Sunday, December 20, 2015

"Why Ultrasound Belongs in EMS"

While perusing the the twitter sphere I found this tweet...

It really caught my eye thanks to the paper I just wrote and shared here. Point of Care Ultrasound (POCUS) has great utility in acute care and it will probably be the only imaging modality that could reasonably be put in an ambulance. Sonosite and Philips just released pocket/tablet form US devices that could easily be kept next to a cardiac monitor. If Philips is listening they will realize they make EMS cardiac monitors and US probes that could be added together... just an idea.

Tuesday, December 8, 2015

Prehospital Ultrasound in Undifferentiated shock, Cardiac Arrest, and the End of Resuscitation.

Please feel free to comment, on the topic or my grammar! This paper has already been graded. ;-)

Prehospital Ultrasound in Undifferentiated shock, Cardiac Arrest, and the End of Resuscitation.
Nicholas Jackson
Southern Maine Community College

For years ultrasound was an imaging modality for sonography technicians who acquired them and the radiologist who reviewed them. With the rapid rate technology has evolved and developed we now have point of care ultrasound. Point of care ultrasound allows physicians in the emergency department and office setting to acquire diagnostic quality imaging at the bedside. While physicians have a vast array of transducers, protocols, and views The question remains, Can paramedics perform the same feats to help our patients? In this paper we will review the “Focused echocardiographic evaluation in life support (FEEL)” protocol, the “Prehospital Evaluation of Effusion, Pneumothorax, and Standstill (PEEPS)” protocol, and assessment of non shockable rhythms under ultrasound.

Friday, July 10, 2015

Beets BLU heart rate monitor review.

I was given this Beets BLU to review by my Papi, Chris from FaithHack. He had received them as a sample to test/review for BeetsBLU.

First impression:

When I first got it i though it was decent looking, it's small and unobtrusive. Wearing it the first time was different and it took a couple tries to get it sized just right. On the inside of the chest band are the two electrodes to pick up the hearts electrical signals. I've found placing it just below the breast line in the 5th rib space sits well and gets good pickup. 

Set up:

BeetsBlu uses Bluetooth smart which means it doesn't connect through the traditional Bluetooth functions. You must connect it from one of their approved apps (I use RunKeeper and the BeetsBLU app), as soon as you figure out you have to use the app first it is easy to setup. 


Running with BLU was easy. It took maybe another 20 seconds to get it turned on and set up. While running I found it was relatively accurate. When I went full blast and was up in the 180-200bpm range it really wasn't that happy... but nether was I. When I did my normal running pace it was niceto be able to just peek and check if I was in the right range. I stopped a couple times and checked it compared to my radial pulses and they marched out with about a 5 second delay from pulse to app. My only complaint is after about 2 miles of pounding pavement the monitor had slipped down my chest a little. It was still picking up a signal and worked appropriately but I was more concerned it would fall down later. I did have to adjust it after getting my hands over my head for a little air break.


After my running experience I was concerned that moving in any way other than a gentle run would displace the device. So I tried a half hour yoga session with it on. It actually stayed better than I thought it would. I never had to adjust it even after major twist and turns. With the Bluetooth smart I was able to keep my phone on the table and out of my way. It is rated for a stable connection up to 10 meters (33 ft). 

Would I buy it?

If I wasn't a poor college student, yes. I found the device worked well, it's low profile and light weight make it reasonable to keep on while running. I liked being able to track how well I was doing and keeping my heart rate controlled. I could also see using it for meditation exercise to see if your getting the biologic responses you're looking for. Anyways, at $39.95 it's not a bad deal at all.

Monday, March 9, 2015

Hold your ground during the charge!

Excuse me? you said what?
"In patients with cardiac arrest presenting in a shockable rhythm during the ROC PRIMED trial, shorter pre- and peri-shock pauses were significantly associated with higher odds of survival. Future cardiopulmonary education and technology should focus on minimizing all peri-shock pauses." (Cheskes et all., 2013)

Decreasing peri-shock pauses is a good thing. 

