Level I recommendation 

      • CTA is the test of choice for detection of vascular injury from a penetrating injury

      • Nearly 100% sensitive

    • Level II recommendation: 

      • If hard-signs of an arterial injury are present, need OR exploration

        • Hard signs: pulse deficit, pulsatile bleeding, bruit, thrill, and/or expanding hematoma

      • If no hard signs, yet abnormal physical exam and/or ABI<0.9, then need further evaluation

        • Usually with CTA imaging

      • If normal physical exam & ABI>0.9, may be discharged

        • Important to note that when used in isolation, ABI’s have a poor sensitivity for detecting vascular injuries 

        • Nonetheless, normal ABI’s WITHOUT associated hard or soft signs, has a high negative LR for a vascular injury

          • Yet soft signs include delayed cap refill, venous oozing, hematoma, reduced distal pulses (which are all commonly seen with penetrating injuries)

          • As well as history of hemorrhage/hypotension, bruit, fracture, major tissue defect

  • Most clinical decision making and practice variation involves patients with no hard signs, normal ABI’s, yet presence of one or more soft signs

    • Tintinalli’s advocates for CTA’s in all these patients

    • Yet close observation in the ED with plan to repeat ABI’s can be considered as well

Calcium Channel Blocker Overdose

  • Calcium channel blocker overdoses involves high morbidity and mortality, therefore typically require aggressive resuscitation 

  • Management of CCB OD

    • GI decontamination with charcoal 

      • 1g/kg

      • If patient arrive 1-2 hours after ingestion

      • Patient needs to be awake, alert and able to participate in ingestion of activated charcoal 

      • Especially important for medications with a long half-life (such as amlodipine)

    • High-dose Insulin Therapy 

      • 1u/kg IV bolus, followed by 1-10u/kg/hr infusion 

        • Remember to replete K+ and glucose as needed 

      • Insulin secretion is reduced by calcium channel blockade in pancreatic cells

        • Leads to a hypo-insulin state and therefore poor glucose utilization in CCB OD

        • Ultimately leading to myocardial dysfunction 

      • High-insulin allows increase in inotropy by supply cardiomyocytes with much-needed glucose 

    • Calcium 

      • 1-5g IV Calcium Chloride 

      • CCB OD involves a calcium-deprived state 

      • Therefore, excess serum calcium will outcompete for the L-type calcium channels 

    • Lipid Emulsion

      • 20% lipid emulsion 1.5cc/kg, followed by 0.25-0.5cc/kg/mib infusion for 30-60mins

      • Intralipid acts as a lipid sink that pulls drug molecules into the plasma 

      • Additionally, intralipid serves as an energy substrate for cardiomyocytes 

    • PLEX Therapy

      • Allows elimination of the CCB because they are protein-bound 

      • Of note, no role for iHD as most of these drugs bind to serum proteins 

    • Nitric Oxide Scavengers

      • Typically considered for refractory vasoplegia as an adjunct therapy

      • Methylene Blue 

        • 1mg/kg over 5-30mins

        • Inhibit NO synthase, therefore preventing peripheral vasodilation  

        • Drawbacks

          • Serotonergic

          • Caution in those with G6PD deficiency 

          • Unsafe in pregnancy

          • Falsely low SpO2

      • Hydroxocobalamin 

        • 5g over 15 minutes 

        • Inhibits NO activity, therefore preventing peripheral vasodilation  

        • Drawbacks

          • Expensive 

          • Causes hypertension

          • Red urine up to 6 weeks

          • Lab anomalies (hgb, basophils, glucose, bili, alk phos, coags are all affected)

Pneumoperitoneum due to a Penetrating Duodenal Ulcer

  • Patient presented with hypotension and preceded to suffer a cardiac arrest 

  • ROSC after 2 rounds of ACLS

  • Started on empiric antibiotics 

  • Subsequent CT scans in revealed pneumoperitoneum 

    • Seen in real-time while patient was still in the CT scanner

    • Consulted ACS emergently

  • Underwent emergent ex-lap

    • Found to have a perforated duodenal ulcer 

  • Successful, aggressive resuscitation, as well as reviewing images in real-time & getting consultants involved early led to this patient’s successful outcome

