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MCMAID Resuscitation Protocol

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This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

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EMERGENCY MEDICAL RESPONDER/EMT

A CODE COMMANDER should assign duties according to MCMAID prior to arrival

  • Establish that the patient is unresponsive, and not breathing normally
  • Rule out DNR status, dependent lividity, rigor mortis

First Priority: M-(metronome) Quality Chest Compressions

  • Turn on Metronome, ensuring a rate of 100/minute
  • Initiate 2 minutes of chest compressions, pediatric-follow AHA 2005 Guidelines

Second Priority: C-(compressions) Quality Chest Compressions

  • Assign two compressors switching every minute, checking each others quality
  • Depth should be at least 2 inches
  • The heal of the compressor’s hand should come off the chest, ensuring full recoil

Third Priority: M-(monitor) Defibrillate

  • AED, push analyze (pediatric patient >1 yr , use peds pads up to 8 yrs if available if not use adult pads)
  • Manual, charge max joules during CPR, analyzing for no more than 5 sec (EMT-I/P) – (pediatric 4 joules/kg)
  • Immediately resume 2 more minutes of compressions

Fourth Priority: A-(airway)

  • Oropharyngeal airway and 10 liters O2 via NRB mask
  • Check patency if chocking is suspected
  • No ventilations until after 3 cycles - (unless pediatric-follow AHA 2005 Guidelines)
  • CombiTube/ET after 3 cycles of compressions, unless 1st  rhythm is nonshockable, then as soon as possible, ventilate at 6/minute only enough volume to just make chest rise

 If ROSC, acquire 12-Lead EKG, ***ACUTE MI SUSPECTED*** see STEMI Guidelines.

Give a status report to the ambulance crew by radio ASAP and ensure ALS has been dispatched.

 AEMT

Fourth Priority: I-(IV) Establish venous access

  • Initiate IO 0.9% Normal Saline unless IV is assured and quick, run wide open (20ml/kg boluses for pediatric patients)
  • Consider second IV and chilling both for unresponsive ROSC. Refer to Therapeutic Hypothermia Procedure

 INTERMEDIATE

 Monitor basic rescuer interventions closely, ensure quality, uninterrupted chest compressions

Fifth Priority: D-(drugs) Proceed to ACLS resuscitation medications

  • Obtain venous access, if not already done
  • Epinephrine 1:10,000 1 mg IV/IO every other cycle of compressions (4 minutes)
  • Vasopressin 40 units IV/IO, repeat dose in 10 minutes if no ROSC
  • If multiple shocks have been given, Amiodarone (Cordarone) 300 mg IV/IO, followed by another 150 mg if still refractory (shocks being delivered)
  • After 3 cycles of compressions, (unless first rhythm in non shockable) place advanced airway without interrupting compressions and begin ventilations at 6/minute, using only the volume to just make the chest rise.
  • If initially non-shockable, Identify and correct reversible causes: The Five H’s and the Five T’s This applies mostly to PEA, but to a lesser extent, Asystole, as well.
  • If rate is <60, Atropine Sulfate 1 mg IV. Repeat every 3 – 5 min to a maximum of 3 mg

 “The Five H’s” (treatment orders are in parentheses)

  1. Hypovolemia (Infuse Normal Saline wide open)
  2. Hypoxia (Place an advanced airway and administer high-flow oxygen at a ventilation rate of 6/minute with only enough volume to make chest rise. [1])
  3. Hydrogen Ion, i.e. acidosis (Perform ventilation [1])
  4. Hyperkalemia [2]
    1. Give Calcium Chloride (10%) 1000mg IV over 2 – 5 minutes. May repeat X 1
    2. Give Sodium Bicarbonate (8.4%) 50 mEq IV
    3. Give Albuterol Sulfate 2.5 mg HHN may repeat X 1
  5. Hypokalemia (not treated in the field.)
  6. Hypothermia (See Hypothermia & Frostbite Guidelines)

“The Five T’s” (treatment orders are in parentheses)

  1. Tablets (See Toxic Exposure/Overdose Guidelines)
  2. Tamponade (EMT-P: Perform Pericardiocentesis)
  3. Tension pneumothorax (Perform needle decompression)
  4. Thrombosis, cardiac i.e. myocardial infarction (See Chest Pain Guidelines)
  5. Thrombosis, pulmonary i.e. pulmonary embolism (No specific pre-hospital treatment available)

