EMS Protocol - Approach to Suspected MI

Duncan Grossman · October 28, 2020 · EMS

Protocol 504 – Suspected Myocardial Infarction is supplemented by two sub-protocols: 504-A – Drug Therapy of Myocardial Ischemia and 504-B – Cardiogenic Shock, and they’re each fairly straightforward, so let’s breeze through.

504 – Suspected Myocardial Infarction: ALS suspects an MI, they start cardiac monitoring, manage unstable dysrhythmias, check a 12-lead, start transport, and monitor vital signs. If the EKG is concerning for a STEMI (either because of the machine’s read or their own), they’ll run it past OLMC (generally FDNY’s OLMC, specifically) for assistance in determining whether the patient is having a slam-dunk, textbook STEMI, and should therefore go directly to a STEMI center, versus being able to be appropriately managed at a hospital that isn’t a STEMI center but might be closer.

504-A – Drug Therapy of Myocardial Ischemia: So, you’ve got a patient concerning for ACS. How are you gonna treat them to start? ALS Standing Orders for this protocol allow for 162mg of aspirin, as well as nitroglycerin every 5 minutes to help with pain. Note that the protocol includes caveats for patients who have recently used erectile dysfunction meds or who are hypotensive. And speaking of hypotension…

504-B – Cardiogenic Shock: Uh-oh, somebody’s hypotensive! ALS is instructed to give a small fluid bolus to these patients to help with preload, but if there’s no improvement in blood pressure at that point, guess what? Peripheral pressors to the rescue! Historically, crews generally had access to dopamine, but as times have changed, so have the protocols, expanding to include norepinephrine and even push-dose epinephrine! Dopamine has stayed in the protocols, however, to allow for services that still carry and are trained in its use. Tough administrative-level decisions often arise in EMS and other health systems when you have to reconcile best medical practices with logistical challenges. Norepinephrine might be the better med, but when you have thousands of providers that would need new training in its use, and a stockpile of dopamine that you’ve already paid for, it’s not hard to see why the change might be a slow one.

That’s it! All of these protocols are Standing Order, so there won’t be much to know for OLMC calls, although occasionally crews may call to ask about switching between pressors (eg, starting on push-dose epi and moving to a norepi drip). Otherwise, bask in your knowledge of EMS care, ever-expanding from these emails, www.nycremsco.org and the protocol binder!

Courtesy of Dr. David Eng, Assistant Medical Director of Emergency Medical Services at Maimonides

What is a DO?

Duncan Grossman · October 26, 2020 · Special Topics

DOs = Doctor of Osteopathic Medicine. Let's take a few moments to learn what the heck those letters mean...

Very quick history lession:

Back in the 1860s, a MD named Andrew Taylor Still lost his three children to meningitis.
He began to question the efficacy of "modern medicine" at the time which was using mercury for constipation, opium for bronchitis, and chloroform for anesthesia.
Still proposed that the body could likely heal itself and that many maladies were often the result of physical misalignments. By realigning the body, he said he could optimize people to get better on their own.

This morphed into the tenets of osteopathic medicine:

The body is a unit, consisting of mind, body, and spirit.
The body is capable of self healing, self regulation, and health maintenance.
Structure and function are reciprocally related.
Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. from osteopathic.org

DO Schools

Wikipedia currently had 48 DO schools listed, compared to 170+ MD schools.
MCATs and GPAs are, on average, lower for DO matriculants.
- (503.8 vs 511.5, 3.54 vs 3.73)
About 25% of med students are now DO students
The curriculum is also four years, though in addition to the basic sciences and standard med school classes, DO students put hundreds of hours into learning musculoskeletal manipulation, known as OMM or osteopathic manipulative medicine.

OMM

These modalities are based on in-depth knowledge of muscle origins, insertions, and actions, though their efficacy has certainly been called into question.
Counterstrain - a technique to reduce tender points in muscles by shortening the agonist muscle for 60-90 seconds
HVLA - rapid movements to mobilize joints through firmly restricted ranges of motion... this is when I crack José's neck in resus when no one's around
Muscle Energy - frankly, kind of a silly name for a similar technique called PNF that other practitioners use - this technique is to lengthen and relax constricted, tight, tender muscles
Soft tissue technique - similar to massage
And various other techniques

Does it work?

Because it isn't possible to blind practitioners, studying OMM is quite hard.
There is limited evidence outside of the American Osteopathic Association's own journal to support its use.
This excellent wikipedia section highlights some of the studies that show its controversy.

More Controversy

Craniosacral therapy is by far the most criticized modality of OMM. It is sometimes taught (and practiced) that providers can feel movement of the skull in full grown adults, and that this rhythmic movement may be altered or change to influence the health of the patient. (Yes, I was taught this in school.) It has been denounced as quackery for years.

Discrimation

DO students have certainly been discriminated against when competing for residency. I don't need a source for this, I can just tell you from personal experience that I've heard people say, "We don't take DOs."
- As a result, DO students often have to put much more work into matching to competitive specialties than their MD counterparts, by completing two sets of boards, the COMLEX and the USMLE (yes, Step/Level 1 AND 2).
- They also are encourage to perform more away rotations -- I did five EM-themed rotations during my last year of med school.
Until recently DOs had their own match day separate from MDs. This has just recently been merged in an effort to further equalize the degree and make the process more fair.

