POTD: EMS levels

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Who am I talking to?

We all deal with EMS almost every day, but I’m not entirely sure we’ve been as educated on what the different levels of EMS providers are.

So here’s a quick overview. Worth noting that the scope of providers ranges pretty heavily from region to region/state to state.  This is a basic overview and some of these rules do not completely apply to NYC EMS providers for a multitude of reasons.  Regardless its worthwhile to have a vague idea of what’s going on so here it is. Thank you and you’re welcome

The basic level is the Emergency Medical Responder

they require roughly 60 hours of training! Woah!

SKILLS: basic first aid and airway (OPA/BVM)

      AED 

      Epi-Pen

The next level is the Emergency Medical Technician (the former EMT - Basic)

How much training you ask? Of note the official book says the number of hours requirement doesn’t exist its just about competency, this goes for all further levels as well…. But estimated time is 150-200 hours!! Bazing!

SKILLS: basic first aid and airway (OPA/NPA and BVM)

      assisting patients in taking home meds!

      limited medication administration (we’re talking ASA, oral glucose - but really depends on the medical directors in the area)

      that sweet sweet oxygen administration 

      and last but not least - monitoring vitals 

Guess what, there’s more - Now w’re talking about the Advanced EMT 

How much training you ask? **expected** 300-450 hours!! Yaowza

SKILLS: start IVs and IOs!! Super important to identify these if you’re doing event medicine.

      limited med admin again as per medical directors 

      Cardiac monitoring and 12-lead ECG - now we’re thinking notifications 

      Airway management (supraglottic airway but NOT Endotracheal tube)

Now we’re at the big boys on the block - Paramedics 

How much training you ask? **expected**1000-2000 hours!! **thud** that was me passing out and hitting the ground 

SKILLS: IVs and IOs

      IV Med administration

      Cardiac Monitoring and 12-lead 

      Manual defibrillation and cardio version 

      Transcutaneous pacing!! 

      Endotracheal tubes

      Needle Chest Decrompression

      Needle/surgical cricothyrotomy

And there you have it. Take it all in and respect your EMS providers

Happy resuscitating!

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POTD: HEMATOMA BLOCK

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OVERVIEW

  • The hematoma block is local anesthesia delivered to the hematoma formation around a fracture site and done prior to reduction

  • Simple, fast, and does not require special equipment

  • Can be used for a variety of fractures (Colles’, ankle) and reductions

  • Has fallen out of favor due to rising popularity of procedural sedation

  • Does not increase the risk of infection

PROCEDURE

  1. Draw up 5 to 20 mLs of local anesthetic

  2. Find landmarks

  3. Clean area with chloraprep

  4. Insert the needle directly into the hematoma, withdrawing as you go

  5. Alternatively, use POCUS to identify the dark, anechoic hematoma

  6. Blood aspiration helps to confirm needle position

  7. Inject anesthetic, remembering not to exceed max dose

  8. Proceed with reduction after 5-10 min

CONTRAINDICATIONS

  • DO NOT perform procedure through a contaminated wound

  • DO NOT perform procedure on open fractures

TIPS and TRICKS

  • Use a combination of lidocaine and bupivicaine for rapid onset and longer acting anesthesia/analgesia

  • Note that after a few hours, hematomas can become unaspiratable

Sources:

  1. Tintinalli's Emergency Medicine, 9th Edition pp 247-248

  2. WikiEM: Hematoma Block

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POTD: DENTAL POSTEXTRACTION COMPLICATIONS

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If you’ve worked in our fast track area, you’re familiar with the variety of dental issues our patients come in with on a daily basis. Here, we discuss post-extraction complications — namely pain, dry socket, and bleeding.

POSTEXTRACTION PAIN

  • Pain and edema is common after extraction of third molars (wisdom teeth)

  • Peaks within the first 24-48 hours after extraction

  • Treatment: ice packs, elevation of HOB to 30 degrees, and NSAIDs

  • NSAIDS preferred over oral narcotics for pain

  • Progressively worsening trismus is worrisome for a post-op infection


POSTEXTRACTION ALVEOLAR OSTEITIS (DRY SOCKET)

  • Total or partial displacement of the clot from the socket, resulting in alveolar bone exposure

  • Can progress to osteomyelitis of the exposed bone

  • Commonly occurs on the second or third postoperative day

  • Associated with severe pain

  • Incidence: 1-5% of all extractions, but up to 30% in impacted wisdom tooth extraction

  • Risk factors: smoking, pre-existing periodontal disease, traumatic extraction, prior episodes

  • Treatment: Pain control with expectant management, gentle irrigation with warm saline or chlorhexidine 0.12% oral rinse to remove debris

  • Intrasocket placement of medications is controversial

  • Give antibiotics for suspected infections


POSTEXTRACTION BLEEDING

  • Soak a 2x2 gauze pad in TXA, apply to socket and ask patient to bite down (not chew!)

  • If this doesn’t work, can apply Surgicel into the socket to serve as a clot-forming matrix

  • Can use loose sutures to hold in place, or to loosely close gingiva over the socket

  • CAVEAT: Tight sutures may cause necrosis of the gingival flap

  • If this doesn’t work, may inject lidocaine with epi or use silver nitrate cautery

  • Still no luck? —> Consult w/ OMFS

Sources: Tintinalli’s Emergency Medicine, 9th Edition pp 1582-1583

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