Paramedic

 If there is ROSC, as seen as a sudden large increase in EtCO2 and/or patient movement

  • Give Amiodarone (Cordarone) 150 mg IV/IO over 10 minutes, if multiple shocks given
  • Reassess the need for airway devices
  • Maintain advanced airway, if the patient remains unconscious
  • If the patient wakes up, the airway may be removed. Use the procedures for removing advanced airway devices in the Respiratory Distress Guidelines.
  • Monitor patient’s EtCO2 and ventilate accordingly (12-20 per minute to maintain EtCO2 around 35 mmHg)
  • Maintain SBP >80 mmHg, Consider Dopamine Hydrochloride 10-20mcg/kg/minute IV infusion
  • Consider inducing hypothermia, See Therapeutic Hypothermic Guidelines
  • Consider RSI See Respiratory Distress Guidelines
  • If post-resuscitation 12-lead EKG shows STEMI refer to STEMI Guidelines
  • Contact Medical Control for the following:
    • To discuss termination of resuscitation in the absence of a valid Wisconsin DNR Bracelet
    • Additional medication orders

 FOOTNOTES:

 1. Do not hyperventilate during cardiac arrest, even if hypoxia and acidosis are suspected causes. Strictly follow the ventilation guidelines described above.

2. Suspect Hyperkalemia when patients with a history of chronic renal failure (dialysis patients) develop cardiac arrest. Pre-arrest history may include weakness, missed dialysis appointment(s), vomiting, concurrent illness, and T waves that are peaked and as large as the R wave.

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This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

Posted by on October 17, 2009 • Filed under: CCC, CCR, cpr, cpr save, DNR, Do Not Resuscitate Order, EMS paramedics, EMS practice, EMS protocols, EMS Topics, intraosseous, intubation, IO, Paramedic, paramedic education, patient care, Patient Management, SMG, SMO, Uncategorized

Daily Training Topics 10/16/09

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Just about every 24 hour shift that I work up in my Northern job I put together a little impromptu training session. It’s a way for me to address things that I think are important for the crews to refresh on as well as a way for me to read up on some things and make sure I remember the stuff I should know. I try to learn the latest things on the chosen topic with a bit of research before I present the class as well. It keeps me sharp, which is good.

Also, (and let’s talk about the important things here) it gives me a cheap and easy blog post which I like because I’m really trying to bump up my posting frequency with this Fancy New Blog and all that.

Today’s training topics were a refresher class on intravenous access as well as BLS Airway Management Skills. We have a good number of EMT-Basics, EMT-IV Techs (here in Wisconsin) and even an EMT-Intermediate ‘99 that are on-duty today. My partner and myself (incidentally, both named Chris) are the duty medics.

So, without further ado, here’s what I taught them. Remember, this was a BLS class, and is geared to newer providers.

- IV Skills: I didn’t do anything on my own here. One of the benefits of the EMS blogosphere is that I have a wealth of training information at my fingertips. A lot of the time, I’ll pop on over to see what Greg Friese is doing on Http://www.everydayEMStips.com – And if I’d like some in-depth EMS knowledge, I’ll head over to Http://paramedicine101.blogspot.com.

For this training, however, I took the tips laid out by Steve over at Http://www.theEMTspot.com – where he wrote “Six Techniques to Nail the IV Every Time” I put it up on the projector and wrote down the bullet points on the white board. (and I gave him the credit for the easy and valuable training both in the class and on here)

- BLS Airway Management knowledge:

For this one, I pulled out every airway and oxygenation management tool we carry in the truck, which in my service includes:

- The Oropharyngeal and Nasopharyngeal Airways

Do you know when to use one over the other? Here’s some tips. First, if the patient is unresponsive enough to take an oropharyngeal airway without triggering a massive gag reflex, the patient NEEDS an oropharyngeal airway. (or an ET tube/Combitube/King LT for that matter)

Nasopharyngeal airways are used for patients unresponsive enough to need an airway adjunct but that still have an intact gag reflex. DO NOT USE nasopharyngeal airways in cases of head or facial trauma. (Why? Because the nasopharynx is separated from the rest of the cranial vault by the Cribiform plate, which is a very thin piece of bone that can be fractured very easily with significant head trauma. If it is fractured, you run the risk of placing the nasopharyngeal airway – or the nasogastric tube for that matter – right into the cranial vault… which is bad. 