Fig. 2. Cheskes et all., 2013
The less time we are squeezing the chest, the less time the victim is perfusing and the less their chances of survival. To maximize perfusion, the 2010 AHA Guidelines for CPR and ECC recommend minimizing pauses in chest compressions. Expert consensus is that a Chest Compression Fraction (CCF) of 80% is achievable in a variety of settings. (Meaney et all., 2013) A viable method to decrease compression pauses is to perform compressions as shocks are charged and delivered*. The purpose of CPR is to compensate for the failure of the heart to adequately pump blood throughout the body. We're trying to perfuse the heart (and brain) well enough to get the heart excitable (Ventricular fibrillation/Tachycardia) and restartable (Shock/defibrillation). 

From RebelEM
*While some evidence suggest CPR during defibrillation is safe and has benefit (Neumann et all., 2012)  the AHA does NOT recommend it. Rescuer safety is the highest priority in any scenario and should stay that way!

However, as technology evolves and research continues we may find a way to safely keep hands on during the entire incident. With the increasing frequency of CPR quality monitoring devices (or CPR pucks as I've called them so far) we may have a viable barrier to protect providers from electrical shocks, with the risk of redirecting high voltage electricity into monitors worth thousands of dollars.

Until that day, remember an 80% CCF and rate of 100-120. feel free to use this excellent reference material for a rate.


Cheskes, S., Schmicker, R. H., Verbeek, P. R., Salcido, D. D., Brown, S. P., Brooks, S., … Christenson, J. (2014). The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the Resuscitation Outcomes Consortium PRIMED trial. Resuscitation, 85(3), 336–42. doi:10.1016/j.resuscitation.2013.10.014

Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenson, J., de Caen, A. R., Bhanji, F., … Leary, M. (2013). Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation, 128(4), 417–35. doi:10.1161/CIR.0b013e31829d8654

Neumann, T., Gruenewald, M., Lauenstein, C., Drews, T., Iden, T., & Meybohm, P. (2012). Hands-on defibrillation has the potential to improve the quality of cardiopulmonary resuscitation and is safe for rescuers-a preclinical study. Journal of the American Heart Association, 1(5), e001313. doi:10.1161/JAHA.112.001313

Thursday, January 29, 2015

No TV week? Keep calm and read #FOAM!

 Have you just started at a service that doesn't have cable? Did your service rip the carpet out from under the feet of Abby and Gibbs? Don't know where to go without DiNozzo? Is your service trying to shield you from the Illuminati grasp on cable media? Well here's some advise for you. Keep Calm and read FOAM.

     But what is FOAM? 

Well it's Free Open Access Meducation says the amazing folks over at Life in the Fastlane. It's a fantastic tool to learn, teach, and grow as a person who providers medical care. It isn't just residents or doctors who use it. Nurses, respiratory therapist, medical assistants, paramedics, and ALL Allied health providers can benefit. FOAM has been facilitating collaboration across the world. In my little services we find it hard to talk to our neighbors, much less work with people in other countries. With social media connecting people on opposite sides of the world, it amazing to see development happening. So how do you access it? That's the fun part!

How do I join?

You're already a part of the #FOAM community if you want to be! So here are the tools used by most.
  • Twitter: Twitter is an excellent tool to share links, articles, and small comments. It's rather limiting with 140 characters and use may be frowned upon by your service while on shift.
  • Podcast: meaning Ipod broadcast is an audio feed. listening to things like FOAMcast and EMCrit is an excellent use of your time. I promise.
  • Google+: 
    • The EMCrit community is strong there! as are many other very smart people. You're service should have any problem. 1) It's Google. 2) none of your friends use it.
    •  I've also been involved with a EMS based community called Quality Box Time with a medic (he runs the Facebook version, I hope G+ is more popular!) for FOAM relevant to EMS/Prehospital providers.
    • FOAMcc is an excellent community! Moderated by Chris Nickson, John Greenwood, Minh Le Cong and Scott Weingart. It has a fairly comprehensive affiliate list. I am slowly getting into more and more of this list as time goes on.
  • Finally! Go look at EMCrits Favorites, you don't have to take it from me!

Does it need a card to be educational?

