Emergency Medicaid

I wanted to touch on a topic that I’ve always wanted to learn more about: Emergency Medicaid. As ER docs, I think it’s important to know what resources we have available for our patients. 

Some of this varies by state, so I would recommend quickly familiarizing yourself with the state guidelines. The information provided below is specific to New York state. 

What is Emergency Medicaid?

The federal government requires each state to provide Medicaid coverage for the “care and services necessary for the treatment of an emergency medical condition.”

What services are considered “emergency?”

• “Absence of immediate medical attention could put the patient in serious jeopardy, seriously impair bodily functions, or cause serious dysfunction to an organ or body part.”

• Cancer treatment: chemotherapy, radiation treatment, prescription medications

• Emergency surgeries (not elective)

• Emergency L&D services

So who’s eligible for Emergency Medicaid?

• Undocumented immigrants may apply for Emergency Medicaid.

• There are four criteria for Emergency Medicaid eligibility:

1. The patient is a district resident

2. The patient has an emergency medical condition

3. The patient meets income requirements

4. The patient is not eligible for ongoing Medicaid due to their citizenship or immigration status

For New York Medicaid (not *emergency* Medicaid), here is the criteria for eligibility. As you can see, it doesn’t capture a lot of our patient population. The patient must be:

• NY resident / US citizen, and

• Pregnant, or

• Be responsible for a child </=18 years old, or

• Blind, or

• Have a disability or a family member in the household with a disability, or

• 65+ years old

Some conditions require you to fall below certain income thresholds:

Have a household income (before taxes) that is below 138% of the federal poverty level. For reference, this translates to:

• 1 member household: <$17,131

• 2 member household: <$23,169

• 3 member household: <$29,207

• 4 member household: <$35,245
  

How do I help my patient sign up for it?

Our social work and case management teams are very helpful in facilitating this process. https://nystateofhealth.ny.gov/

How long does it last for?

• If Emergency Medicaid is approved, it will cover future and past costs associated with the medical condition for a maximum of fifteen months.

• Retroactive coverage maximum: 3 months

• Prospective coverage maximum: 12 months

• It can last for up to twelve months or as long as the person is experiencing the emergency, whichever is shorter.

Misc:

• Emergency Medicaid does not affect someone’s ability to apply for legal status

• This is not reported to US Immigration & Customs Enforcement.

References: 

http://www.wnylc.com/health/entry/70/
https://www1.nyc.gov/assets/ochia/downloads/pdf/fly-957-emergency-medicaid-english.pdf
https://dhcf.dc.gov/service/emergency-medicaid
https://www.benefits.gov/benefit/1637  https://www.health.ny.gov/health_care/medicaid/emergency_medical_condition_faq.htm

The Double Set-up

Hi all,

This is going to be a short but important POTD!

I wanted to write about an airway set up technique, colloquially termed “The Double Set Up” that the trauma and northside teams used yesterday during a level 1 trauma.

Without giving any secrets away for a case that will likely be an M&M in the future, for some situational background, the patient was getting progressively hypoxic with vomitus covering the entire airway. It was hard to get visualization of the airway using the Glidescope. The airway options were clear: either tube via DL or crich.

The team smartly employed the double set up technique to secure the airway. 

What does this term mean?

The double set up is when you have simultaneously set up for an orotracheal intubation and for a cricothyroidotomy. The EM/ anesthesia physician is at the head of the bed with the orotracheal airway equipment, while the surgeon is completely prepared for the crich with the scalpel in hand at the neck of the patient. The neck should already be prepped, and the landmarks should be identified.

When should we do the double set up?

Strayer has an amazing blog post about this (see below). Here are some indications where you might want to do the double set-up:

• An unstable maxillofacial trauma patient

• As a last ditch effort to secure the orotracheal tube after a failed attempt

• Rapidly desaturating patient with challenging anatomical features / cannot be successfully bagged

• Concern for an obstructed airway

If the intubator is ultimately unsuccessful, they indicate to the surgical airway physician to proceed. If the orotracheal intubator is successful, then the surgical airway physician can stop.