The oropharyngeal airway is measured from the corner of the mouth to the angle of the jaw. The Nasopharyngeal airway is measured from the nare (nasal opening) to the earlobe.

On a side note, do you know how to check for a gag reflex? My almost never-fail method is to use the eyes. If the patient is unresponsive, running your finger lightly through their eyelash should elicit a response (i.e. wiggling) if the patient has an intact gag reflex. Further, a variation on the theme is to lightly open their eyelids with your gloved fingers and lightly blow into their eye. Don’t do it hard, and certainly don’t blow hard or use any pressure with your fingers, but if a person isn’t unresponsive and can tolerate that without flinching… they aren’t human.

- The Combitube

Honestly, I’ve not had a good track record with the combitube. I prefer the King LT. (Sorry Happy)

- The Endotracheal Tube

For this part of the training I looked at the various parts of this procedure that an EMT-Basic might be asked to participate in, such as preoxygenation with a BVM before the procedure, setting up the equipment for the ALS provider before he/she needs it, choosing the various adjuncts to assist the ALS provider in confirming tube placement, and various methods to secure the tube.

- CPAP

This is a miracle treatment. CPAP, or Continuous Positive Airway Pressure has revolutionized the management of congestive heart failure and pulmonary edema. Every EMT should know how to use this, when to use this, and how to properly apply this wonderful thing.

- Non-Rebreather O2 mask, Nasal Cannula (Adult and Peds)

If you don’t know how to use this, you probably should.

- The Nebulizer set up (We use Albuterol (Proventil) and Ipatropium Bromide (Atrovent)

We covered the proper set-up of the nebulizer and the various differing ways that it can be employed. Sure, you can use the duckbill for the patient to hold, but you can also pull the reservoir bag off of a Nonrebreather mask, insert the nebulizer chamber where the bag went and you’ve got yourself a handy mask neb.

We also went over the proper way to connect the nebulizer to the Bag Valve Mask. Depending on your equipment this setup could vary. Ours did like 3 ways. Check yours.

- Bag Valve Masks of assorted sizes

Learn how to properly seal the masks, the proper ventilatory rate (8-10 per minute) and the proper size for each variation in patient population.

- A Pocket Mask

Haven’t used one of these in a while, have you?

- The Surgical and Needle Cric kits

The basics don’t need to know how to use these, but it’s good to practice. Three of us had to hold the student down to do it, but we got it in on the second try!

I’m really liking my new home.

Posted by on October 17, 2009 • Filed under: Emergency Medical Services, EMS, ems scenario based education, EMS Topics, EMS training, ET Intubation, intubation, paramedic education, patient care, Patient Management

Scenarios. A lot of EMS, a little Einstein

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A while back ago I had a kick where I did a scenario-based EMS ethics piece that took a look at a possible situation that could be faced by some Paramedics and asked readers what they would do in that case.

The response was pretty good. You should add your opinion here.

I use a lot of scenario based training for the EMS people that I teach. I teach a lot. Being the old, grizzled veteran that I am (shameless self plug but looking at the kids these days entering the profession sometimes I feel like shaking my fist at them, hiking my jeans up to my navel, and yelling at them to “Get off my lawn!”) I have the opportunity to mentor a lot of newer providers and precept a fair amount of students. During our slow periods, I find that giving the students an informal scenario helps them to step outside their thought processes and really think about what they would do when faced with a like situation.

I like it so much, that I even do it to myself. I’ve mentioned that I come up with most, if not all of my blogging ideas when doing other, mindless tasks. A great deal of my post ideas come while driving. I allow my mind to wander to imaginary concepts and ideas. Since I’m so immersed in EMS on a daily basis, a lot of those thoughts go right back to EMS, and “what if” scenarios come into my mind. Some of them are about patients that I’ve had, the “what if this had happened” kind of questions. Others are completely random scenarios that I wonder what I would do if I happen to be faced with the situation.