DO's in the Maimo ER

Have I used OMM in the ED? Once, on a wussy 17yo who couldn't move his arms after he lifted weights the day before. Yes, it worked.
As I'm sure you've seen by now, DOs in the ED are indistinguishable from their MD counterparts. In this clinical setting we are all just ER docs with the same job and same capabilities.

The whole MD vs DO thing has been re-sparked recently because some jerk decided to go and make a fool of himself on international television... and he happened to have a "DO" after his name. Anyway, I hoped this was mildly interesting. Feel free to ask me anything you want about the DO world, happy to chat about it and speak candidly.

Ref:

https://osteopathic.org/what-is-osteopathic-medicine/what-is-a-do/#:~:text=Doctors%20of%20Osteopathic%20Medicine%2C%20or,get%20healthy%20and%20stay%20well.

http://www.osmosis.org

Presidential Pathology

Duncan Grossman · October 22, 2020 · Special Topics

In honor of election season, let’s review some pearls and boards material surrounding our nation’s presidents!

Woodrow Wilson – Influenza, Stroke

1918: There is some suspicion that President Wilson caught the famous virus from the 1918 flu pandemic. He later suffered a TIA and a massive stroke (L hemiplegia) – his staff hid the severity of his stroke while his wife supervised his duties.

Influenza:

· Antigenic drift = small mutations that create different seasonal flus

· Antigenic shift = switches species

· Tamiflu = all hospitalized & high risk patients ASAP, low risk patients within 48hrs

o Tamiflu debate, click here

Stroke:

· Highest risk of stroke after TIA = 48hrs

· Blood pressure goals:

o Ischemic stroke, TPA eligible = Keep below 185/110

o Ischemic stroke, no TPA = 220/120

· TPA to be given within 4.5 hours

FDR – Polio

1933-1945: Photographers avoided taking pictures of FDR while he was in his wheelchair as it was viewed as a sign of weakness. Photos of him were deliberately taken only while the president was in a car or behind a desk.

Polio

· The WHO anticipated eradicating polio from the planet by 2023. However, President Trump’s withdrawal from the organization had led to a severe decrease in funding and that may need to be reconsidered. Check out this clip from Sunday’s Last Week Tonight With John Oliver to learn more.

Eisenhower – MI, Crohn’s Disease

1955: He stayed in Fitzsimons Army Hospital in Colorado for 7 weeks after his heart attack, but I couldn’t find how they treated it. Just a few months later, six months prior to his next election, he was diagnosed with Crohn’s Disease and required surgery. He went on to win the election.

MI: Lysis vs Cath

· Lysis if PCI cannot be performed in the “appropriate timeframes” below

· PCI timeframes:

o AMI within 2hrs = PCI in 60 minutes

o AMI within 2-3hrs = PCI in 60-120 minutes

o AMI within 3-12hrs = PCI in 120 minutes

Crohn’s Disease

· Typically 2nd/3rd decade of life, male, hx of IBD in the family

· Any part of the digestive tract from mouth to anus

· Skip lesions

· Full thickness inflammation (unlike UC = epithelial layer only)

Jed Bartlet – Multiple Sclerosis

2000: Widely acclaimed as the greatest president of our time, the Bartlet Whitehouse was rocked by scandal and outrage when it was revealed that the president and members of his administration had willfully omitted knowledge of the president’s devastating demyelinating disease. Despite the controversy, Americans saw past this lapse of judgement and reelected President Bartlet for a second term.

MS

· Autoimmune, more in females, connected to psoriasis and thyroid disease

· Internuclear ophthalmoplegia = difficulty adducting eye = pathognomonic

· LP = Oligoclonal bands & IgG in the CSF

· MRI = optic nerve lesions, juxtacortical lesions, and Dawson Fingers

· Steroids for flares (inpt or outpt)

George W. Bush – Colonoscopy

2002, 2007: Colonoscopies aren’t that interesting but Bush did, indeed, hand over the power of the presidency to Dick Cheney on two occasions, each lasting just over 2hrs while he had routine colonoscopies.

Colonoscopy

· Q10yrs, starting at age 50 (unless family hx, familial adenomatous polyposis, etc.)

· Complications:

o Pyogenic liver abscess

o Infection

o Bleeding (post-polypectomy, 1 week after procedure)

o Perforation

o Post-polypectomy syndrome: peritonitis without perforation after a transmural burn in the colon

Kennedy – Addison’s Disease

1961-1963: It looks like JFK suffered from quite a number of medical problems: chronic back pain, colitis, UTI, abscess, possibly malaria, and apparently was on a brief course of antipsychotics after a change in mood when he started some antihistamines. The most famous of these maladies was his Addison’s Disease, for which he was on daily steroids.

Interestingly, Kennedy was wearing his back brace on the day he was assassinated, which kept his posture fully upright in the limousine prior to getting shot.

Addison’s Disease:

· Chronic adrenal insufficiency, autoimmune – patient’s on chronic steroids

· Hyperpigmentation

· Must be distinguished from acute adrenal insufficiency:

o Look for hyponatremia and hyperkalemia (low aldosterone)

o Hypoglycemia

o Refractory hypotension

o Hydrocortisone 100mg IV

REFERENCES:

https://www.cnn.com/2020/10/07/health/us-presidents-health-problems-wellness/index.html

https://www.healthline.com/health/diseases-of-presidents

https://www.ahajournals.org/doi/10.1161/STR.0000000000000211