References:

• Check out Strayer’s excellent post on this: https://emupdates.com/the-emergency-department-double-setup/ 

• https://www.emed.theclinics.com/article/S0733-8627(17)30075-5/pdf 

• http://maryland.ccproject.com/wp-content/uploads/sites/8/2015/09/Leeuwenberg-2015-Airway-Management-of-the-Critically-Ill-Patient-Modifications-of-Traditional-Rapid-Sequence-Induction-and-Intubation.pdf
  

POTD: Neonatal Resuscitation

We’ll be going over a few high yield topics pertaining to NALS today. 

It’s 7:30 AM, and you’ve just unwrapped your BEC sandwich and taken your first sip of coffee. You’re settling into the morning getting ready for your 12 hour peds shift… until the phone rings, and you get a note: 

“Mother 38w delivered her baby at home 30 minutes ago. Baby is having labored breathing, and is bradycardic. EMS will be here in 2 minutes.”

Take a deep breath. First, remember the basics. If you’re in a facility that has Peds/NICU, call them immediately. Call respiratory. Call pharmacy. Call Hector. Use the resources available to you. 

The set up.

Get the warmer and set it to 25 C

• Avoid hypothermia in these patients. The goal is > 36.5-37.5C

Grab the Broselow tape so that it’s available for immediate use.
Get the backboard.
Grab the code cart, zoll
Get a towel to warm and dry the baby.
Get your airway equipment ready:

• Suction x 2, plugged in, ready to go

• Oxygen: grab the neonatal BVM and plug it into the oxygen port

• Airway equipment: have both DL/VL equipment,

  • LMA size 1

  • Pre-loaded tubes

    • 2.5 and 3.0 uncuffed tubes

  • Blades: 0 and 1

  • EtCO2

Access: IO gun + pink needles ready for use; umbilical vein catheters (future POTD)

Grab your PALS card or open up your PediStat app
Ultrasound

Assess the patient.

Pediatric assessment triangle:

• Appearance – crying? Good tone? Tracking?

• Breathing – nasal flaring? Stridor? Grunting? Head bobbing?

• Circulation – Pallor? Cyanosis? Mottling?
  

Off the bat, there are two numbers you need to remember:
HR < 100→ initiate positive pressure ventilation (PPV)
HR < 60→ initiate CPR / epinephrine if this is sustained more than 30 seconds despite adequate ventilation.

• NOTE: Bradycardia is almost always related to hypoxia, so atropine isn’t routinely indicated for these patients.

Remember, the most important part of neonatal resuscitation is positive pressure ventilation.

PPV.

If the patient is spontaneously breathing but labored, you can place them on CPAP.
Remember, the targeted SpO2 after birth is much lower for neonates, so see the box below. You’re more interested in ventilating than the oxygenation.
For gasping / apneic / HR < 100 patients, initiate PPV. You can use 5 on the PEEP valve.

• Rate: 40-60 breaths / minute
  

MR SOPA mnemonic for ventilation tips:

• Mask, right size

• Reposition airway

• Suctioning nares

• Open mouth

• Pressure increase to PEEP to ~5

• Advanced airway: ETT / LMA
  

BGM.

They also have lower BGMs. Hypoglycemia for neonates is < 30 for a patient < 24 hours old. It’s recommended to give D10 bolus 2ml/kg if the patient is hypoglycemic.

You can give glucagon IM too: 0.03mg/kg max 1mg

CPR.

It’s recommended to secure an airway (supraglottic or ETT) prior to doing compressions) since most these codes are usually due to respiratory events.
The ideal ratio is3 compressions:1 breath

• Goal is 90 compressions: 30 breaths in one minute
  

2 thumb compression technique (*preferred) or 2 finger technique
Pulse checks q1 min
Depth: ⅓ chest diameter

Epinephrine.

IV dosing: 0.01mg/kg q3-5min
ETT dosing: You can give epinephrine through the ETT too if you don’t have access yet! AHA recommends a larger dose 0.1mg/kg of 1:1000 ETT

• Max dose is 10mg, and follow it with a saline flush
  

I highly recommend reviewing the following flowchart linked.

I hope this was a good refresher on some of the most important concepts. I would love to learn other tips that others have in managing these stressful situations!

References:

https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation 

https://emergencymedicinecases.com/neonatal-resuscitation/