    • Discharged to inpatient rehab on HD23

    • Presented as the win for the month

R4 CASE FOLLOW-UP: CASES OF NEAR MISSES WITH DR. MULLEN

Case #1

  • Young male presenting with a left eye injury with concerns of wood particles in his eye

  • On exam, reduced visual acuity and small amount of fluorescein uptake noted

  • Initial concern for corneal FB

    • First attempt for removal with a cotton swab

    • Then called ophthalmology, who had concern for corneal laceration & subtle positive Seidel's sign 

    • Subsequent CT scan showed an unexpected nail embedded in the affected eye  

  • Found to have an ocular foreign body with globe rupture

    • Went to OR for extraction and corneal laceration repair 

  • Risk factors for corneal FB:

    • Males in their 30’s 

    • Usually occurs at work or home

    • Usually involves sharp objects such as nails, scissors, screwdrivers 

  • Severity of injury depends on:

    • Size, shape of object

    • Speed at which it hits the eye 

    • Organic material are at most risk of inflammation/infection such as wood 

  • Evaluation 

    • Try to AVOID excess pressure on the eye

    • CT is the imaging modality of choice 

      • Can consider US while consciously applying minimal pressure on the eye

      • avoid MRI if unsure of composition

    • Surgical management 

      • Ophthalmology consult early on, as these patients will likely need surgical manipulation 

    • Medical management

      • Antibiotics, eye shield, tetanus vaccine

  • Prognosis

    • Poor visual prognosis if metal-on-metal mechanism, initial visual acuity is poor, presence of afferent pupillary defect, increase wound size, younger patient, presence of hyphema/vitreous hemorrhage, endophthalmitis

Case #2

  • Middle-aged female presenting with atraumatic R eye redness and pain

    • Also reported nausea, vomiting, dizzy, fatigued

    • As well as LLQ abdominal pain 

  • Physical exam 

    • Normal ocular exam 

    • Yet, notable LLQ abdominal pain 

  • Testing 

    • Unremarkable CBC, BMP, LFT’s, hsTN, UA

    • NSR on EKG 

    • Unexpectedly found to have a positive b-HCG & then a serum b-HCG quantitative level of >79,000

  • Found to have an IUP on bedside US

    • Patient did not know she was pregnant at the time

    • This was a non-IVF assisted pregnancy 

  • Woman’s peak reproductive years between teens to late 20’s, yet can still get naturally pregnant at an older age as well

    • By age 30, fertility begins to decline 

    • By age 45, unlikely to get pregnant naturally

    • Radiology department typically uses age of 60yo as cut-off for bHCG prior to CT scans 

Case #3

  • Female in her 30’s with a PMH of seizures presenting with AMS

    • Collateral from parent reveals that the patient typically develops agitation/combativeness after a seizure

    • Also, concerns for poor adherence to prescribed AED regimen (which consists of Depakote)

  • Chart review with multiple ED visits with agitation in the postictal state 

  • Physical exam 

    • Mumbled speech, head nodding, not following commands, RUE weakness 

    • Meanwhile, also found to be agitated and intermittently yelling at staff

  • Labs were overall reassuring 

    • Normal CBC, BMP, coingestant levels, ethanol levels, etc.

  • CT without contrast notable for L MCA ischemic stroke 

  • Subsequently underwent thrombectomy 

    • Left M2 occlusion was evacuated (TICI 2b re-perfusion)

  • Prolonged NSICU admission 

    • Found to have a protein C deficiency and a small PFO

  • Follow-up since discharge 

    • Issues with emotional lability 

    • Yet, 5/5 strength in all extremities

    • Also, able to ambulate on her own without documented ataxia

  • Though rare, young patients can still develop strokes 

    • Multiple risk factors specific to women include: pregnancy, contraception use with estrogen

    • Cardiovascular risk factors include: HTN, AF, DM, obesity 

    • Lifestyle risk factors include: tobacco-use, poor diet, heavy EtOH use, drug use

    • Other risk factors include: PFO, inherited thrombophilias or prothrombotic/hypercoagulable states 

R1 CLINICAL KNOWLEDGE: TRAUMATIC BRAIN INJURIES WITH DR. HAJDU

Mild TBI’s & Concussions in the Emergency Department

  • TBI’s are relatively common

    • >3 million TBI’s in the US annually 

    • 2.5 million presentation to ED’s throughout the US

  • Usually occur due to falls

    • Also commonly occur due to sports, MVC’s, etc.  