Einstein conducted what he called “Thought Experiments” to assess theories that he could not experiment with in a laboratory. One of the ones that I’m most familiar with is his “Flashlight on a Train” thought experiment. In this well documented case, he hypothesized that the speed of light was a constant and was not affected by outside forces. He imagined himself on a long, open railroad train with himself standing at the caboose, or end car of the train. He imagined shining a powerful flashlight from the rear of the train through the cars to the front engine. Using some logic that I am not familiar with because I’m no Einstein, he was able to theorize that the light from the flashlight would hit the train’s engine at the same time and that the light would travel at the same speed no matter how fast the train, and therefore the light source, was travelling. Unlike a missile fired from a jet plane that’s speed would be affected by the speed of the plane that fired it.

So how do Einstein’s thought experiments connect to EMS?

I equate the personal scenarios that I think of and the scenarios that I use to keep my students thinking outside the box to Einstein’s thought experiments. There are things in EMS that we do not do very often. Skills like synchronized cardioversion, surgical airways, and complicated drug administrations aren’t everyday things. Neither are difficult patient presentation with complex layers of comorbid conditions. These are high-risk, low frequency events that trial lawyers dream about. When you need to perform these tasks or think around a list of contraindications when your patient needs action now, having thought about them prior to having to perform is lifesaving.

One of the things I hear the most from paramedics and EMTs is how they run though a list of possible scenarios, patient presentations, and treatment modalities in their heads when dispatched to what sounds like a particularly nasty call. I do that sometimes too, although less now than I used to. Spending the time thinking about these things when you have the time to really ponder the issues is very beneficial and even fun… if you’re an EMS geek like me.

So next time you and your partner are bored sitting in your parking lot waiting for the next call, toss around a few “way out” scenarios. Your care will benefit from it. You might too.

Posted by on September 22, 2009 • Filed under: Emergency Medical Services, EMS, EMS Blog, ems education, EMS practice, ems scenario, ems scenario based education, EMS training, everyday ems ethics, mental imagery, Paramedic, paramedic education, patient care, scenario, scenario based training, whattaya do

Soapy Pictures – The EMS Narrative Report

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EMS reports come in various flavors these days. When I first started in this game back when I was a young, idealistic EMT-Basic (as opposed to a still young idealistic paramedic) all we had were these gosh-awful paper reports. We called them "bubble sheets" and if you've grown up as an Illinois EMT you've probably seen your share of them. Illinois bubble sheets were these multiple carbon copy monstrocities that included two pages just chock full of fun. You had to fill them out for everything the state thought was important, making sure that all of the bubbles were colored in exactly right or the state would kick it back to you however later it was they actually fed it through the machine. It was like taking a test every time you had a patient contact. Nobody read the bubbles but the machine. So if you actually wanted to communicate useful information about the patient to future caregivers or if you wanted to remember details about the call for whatever reason afterwards, the State saw fit to give you a really small box with really small lines for you to write a narrative report.

I hate those things. Notice that the previous isn't a past-tense statement. Some EMS services in the State of Illinois still use those awful things for EMS reporting. Really. Ambulances in Illinois are still required to carry at least ten of them in every ambulance per Illinois Department of Public Health (IDPH) regulations. Honestly, I threatened to go back to using them when one of my services switched to a new EMS reporting software that I'm not sure I like. Let me just say that .html databases are not useful for large data collection projects. They're clunky, prone to losing data, and aren't user friendly.

Here is a little bit of information on data. I am a database specialist of sorts. In one of my positions I work in data management and control. I take huge volumes of aggregate data collected from disparate data sources, mash it together, break it into single data pieces, numbers, and "Yes/No" answers, and then ask questions of it to get back useful reports. I'm not a database genius like some (and real database pros may disagree) but the way that I understand data processing is that data can be computed when it is processed into "Yes" and "No" answers and/or numbers. "Yes" answers are "+1" and "no" answers are "-1" or "0" depending on the question. When data is broken down into these Yes/No questions, it can be processed through a mathematical formula to obtain clear, actionable results. That's why you see categories of data, lots of radio buttons and check boxes, and prewritten answers in the new reporting software that has to be NEMESIS compliant.