     The overwhelming answer to this is no. Unfortunately most of our educational budgets are consumed by keeping people competent. So it lands with the individual providers to learn more. Yes, that means you. The good news is you aren't alone, everyone else can use to learn more. Every day I learn something new that changes what I was taught before. I was told that we can not differentiate between a MI and a LBBB. Well we can with Sgarbossa Criteria, "A total score of  ≥ 3 has a specificity of 90% for diagnosing myocardial infarction."  (1,2), Go check out LITFL for more on that. 
     So who wants to have a four hour refresher on ACLS with information from 2010? FYI, the "Proven fact" that cooling our patients to 33°c has mortality benefit was debunked in 2013(3,4). I do not, but I must, because I need to keep a current card. I've learned the information and at this point, "refreshing" dosages and algorithms seems like something I could do more easily while sitting around base on my own or with coworkers as a full simulation. Without TV being a major barrier to get by I would hope people would be more then willing to "play". 
     As good medical professionals we are responsible for keeping ourselves up to date and well trained. With the excellent resources presented to us as FOAM it is very hard to cling to ignorance any longer! Hopefully this will spur a movement make learning a daily adventure and not an annual or monthly drag.


  1. Sgarbossa Criteria. Mike Cadogan. Life in the Fastlane
  2. Sgarbossa, E. B., Pinski, S. L., Barbagelata, A., Underwood, D. A., Gates, K. B., Topol, E. J., … Wagner, G. S. (1996). Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. The New England Journal of Medicine, 334(8), 481–7. doi:10.1056/NEJM199602223340801
  3. Kim F, Nichol G, Maynard C, et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2014;311(1):45-52. doi:10.1001/jama.2013.282173.
  4. Nielsen N,Wetterslev J, Cronberg T, et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med 2013; 369:2197-2206December 5, 2013DOI: 10.1056/NEJMoa1310519

Saturday, December 6, 2014

Cranial nerves and hard ons, oh my...

"Ooh, Ooh, Ooh, to touch a female vagina, gives Victor a hardon."

Patrick J. Lynch, medical illustrator
See, I said it. Vagina, hard on, and I'll just go ahead and add penis to this sentence. However, It worked for it's purpose. Remembering the 12 Cranial nerves.

I – Olfactory
II – Optic
III – Oculomotor
IV – Trochlear
V (1,2,3) – Trigeminal
VI – Abducens
VII – Facial
VIII – Vestibulocochlear
IX – Glossopharyngeal
X – Vagus
XI – Accessory
XII – Hypoglossal  - (Via Wikipedia)

(Yes, I'm using Wikipedia as a source. No this isn't a scholarly or even very intelligent post, it's okay.)

Sooo, I was suppose to memorize the 12 cranial nerves and their function (sensory, motor, or both) for a test this semester. I didn't, the test didn't go well. this is the point of test (or is how I use them at least). They are to show you what you need to learn! Within hours of that class ending, the tale of Victors sexual adventure was being repeated in my head over, and over, and over. The names of each nerve sticking out to me as much as the same nerves in my head. With the names cemented I needed a way to remember the function, and in came Victors brother.

"Some say marry money but my brother says big brains(and/or boobs) matter more" ~Dr Tim Luijkx and Dr Frank Gaillard et al

Sensory, Motor, or Both? That is the question... So we take our list of cranial nerves and line them up like so.
Some – Olfactory
Say– Optic
Marry – Oculomotor
Money– Trochlear
But – (1,2,3) – Trigeminal
My– Abducens
Brother– Facial
Says– Vestibulocochlear
Big– Glossopharyngeal
Brains/Boobs– Vagus
Matter– Accessory
More– Hypoglossal

That gives us the basic breakdown. Which is all I need for now. I hope someone finds this as helpful as I did! I wonder if anyone has done a study to see if the more inappropriate the mnemonic is the more effective it is to help people remember. Or maybe I'm just a little extra goofy and dirty minded... uh oh...

Friday, November 14, 2014

Medic school paper - Appropriate Utilization of Helicopter EMS - Draft

(Please comment! If you want to comment on the paper in Google docs then I will happily share the link! Thank you!)

