EMS Protocol of the Week - Pediatric Asthma/Wheezing

Last week, we went over the REMAC protocol for asthma, but in a cliffhanger not seen sinceAvengers: Infinity War, we were all left wondering what NYC EMS does with asthmatic/wheezing kids. Well worry not, faithful readers, because this week we’re taking a look at Protocol 554 – Pediatric Asthma/Wheezing!

There are a bunch of pediatric-specific protocols (remember that for the NYC REMAC, pediatric means up to 15 years of age), each with certain differences from its adult counterpart. Some differences are subtle, some not, so it’s worthwhile to at least have some awareness that these peds protocols exist in case the OLMC phone rings for a kid.

Protocol 554 is a good place to start with pediatric protocols since it’s not hugely different from 507, which we discussed last week. Albuterol and ipratropium are still being utilized as Standing Order, although a half dose of ipratropium is instructed for kids less than 6 years old. Further, while the adult protocol permits for continuous albuterol to be used, the pediatric protocol only allows for 3 doses as Standing Order. For children older than one year in severe distress, medics will also give epinephrine as Standing Order at a weight based dose (up to 0.3mg IM, the adult dose). After this point, OLMC may be utilized to request additional albuterol nebs and repeat doses of epi.

At this point, the only other significant difference in management is that the pediatric protocol does not include steroids or magnesium as adjuncts to treatment, either as SO or MCO, so just be aware that these kids will likely not have received any of those meds by the time they reach the ED (as opposed to adult patients).

That’s pretty much it for pediatric wheezers. Similar to the adult protocol, this one will generally leave most kids (and their parents) feeling much better by the time you see them, but just be aware of what may or may not have been done for them before immediately sending them out the door.

We’ll revisit other pediatric-specific protocols in the future, so be sure to keep an eye out! In the meantime, here’s your weekly plug forwww.nycremsco.org and the protocols binder by the OLMC phone.

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

POTD: Felon

POTD: Felon

• Subcutaneous pyogenic infection of the pulp space compartment of the distal finger

• Can often be confused with paronychia or herpetic whitlow (fingertip pain but should not cause taut erythema) which can sometimes present with volar erythema

• High risk to progress to osteomyelitis, Flexor Tenosynovitis!

Clinical Features:

• Erythematous, edematous, tense distal pulp space with significant pain and tenderness

• May see necrotic appearing tissue distally due to increased pressure in space 

Work Up:

• Usually diagnosed clinically

• XR: No foreign body, soft tissue swelling pulp of thumb

• US: Use the water bath technique to see a potential fluid collection

• Digital Nerve Block

• I & D is the cornerstone of management: 

• Apply a latex glove finger tourniquet

• If the felon is on patient’s index, middle or ring finger, make the incision of the ulnar aspect

• If the felon is on patient’s thumb or pinky, make the incision of the radial aspect

• Using your #11 blade start your incision 5mm distal to flexor DIP crease and end 5mm proximal to nail plate border. Digital arteries and nerves arborize near DIT. Avoid those!

• Blunt dissect and break any loculations until the abscess is decompressed

• Avoid the "fishmouth" incision. Potentially can cause an unstable finger pad, neuroma or loss of sensation

• Antibiotics: Cover for Staph (MRSA) and strep

Disposition: 

• Home with follow up in the hand clinic or ED in 1-2 days. 

Check out this video to see it done:  

• www.emrap.org/episode/felonincision/felonincision 

Stay well,

TR Adam

Hello, World!

POTD: An Uninvited Guest (Wellness Friday)

POTD:  An Uninvited Guest (Wellness Friday)

an uninvited guest

settles in the valley of my heart

makes a home within my chest

and refuses to depart

the mountains of my lungs

are crumbling down beneath his weight

as he pollutes the peace once there

with oppression and hate

there are waves of emotions

that pound against my veins

lost in a whirl of wind

as they rage in a hurricane

the currents get rough

and I find myself lost at sea

within a jagged ocean as vast

as the emptiness I flee

my nights have grown longer

as I struggle to fall asleep

my days have blurred together

and my body has grown weak

tracks run over my wrist

as the departing train voices its last call

is it better to feel pain

than to feel nothing at all?

emotions cloud my thoughts

smoke fogs up my mind

they tell me I’m not good enough

that I’m not worth it to the Divine

my faith is shaking

I can’t find who I am

I am enchained by anxiety

as desolation takes command

saltwater shakes my core

and spills over the rims of my eyes

as the ocean drowns me

I succumb to numbness inside

I frantically glance into the distance

and find His lighthouse shining from miles away

guiding me home

from tides that make me stray

He shows me the universe;

constellations trace my skin

and even when I’m breaking,

my galaxies shine from stardust within

He shows me the dawn;

as it breaks, so do I

but there’s a beauty in my breaking

as red and gold paint the morning sky

To Him I am worth more

than this world entirely

and that’s all I need to overcome

my haunting thoughts of mortality

an honorable guest

has settled in the valley of my heart

He illuminates it with hope and light

in places I’ve broken apart

-SS Barkat

________________________________

It's World Mental Health Day tomorrow!

One in five adults suffer from a mental illness each year within the United States. More Americans struggle with depression than they do with coronary heart disease, cancer, and HIV/AIDS2. Unfortunately, stigmas founded on misunderstandings of mental illnesses are common. Some may inappropriately label the lack of energy that a depressed individual struggles with as laziness. In turn, those that are suffering turn away from getting the professional help that they need from fear of what people may say.

The “uninvited guest” in this poem refers to depression. The poem’s title aims to demonstrate that depression is just as real as any other physical disease that one may have. It isn’t a state that those suffering choose to be in; rather, depression appears uninvited and begins to govern the mind and body of the victim. Overall, the purpose of this poem is to share the complex nature of depression, the thoughts that may plague the minds of those that are depressed, and ways in which we can all look at the signs around us to remember our self worth in times that we feel lost and hopeless.

By sharing experiences and having open and honest conversations about mental health, we can become a step closer to shattering stigmas and improving access to treatment and services as a community of health care workers.

Have a friend who needs help?; Give them a hug, a pat on the back. Let them cry on your shoulder or your lap. Don't underestimate the power of simple things.

 Ask for help when it gets too much:

National Suicide Hotline: 1-800-273-8255

NYC Well: 1-888-NYC-WELL or Text "WELL" to 65173

In-house: Erica Hutchinson, Ph.D.

Office: (718) 283-8174

Work Cell: (347) 996-6090

Have a great weekend and stay well,

TR Adam