(In a later post, I'll analyze data harvesting, structuring, composition, computation, and reporting as it relates to EMS. And, if anyone needs the skills of a Data Ninja, I'm available for EMS data processing. Free for small projects)

Unfortunately for us humans, and especially us humans that work in an almost completely unpredictable and not-easily categorized environment, the type of information that we like to communicate with does not fit well into the structure needed by computers. Us humans communicate in ideas, in words, and in fluid conversational form where ideas are not rigid, and the same information can be quite different when read contextually.

Therefore, my favorite part of the EMS Patient care report or any patient chart is the narrative. If you've had the opportunity to read many patient charts, or even if you've flipped through the paperwork on patient transfers, the parts you probably gravitate to are the narratives. You probably also read the lab results. There's a reason for this. Humans like reading stories which are what narrative reports are. We also like quantifiable numbers, which are what the lab results are. These are pieces of information that we can wrap our brains around, sink out teeth into, and really understand. I would bet that there aren't many people out there who ever even read the canned data areas. I don't.

I write a stock EMS narrative report every time. Not word-for-word, but I follow the exact same formula and use different tools in my reporting as needed to fit the situation.
Here's an example of a patient that I'm completely making up off of the top of my head (really):
Ambulance 1 dispatched emergent through the 911 system for the 42yo F Pt (patient) for the chest pain. UOA (Upon our arrival) we were met by the Pt's family who directed us in to the patient. Found the Pt sitting upright in a chair CAOx3 c ABCs intact (Conscious, Alert, and Oriented with Airway, Breathing and Circulation). Pt c CC of substernal chest pain that she std (stated) began approximately 1hr prior to her calling 911. Pt described the pain as a "deep pressure" that she std began in the inferior sternal area and radiated to the L shoulder and into the L arm. Pt rated the pain at a "7" on a 10 scale and denied any provocative or palliative features. ALS ASSESSMENT (By: Ckemtp): (Note: Billing services want that last part) Skin pale, warm, and moist. Pupils PERRL, no JVD (Jugular Veinous Distention), Trachea Midline/Mobile, Chest Equal Rise/Fall Bilat c Clear Lung Sounds and as described above, ABD Soft/non-tender, Extrem (Extremities) c good PMS (Pulse/motor/sensastion) and Temp. TREATMENT: 12-lead EKG obtained showing NSR (Normal Sinus Rhythm) with occasional PVCs and ST Elevation noted in leads II, III, and aVF with machine and EMT-P interpretation of probable acute MI. o2 applied at 4-LPM via NC (nasal cannula). Pt secured on cot and taken to rig. IV established in R forearm running 1000ml warm NS TKO. Pt given 325mg ASA (Aspirin) PO and 0.4mg SL x 1 bringing her pain to a "5". STEMI alert called to St. Elsewhere with report given via MERCI (Medical Emergency Radio Channel – Illinois). Pt given 0.4mg NTG SL again bringing her pain to a "4" and again bringing her pain to a "3". Pt given 2mg MS04 (Morphine Sulphate) bringing her pain to a "2". Pt transported and transferred to St. Elsewhere ER RN staff s incident or exacerbation.

I've been writing that same report for years with each patient. It's evolved a bit, but I can fit everything I need to fit into it. I would think that any further healthcare providers would be able to discern the patient presentation from that report, and I would be able to recall the events of the call in the event that I had to. When I first started writing narratives, I was told to use tools like "SOAP", "CHART", and other acronymns. I hated them, because I felt overly confined by their rigidity. I decided that I would use the chronological narrative method, and I thought that I was using it for years… until I realized that my narratives reports are just SOAP charts with my spin to them.