Helicopter based emergency medical services (HEMS) are an essential part to any EMS system.  The first benefit noted with HEMS is that it gives prehospital providers access to rapid transport without the difficulties of traffic or terrain. HEMS utilizes staff ranging from a critical care paramedic to a physician led team. Working under an expanded scope of practice compared to the traditional ground ambulance. However, HEMS can be misused and abused like the rest of the EMS and emergency response system. According to Taylor, C. B. (2010) annual cost range from $115,777 to $5,571,578.  The LifeFlight Foundation annual report states that in 2013 alone Maine’s very own “Green Angels” had expenses equalling $9,109,732 (2013, p. 22). That cost can be placed with the patients and insurance or absorbed by the government and citizens. No matter where the funding comes from, it is associated with significant cost. The question is are we, as ground based field providers, properly utilizing HEMS as the valuable and equally expensive resource it is? To decide that we are going to look at HEMS response, skills provided by HEMS, and issues or risks associated with HEMS.
The first decision we need to make is when the proper time is to activate HEMS, and when is air transport beneficial over ground transport. The first thought is almost always trauma. From my first day learning the management of trauma as an EMT, I was taught that “bright lights, cold steel” are what save the lives of trauma patients, and that getting them to a trauma center as quickly as possible is the best way to help that patient. It’s easy to assume that calling a helicopter will decrease that time. Helicopters fly faster than we can drive and don’t deal with rush hour traffic; unfortunately life is never that simple. Shepherd, Trethewy, Kennedy, and Davis performed a retrospective study. “To profile a helicopter emergency medical service in rural Australia. To assess patient injury severities and outcomes. To compare missions involving ambulance officers with physicians. To determine any time advantage of the aircraft over ground transfer.” (2008, p. 1). While Maine may not be as interesting as Australia it does have many places that fit into the rural category.
When comparing air transport to the computer calculated ground transport by local ems, Shepard, Trethewy, Kennedy and Davis found that in transports under 50Km (31 Miles) road transport calculated to a mean of 29.44 minutes, while air transport had a mean of 48.11 minutes. This is due partially to pre-flight preparation and increased response distance compared to local ground EMS. It was noted between 50 Km and 100 Km that times were very close with a mean time of 56.34 minutes for ground and 62.63 minutes for air. When looking beyond 100 Km (62 Miles) a significant difference is found; the mean transport time of the helicopter being 93 minutes while ground transport reached a mean of 141 minutes (2008, p. 496-497). Shepherd, Trethewy, Kennedy, and Davis concluded, “we believe that in comparable environments and in the absence of special circumstances, a helicopter response within 100 km from base does not improve time to definitive care” (2008, p. 498).
Take a map of Maine, and draw circles of a 30 mile radius of every trauma center. If your service falls in this circle, than even in trauma without special circumstances (e.g. patient entrapment or airway interventions beyond paramedic scope of practice) strongly consider transporting directly to the trauma center. On the other side of the equation, if your service covers an area 60 plus miles from a trauma center or the call requires prolonged extrications, or advance airway interventions outside of the paramedic scope of practice, then strongly consider HEMS in severe trauma.
LifeFlight has access to multiple tools that are either prohibited by cost or law to ground transport. Tools like rapid sequence intubation protocols, mechanical ventilators, portable lab equipment, invasive blood pressure monitoring, and blood products. Utilizing a paramedic and nurse team gives them the ability to provide the appropriate care to the most critical patients quickly and rapidly transport to the appropriate facility. While HEMS can use more tools than most ground based EMS and possibly use them better due to higher frequency skill use and proficiency.
“...prehospital intubation in patients with severe head injury was associated with worse survival and functional outcome in their overall population, but was associated with improved outcomes when performed by helicopter crews”. (Brown, 2013, p. 282)
It was noted in the article that in a separate study, HEMS crews had a much higher intubation frequency (80%) as compared to their grounded EMS counterparts (10%), and had a lower mortality rate in head trauma patients of 34% (Brown, 2013, p. 282). we have evidence that attributes lower mortality to a specific injury process and we should strongly consider it.
