At this point, we've gone over everything EMS is capable of doing for an adult in cardiac arrest. This includes what they will do under Standing Orders, as well as what they may request of OLMC as a Medical Control Option. But what if they are unable to obtain ROSC after all of those interventions? Or what if they’ve only performed Standing Orders, and you don’t think any of the Medical Control Options will make a difference? Do all of these patients need to be transported to the hospital?
No!
There are plenty of instances where you’ll be asked – or where you deem it appropriate – to terminate resuscitative efforts of EMS providers in the field, rather than having them transport the patient to continue efforts in the ED. Attached are current guidelines for when you, as the OLMC physician, may consider Termination of Resuscitation (ToR), but keep in mind that these are just guidelines and thus exist secondarily to your own clinical judgment. You are not required, for example, to insist on exactly 30 minutes of resuscitative efforts on the 106-year-old who was last seen alive a week ago. But given that these guidelines are based on a combination of AHA recommendations and other EMS best practices, it’s worth your time to look over these criteria. In general, they tend to identify those patients with the least likelihood of making a meaningful recovery, which ideally is what you’re already assessing for when speaking with the paramedics on the phone.
Any questions? Always feel free to reach out! Otherwise, you’ve got www.nycremsco.org and the protocols binder to keep you company until next week!
Dave
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Embracing Fear in Emergency Medicine
This POTD is from a talk Dr. Chung gave at a grand rounds last year at Kings County.
Common Fears Physicians Face:
o Hurting Someone
o Killing Someone
o Not knowing what to do
o Doing the wrong thing
o Being Sued
o Losing Credibility
o Getting stuck
o Hating my Job
o Not Being Liked
o Having no Friends
Fear is complicated (psychologists look at fear in multiple ways):
o Basic Emotion
In conjunction with happiness and sadness
o Social Construct
The way we experience fear, the things we are afraid of and our response to fear are socially driven depending on the countries we grew up in
o Survival Response
o Adaptive response
o Personality
Types of Fear:
o Physical Fear
o Identity Fear
How we conceptualize ourselves
How we identify ourselves
o Social Fear
Fear is normal we all feel and experience fear. Fear comes from 3 different things:
o Having a fixed vs growth mindset
Fixed: We are born with all the skills and abilities we will have for our entire life
Growth: Potential for growth is unlimited. We are not born with any skills and/or abilities, we acquire them through life.
Failure is perceived as an opportunity to learn from and change
o Hidden Curriculum
Formal Curriculum: conference, assigned homework
Informal Curriculum: on shift learning
Hidden Curriculum: Things that are not said but implied
o Imposter syndrome
You feel you are not qualified to be in the position you are in
Instead of Dealing with Our Fears we try to put on “Armory”:
o Perfectionism
o Numbing
o Being Right
o Crush or be crushed
o Cynicism/Sarcasm
By putting on this “Armory” we prevent ourselves from feeling joy, feeling fulfilled and realizing the good we are doing. This ultimately can lead to burn out and satisfaction with your job.
We need to Embrace our Fears. It takes a lot of courage and bravery to acknowledge when you don’t know something. Bravery allows you to gain the strength to face your fears. People that can realize and acknowledge their fears are able to be more successful. It’s important to remember to approach your seniors, attendings, and mentors when you feel fear. They may have similar stories to share and have ideas to overcome these fears so you can be more successful.
How to be more comfortable with fear:
o Be prepared (prepare yourself to experience fear throughout your career)
o Be human (its ok to have emotions weather you feel sad, joy, need to cry this is all normal)
o Be vulnerable (share your stories with others)
o Be empathic (support your coworkers and find the support systems that help you)
Embracing your fear can help you prevent yourself from burning out and having a life-long career that you will love and enjoy.
References:
POTD: Emergent Trach Complications
Most common Tracheostomy Complaints Include the Following:
o Dislodgement
o Decannulation
Equipment:
o 3 parts (past photo)
o Outer cannula (rigid)
§ Top portion of the trach is called the neck plate
· On the right upper hand corner you will find all the information you need in terms of sizing
o Size 4, 6, 8 is the measurement of the inner diameter
o Inner cannula
§ Must be inserted into the outer cannula to be able to bag the patient or connect the patient to the vent
§ You do not need the inner cannula if the patient is trach to air
o Obturator
§ The most distal portion of the outer cannula is blunt and has sharp edges the obturator prevents you from causing any damage when inserting the outer cannula
Important things to know when you get a tach patient
o Size ( 4,6,8)
o Cuffed or uncuffed
o Reason for Trach
o Date of placement
o Stoma healing roughly 7-10 days
§ Increased risk of creating a fall passage if you replace the trach within 10days
Uncuffed trach are mostly used in patients to allow them to speak. If you need to ventilate a patient you must have a cuffed trach
Step-wise Management of Patient with respiratory Distress in the Setting of a Trach
o Default action for all patients in respiratory distress is to bag the face and the neck
o High flow or PPV
o How to bag the stoma if the trach is dislodged
o Pediatric BVM
o LMA (inflate a size 3 or 4 LMA and seal it around the stoma)
o Remove the inner cannula and clean it. Replace it with either a new one or the clean one
o Insert a sterile in-line suction catheter
o If you can only insert the suction 1-2cm your tube is either dislodged or obstructed
o If suctioning fails will need to deflate the cuff and push it in further and re-inflate it
o If deflating the cuff fails will need to remove the trach tube
o Can now intubate through the stoma or oropharynx
Laryngectomy patient:
o Cannot intubate through the mouth must go through the stoma
If inserting an ET tube into the stoma only go until you loose site of the cuff then stop and inflate. Very short distance the tube needs to travel for a trach compared to an oropharyngeal intubation
Algorithm
o Green Algorithm (patent upper airway)
o Red Algorithm (laryngectomy patient)
References:
o https://www.youtube.com/watch?v=szNsOtwEU8k
o https://emcrit.org/wp-content/uploads/2012/09/guidelines-trach-emergencies.pdf
o https://wikem.org/wiki/Tracheostomy_complications
o https://first10em.com/tracheostomy/