"SOAP" is an acronym that stands for "Subjective, Objective, Assessment, and treatment Plan". As it goes, the "Subjective" information is the information regarding the call, the events that you found when you got there, and a bit of history regarding the subject of the report. The "Objective" information is the information that you found through objective observation of the subjective information. The "Assessment" is just that, and to signify it in the report I write "ASSESSMENT" in capital letters. In the assessment portion of my report, I include "pertinent negatives" or a full sentence regarding my secondary assessment findings. In this section, I put in the findings such as the skin condition, the lung sounds, and the abdominal condition. While the old adage is that if you didn't write it, you didn't do it. I say that if you didn't write it, you didn't do it… unless it was bad. Then if you didn't write that you didn't do it, you did do it. (G'head an
d read that last sentence again until it makes sense) Including the pertinent negatives in the report shows that you did a thorough secondary assessment which is helpful for defense in case there is a bad patient outcome. Finally, the treatment plan shows the treatment that you performed and the response that you got from that treatment. Be thorough. At the end of the report, I put in the stock information that I passed the patient to the facility staff after calling in a report.

A good EMS Narrative report does a few things. First and foremost, it presents information about the patient's condition and the care that they recieved. The information that EMS gathers is important to their further care. The observations we make and the assessments we take are a view of the patient when their illness or injury is most acute. Our information can set the stage for the entirety of the patient's care down the line. The EMS Narrative also serves to refresh our memory for when we get called in to the office for an unknown reason a year or so down the road. Remember, you're always writing the report for your own legal defense. I also like the narrative because since I write it the same every way and always try to make it as detailed as possible, I can catch when I didn't do as thorough of an assessment as I would have liked to.
The EMS narrative report is the best way we have to tell the story of our patient care. Make it good, make it detailed, and for goodness sake, use proper spelling, grammar, and punctuation. You will be judged by other healthcare professionals on the quality of your narratives, make them good and not only will you look good, but your patients will get better care.

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I'd love to see some report styles used by different providers. So I'm asking y'all if in the comments section you would make up a narrative report and post it so that we all could see examples of other EMS Narrative reporting. I think that it'd be educational, and maybe if you're a geek like me… fun.

This post is part of a group of posts on EMS narrative reporting:

For more information, please read the following information on the EMS narrative report, SOAP charting, EMS Charting, and EMS Patient Care Reports.

More on EMS narrative reporting

Six Tricks You Can Use Today to Improve your EMS Narrative Report

Posted by on June 13, 2009 • Filed under: Ambulance, ambulance report, Emergency Medical Services, EMS, ems education, EMS Health & Safety, ems patient care report, ems report, EMS Topics, EMS training, EMT, Fire Rescue Topics, idph, illinois, narrative, Paramedic, paramedic education, paramedic narrative, patient care, Patient Management

EMS Documentation – EMS Narrative Reporting – Paramedic – EMT – ReportPage

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Somehow I've become the go-to site for information on the EMS Narrative Report. I'm very much OK with that. I believe that the Narrative Report and the EMS Report is the most important information-sharing tool for the Paramedic or EMT.

Here are some of the things I've written concerning the EMS Narrative Report, and for EMS Charting general.EMS 2.0 logo

Soapy Pictures – The EMS Narrative Report

This article is about the evolution of my narrative style, and shows how I went from just writing something into actually charting about the patient in the best way that I can. It shows how I fuse the "Chronological Narrative" reporting style with "SOAP Charting" (using the SOAP method to write the EMS narrative) – There's a lot of tips in here.
 

More on EMS narrative reporting 

This article is a more in-depth "nuts and bolts" how-to guide for the paramedic or EMT to use in designing their narrative reporting style. I emphasize how to properly place information and how to share it with the user of the information. Emphasis is placed on using the SOAP charting method.
 

Six Tricks You Can Use Today to Improve your EMS Narrative Report

Don't have time to read due to your call volume? Use these tips and tricks as a quick tutorial and begin writing professional EMS narrative Reports today. Whether you're a paramedic or an EMT, these tips will have you writing your ambulance run sheet like a pro.
 

For more information, please read the above information on the EMS narrative report, SOAP charting, EMS Charting, and EMS Patient Care Reports.

 

 

 

Posted by on February 26, 2009 • Filed under: ambulance report, Emergency Medical Services, EMS, ems narrative, EMS narrative report, EMS paramedics, ems patient care report, EMS Topics, EMS training, EMT, Fire Prevention & Education, Fire Rescue Topics, Paramedic, paramedic education, paramedic narrative, patient care, Patient Management, run sheet, soap, soap charting, Training & Development, training-fire-rescue-topics
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