  • 18-24yo make up majority of ED presentation

    • Meanwhile, >75yo make up majority of patients with mortality and morbidity due to TBI’s 

  • Definition of a TBI

    • Traumatically induced, physical disruption of the brain that includes period of LOC, loss of memory for that event, or any alteration in mental state at the time of following the event

    • Classification based on GCS

      • Mild (GCS 13-15)

        • further broken down to uncomplicated versus complicated

        • complicated mild TBI involves an acute intracranial abnormality on neuroimaging

      • Moderate (GCS 9-12)

      • Severe (GCS 3-8)

  • Definition of a Concussion 

    • Multiple definitions 

      • Commonly used synonymously with an uncomplicated mild TBI

      • Yet can also be used to describe the symptoms that patient may experience following a mild TBI

    • Entirely a clinical diagnosis with four main symptom domains

      • Emotional functioning 

        • emotionality out of proportion to circumstances

      • Impaired cognitive functioning

        • inability to concentration, lack of awareness of surroundings, incoherent speech, amnesia

      • Physical/Somatic Symptoms

        • HA, nausea/vomiting, dizziness, sensitivity to light & noise

      • Seep disturbances

  • Pathophysiology of TBI

    • Primary injury

      • initial impact that causes the displacement and injury of the brain

    • Secondary injury

      • the changes that occur after the initial incident

      • cascade of cellular and biochemical events including release of excitatory neurotransmitters

  • Complications of a TBI

    • Post-concussive symptoms 

      • Persistent symptoms seen in about 10-20% of patients with a concussion

        • >2weeks in adults

        • >4weeks in children

      • Typically treated with physical rehab, as well as psychotherapy & physiotherapy

    • Second Impact Syndrome 

      • Rare phenomena 

      • Seen when patient undergoes second blow when the initial injury has not had enough time to recover

      • Characterized by rapid intracranial swelling due to malignant cerebral edema

    • Chronic Traumatic Encephalopathy (CTE) 

      • Slow, progressive neurodegeneration due to repeated head trauma

        • expect memory disturbances, personality changes, speech & gait issues

      • Involves Tau protein deposition 

  • Evaluation of Mild TBI’s in the ED

    • HPI

      • Ask specifically about mechanism, timing, severity of symptoms

    • PMH

      • Ask about prior TBI’s, co-morbid mood disorder/migraines/sleep disturbances 

    • Exam

      • SCAT5 can be used as an adjunct to the physical exam 

    • Imaging 

      • Use clinical decision rules such as Canadian Head CT rules, NEXUS criteria, etc.

  • Disposition 

    • Indications for admission 

      • GCS<15, focal neurological deficits, seizures

      • Intractable vomiting

      • Significant Abnormal CT results 

    • Discharge criteria

      • Normal GCS, exam

      • Caregiver at home 

      • Certain abnormal CT 

        • Isolated & non-depressed calvarial skull fractures

        • <1cm diameter of solitary cerebral contusions

        • <1cm width of epidural or SDH

        • Stable, trace SAH

  • If planning to discharge, appropriate counseling in the ED is especially important 

    • Discuss expected symptoms 

      • emotional/cognitive/physical symptoms, as well as sleep disturbances

    • Discuss expected timeline for recovery

      • usually 2-4 weeks to return to baseline

    • Arrange outpatient follow-up 

      • Typically want follow-up in 2 weeks 

      • This is due to the high prevalence of incomplete recovery months down the road 

      • May need PM&R, PT, OT, etc. in the future 

    • Counsel for return to activity 

      • Prescribed rest for the first 24-48h

        • Still try to do ADL’s at home that do not exacerbate symptoms 

        • Do NOT need to sit still in a dark lit room

      • Then, gradual return to physical activity/work 

        • Stepwise approach on a daily basis

      • Aerobic exercise as tolerated and limited by symptoms 

      • Do not return to sports until

        • Asymptomatic

        • Plus, cleared by a provider

AIR CARE GRAND ROUNDS WITH DRs. hinckley, goff, & winslow

TOWAR Study

  • Acronym for Type O Whole blood & Assessment of Age during prehospital Resuscitation)

  • Purpose of study is to assess if whole blood is the best resuscitative agent for trauma patients in hemorrhagic shock 