Currently, LifeFlight uses two helicopters. One is located at Central Maine Medical Center in Lewiston and the other is, located at Eastern Maine Medical Center in Bangor. These two HEMS units cover the entire state of Maine which leaves some obvious access limitations. I personally have called for LifeFlight for a severe trauma and was told that the closest unit was over an hour away in New Hampshire. The reason? Both helicopters were transporting critically ill patients from smaller, community hospitals to large, tertiary hospitals. LifeFlight provides critical care interfacility transport to all the hospitals of Maine, taking an already limited resource and stretching it further. However, this is an essential task to providing good care to the population of Maine. Unfortunately, HEMS units may be available but unable to fly as well.
In EMS we have the difficult job of actually finding and retrieving the patient, no matter where they are. When the EMS system is activated we are obligated to respond in worse conditions than the Mailman. Rain, snow, and ice are all too frequent response conditions in Maine. I do not have the option of saying no to a 911 call. When winter comes and I have to respond to one of the many crashes, caused by snow and poor decisions, I will slowly and safely respond.
Most HEMS on the other hand can refuse a call for any reason, due to the increased dangers of flight and helicopters. The most common one being weather. With the dangers of operating a helicopter in inclement weather it is reasonable for a crew of three people to refuse a dangerous mission. They are not only responsible for their own safety like every EMS provider on the ground, but they also have to think of the patient and the risk over benefits of air transport in poor flight conditions.
It is not only the HEMS medical team that has to consider risk and benefits to the patient, the ground system requesting HEMS also has to consider it. Cost should never be a major factor in directing patient care, but we should always advocate for our patients. With air transport cost being substantially higher than ground, we have to use good critical thinking and medical decision making in deciding “should this patients be flown”? Does the benefit outweigh the cost and risk? Is it reasonable to saddle the patient with transport bill in the tens of thousands of dollars range for injuries or illness that is affecting them? As an EMS provider it is very easy to be afraid for your patient and want to give them the best possible chance by flying them. With any high index of suspicion due to apparent injury, clinical presentation, or mechanism of injury it is reasonable to activate HEMS. It is a different story if do not want to sit with the patient. If you are afraid of treating a patient for the time it will take to get to a trauma center then consider additional help in the back the ambulance instead of having HEMS transport. If for some reason a provider did not feel like giving the effort or the time to treat and transport a sick or injured patient this would be an obvious misuse of resources. It would be unethical for a provider to hand off a patient to a valuable resource as HEMS for personal convenience.
As much as I wish we had a scanner like “The Doctor” has in Star Trek: Voyager, we do not. We have to rely on a solid clinical assessment and factors like the mechanism of injury when it comes to requesting HEMS transport. The choice should never be made lightly, but if a provider has a strong feeling that the patient would benefit from HEMS for any of the reasons that have been discussed, like trauma with distances over 100Km, prolonged extrication, head injury with or without need of airway management. Patients who would benefit from medication assisted intubation, blood products, or invasive monitoring. It is important to recognize however, that HEMS is not always available or could have a significant response time. HEMS crews can refuse to respond for their own and the patients safety. In the critically injured or ill patient we as prehospital providers should always advocate for our patients and consider the risk and benefits of all of our interventions, that includes “calling the bird”.

Mommsen, P., Bradt, N., Zeckey, C., Andruszkow, H., Petri, M., Frink, M., & ... Probst, C. (2012). Comparison of helicopter and ground Emergency Medical Service: A retrospective analysis of a German rescue helicopter base. Technology & Health Care, 20(1), 49-56.

Shepherd, M., Trethewy, C., Kennedy, J., & Davis, L. (2008). Helicopter use in rural trauma. Emergency Medicine Australasia, 20(6), 494-499. doi:10.1111/j.1742-6723.2008.01135.x

Brown, J., & Gestring, M. (2013). Does helicopter transport impact outcome following trauma?. Trauma, 15(4), 279-288. doi:10.1177/1460408613497153

Taylor, C. B., Stevenson, M., Jan, S., Middleton, P. M., Fitzharris, M., & Myburgh, J. A. (2010). A systematic review of the costs and benefits of helicopter emergency medical services. Injury, 41(1), 10-20. doi:10.1016/j.injury.2009.09.030

LifeFlight Foundation. (2013). Annual reports [PDF]. Retrieved from Annual-Reports/Annual-Report-FY13-FINAL.pdf.aspx