  • Primary end-point

    • 30d mortality 

  • Secondary end-points 

    • Lower early mortality 

    • Lower blood transfusion requirements 

    • Lower incidence of coagulopathy

    • Improved hemostasis

    • Improved platelet function

  • This is a multi-center trial 

    • Locally includes UCMC and University of Louisville

      • Yet, enrollment in TOWAR study should NOT dictate where the patient is being transported

    • Of note, CCHMC is not participating in TOWAR study 

      • Please do not administer O+ whole blood to >18yo trauma patients going to CCHMC

  • Randomized by Air Care base & on a monthly basis

    • Need to check calendar at start of your shift to know what components are inside blood cooler at your specific base that day

      • If TOWAR month: expect 2u O+ whole blood, 1u pRBC’s, 2u FFP in cooler

      • If not a TOWAR month: expect 2u pRBC’s, 2u FFP in cooler

  • This study qualifies for exception from informed consent (aka a EFIC trial) 

    • May encounter patients in community with armband that exempts them from TOWAR study 

  • Inclusion Criteria 

    • SBP ≤90mmHg and/or HR≥108bpm

      • These vitals do NOT need to be present at the same time 

      • These vitals can occur at ANYTIME, including prior to AC’s arrival 

    • Or, SBP ≤70mmHg regardless of HR

    • Regardless of actual time of the injury 

  • Exclusion Criteria

    • ‘NO TOWAR’ bracelet 

    • Objection for TOWAR study by patient or family members at the scene 

    • Age >90yo or <18yo

    • Isolated fall from standing

    • Isolated drowning or hanging 

    • Isolated burns WITHOUT evidence of traumatic injury 

    • Known prisoner and/or pregnancy 

    • Traumatic arrest with >5m of CPR without ROSC prior to enrollment 

    • Penetrating brain injury or brain matter exposure 

    • Unable to obtain IV or IO access

  • Women of childbearing age

    • If meet TOWAR study criteria, can administer whole blood

    • If does not meet TOWAR study criteria, can still consider whole blood administration if needed 

      • May start with components

      • Then, whole blood if needed 

  • If blood cooler is opened, please enroll patient in study BEFORE leaving UCMC

    • Call 513-558-6223

    • Complete QR code survey (found on badge buddy, inside cooler lid, by elevators near helipad)

Pediatric Scene Call: Status Epilepticus 

  • New-onset pediatric seizure

    • Consider CNS involvement including meningitis/encephalitis triggering new onset seizures

    • Core competencies in all Air Care missions:

      • Obtain a history from whomever is at bedside (family, EMS, hospital staff) 

      • Followed by a primary survey (organized by ABCD for medical and MARCH3 for trauma) - insist upon and respect the information from EMS while moving forward in an intentional and focused fashion!

    • Point of care glucose for any patient with altered mental status

    • Establish the weight of the patient early on, particularly in pediatrics, and have a reference tool ready

      • Reference tools include Air Care RSI book, Pedi Stat app, Broslow tape 

      • If possible, try to determine age or estimated weight on the way to the call and prepare reference as well as equipment if needed

        • turn on vent to allow pre-checks, switch out circuits if less than 3 kg, pull specialty cells from critical care bag

    • Air Care has the tools to begin treating sepsis in the undifferentiated patient 

      • Initiate volume resuscitation

        • Remember that there is 1 liter of LR in the MN tube kit

      • Broad-spectrum antibiotics (cefepime)

  • Status epilepticus 

  • Definitions

    • Seizure refractory to medications or patient does not return to baseline between seizures

    • Seizures lasting greater than 5 minutes are at increased risk of becoming refractory to interventions and seizures lasting greater than 30 min contribute to cytotoxicity and neuron death - escalate care to obtain control by 30 min!

  • Start treatment of seizure with benzodiazepines

    • midazolam IM or lorazepam IV/IO

  • May repeat benzodiazepine and add a second AED

    • Keppra on Air Care

    • Load the patient to the extent possible (2g max on aircraft)

  • If patient remains refractory complete RSI to support airway and initial additional agents with anti-epileptic properties

    • Induction agents including ketamine, propofol, midazolam

  • Transport to a center with comprehensive neuro capabilities such as EEG

  • Pediatric RSI

  • Use a reference aid as noted above and seek a DASH1a airway

  • Baseline measures to support improvement in DASH1a success: 

    • Resuscitate before you intubate (blood products, IVF if indicated) 

    • Utilize apneic oxygenation 

    • Utilize the RSI checklist 

    • Video laryngoscopy with McGrath VL device  

  • Bougie first intubation when using standard geometry blade 

  • New measures contributing to improvement: 

    • Air Care monitors during RSI 

    • Seek to achieve at least an SpO2 of 97% before first attempt 

    • If SBP<100 mmHg, give push dose pressors (Epi, Neo) 

  • BVM through induction

    • Safe pressures on manometer (<20 cm H2O)

    • Open airway via jaw thrust by assistant 

  • If using rocuronium as paralytic, dose at 1.5 mg/kg of IBW 

  • Seek to match a patient's minute ventilation with TV and RR after intubation

    • Intentionally match patient's intrinsic RR noted prior to intubation

    • Note that healthy lungs can handle 8 mL/kg, based on IBW, if that is useful for compensation

  • Secure your ETT

    • Thomas Tube Holder is a new ETT holder on Air Care for ETT down to size 6.5

    • otherwise use the standard twill tape

Air Care Documentation in emsCHARTS

  • During the second half of the academic year, R1’s should complete charts in emsCHARTS 

    • Especially when they are the provider in the doc’s seat 

    EMS charts will cross over into Epic in real-time

    • Importance of completing charts in a timely matter 

    • Ideally, charts should be completed within 24 hours of the flight

    Documentation tips/tricks 

    • Page 2

      • Impression: is most important to complete (red flag, aka hard stop, if not completed)

      • CC: put patient’s complaints, as well as their actual diagnosis (ex: AMS, SDH)

      • Patient belongings: discuss with flight nurse who is completing this section 

      Air Care HPI

      • Discuss everything that happened PRIOR to air care’s arrival 

        • This includes test results, such as troponin levels & glucose 

        • As well as interventions, such as heparin ggt initiation & cervical collar application

      Physical exam 

      • In general, free-text is better than click boxes

      • Should be as thorough as your documented physical exam in the ED

      • Do not forget the neuro exam (page 3)

        • LOC, pupil findings, sensory, motor exam

        • GCS is a hard stop (note that you are unable to write ‘T’ for GCS score) 

        • Can write your full neuro exam in the comments section on page 3 as well 

      • Respiratory exam (page 4)

        • Write full respiratory exam under breath sounds section

        • Add vent settings from referral center in ventilator tab 

      • Cardiac exam (page 4) 

        • Write exam under cardio exam comments

      • Overall physical exam (page 5) 

        • General extremities tab- good place to write no trauma to extremities 

        • If a full neuro, resp, cardiovascular exam where appropriately documented on page 3 & 4, there is no need to repeat things on page 5

      • Activity log (page 8)

        • Where documentation for performed procedures is inserted 

        • Need to click add “action” to add a procedure 

          • Use procedure templates found on emsCHARTS

          • human resources tab-> document warehouse -> references:documentation

          • Copy and paste these templates into the action tab on page 8, then fill out appropriately 

      • Narrative 

        • Includes information from when Air Care arrives, until patient arrives to receiving facility & care is rendered

          • May sometimes include information before you meet the patient, such as delays experienced

        • Need indication for flight at the top of the note 

          • For example, patient with cardiogenic shock and needs transport to CVICU with cardiac surgery capabilities 

        • Narrative includes the medical decision making process 

          • For trauma patients, use MARCH format for documentation 

            • Massive hemorrhage including sources and interventions 

            • Airway including ETT, RSI meds

            • Respiratory 

            • Circulation including form of IV access

            • H has three components (head injury, hypothermia, hypoglycemia) 

          • For medical patient, use typical ABCD format for documentation 

          • Remainder of narrative involves what you did and explaining the medical decision-making process behind your actions

            • As well as what you didn’t do and why 

            • Interpretation of labs, exam, etc. 

            • Include PR callback information at the bottom 

        • Sign chart and push it 

          • Review yellow flags, yet do not need to necessarily fix to push the chart 

          • Meanwhile, red flags are a hard stop for pushing the chart

          • Charts need to be pushed within 24 hours of the flight (72h at the latest) 

        • All charts undergo a formal QA process