FOAMfrat Podcast

Lab value interpretation sadly wasn't included in my initial paramedic education. I was absolutely ecstatic to attend a critical care program and learn about lab values - I had always found it very impressive when people could interpret lab values. I wanted to be a lab value wizard too! Unfortunately, in critical care class, our lectures and resources were nothing like what I had hoped for.I hope this series of blogs serve as a resource for those who are eager to learn more about the art of interpreting labs. I wouldn't recommend tackling this whole thing in one sitting ;) We'll be starting with the positive charges (cations) in this blog, then handling the other parts of the basic metabolic panel in weeks to come (negative charges, renal, and glucose). Before we get started, I want to get us in the right headspace for learning about lab values. This stuff is kind of dense, and there are a lot of different conditions that will cause lab values to reach their outer limits, or beyond. While I'll present a lot of information for each lab value abnormality, the theory of what's going on is far more important. Once you understand the theory of why a problem occurs, you can find a formula, calculator, or treatment guideline to get you the rest of the way. Now let's what happens when cations reach their outer limits!

200 comment Facebook post where I asked, \"what questions would you like me to ask the NREMT?\" These are the questions that seem to be the most popular.","type":"unstyled","depth":0,"inlineStyleRanges":[],"entityRanges":[],"data":{}}],"entityMap":{},"VERSION":"8.46.0"}"> In this episode, I interview NREMT's Chief Certification Officer, Mark Terry, and Certification Manager, Megan Hollern. I really enjoyed this conversation and felt it cleared up many misconceptions and confusion surrounding initial certification and certification renewal. After carefully going through a >200 comment Facebook post where I asked, "what questions would you like me to ask the NREMT?" These are the questions that seem to be the most popular. 200 comment Facebook post where I asked, \"what questions would you like me to ask the NREMT?\" These are the questions that seem to be the most popular.","type":"unstyled","depth":0,"inlineStyleRanges":[],"entityRanges":[],"data":{}}],"entityMap":{},"VERSION":"8.46.0"}"> 200 comment Facebook post where I asked, \"what questions would you like me to ask the NREMT?\" These are the questions that seem to be the most popular.","type":"unstyled","depth":0,"inlineStyleRanges":[],"entityRanges":[],"data":{}}],"entityMap":{},"VERSION":"8.46.0"}"> 1. Besides reciprocity amongst select states, what is the benefit of maintaining your NREMT? 2. If I let my NREMT lapse, or never even got my NR, what is the process in order for me to get it back? 3. The hour requirements are broken down into general categories (i.e. trauma, cardiology, etc.), are the subcategories mandatory or suggested? 4. Do you ever see the instructor-led hour requirements coming back?

Welcome to round two! We'll be going over fewer laws than last time, but this will round things out nicely! We'll be covering the laws of Fick, Graham, and Dalton/Amagat. Mike Brown joins me again as we look at the clinical application of some lesser-known gas laws.

In this episode, Tyler interviews Tom Bouthillet and Dr. Stephen Smith on who exactly should get a right-sided ECG. Do not delay transport to PCI to grab a right-sided ECG. If you do decide to perform a right-sided ECG, it should not be for the decision on whether or not to give nitro. If time permits, it may be helpful and confirm your suspicions of RV involvement. Isolates RV infarcts are extremely rare. In EMT school, I was taught how to assist a patient taking their own nitroglycerin if they developed chest pain. I had to make sure they weren't on any phosphodiesterase inhibitors, grab a blood pressure, and make sure they took the right dose. We would obtain a 12 lead, but I had no clue what I was looking at, and my decision to give nitro was not based on any specific ECG finding. Fast-forward to paramedic school, and I am taught to ALWAYS perform a 12 lead before giving nitroglycerin. Why? Wellll If they had an inferior wall MI, nitroglycerin was a hard stop. Every time the student would give nitro before obtaining a 12 lead in simulation, their patients would code...Every. Time. I thought this was weird because patients were prescribed nitroglycerin if they developed chest pain at home. They were certainly not performing a 12 lead on themselves prior to doing this. So what was the fear? The Fear EMS is full of cautionary tales (as my buddy Brian Behn points out in this blog). The fear of administering nitroglycerin to a patient with an inferior wall MI is the possibility of plummeting the blood pressure if there is right ventricular (RV) involvement. Because the RV is preload dependent, dropping preload with nitroglycerin could cause hypotension. This is probably a good place to say that the LV is preload dependent too, but the LV preload is dependent on the RV preload. So if you wipe out the RV, the LV follows. I believe the fear of nitro is probably healthy, but not for JUST inferior wall MIs. The benefit of sublingual nitro has yet to be proven (as Dr. Smith points out in the interview) and on top of that, a study published in Prehospital Emergency Care in 2015 found that hypotension occurred post-NTG in 38/466 inferior STEMIs and 30/339 non-inferior STEMIs, 8.2% vs. 8.9%, p = 0.73. That means it makes literally no difference where the MI is.

We've been exposed to gas laws our whole life, and we have intuition about what will happen to gas under certain conditions. For example, people notice that the pressure in their tires might become low on a very cold day. Or perhaps you've been at very high altitudes and you've been short of breath. And everyone knows that if you shake a carbonated beverage before opening it you'll be cleaning up a mess very shortly. Each of these observations has been classified into the laws, and we'll be splitting them up between this blog and the next. Stating the laws is one thing - anyone with google can copy and paste their definitions. However, we have a special interest in these laws as medical professionals because we deal with them on a different level. Sometimes we're manipulating these gas laws on purpose, and other times we're dealing with their side effects. Or perhaps we're just trying to pass our FP-C, CCP-C, or CFRN exam ;) Let's dive (pun intended) right in!

The concept of taking blood out of the body, oxygenating it, removing the CO2, and then putting back in, fascinates me. A few years ago I admittedly knew very little about extracorporeal membrane oxygenation (ECMO) and its indications. I remember going to a class on ECMO at Life Link III and having questions like: Are we actually pumping blood backward through the body? What happens to the blood in the heart when using ECMO in cardiac arrest (ECPR)? What kind of vent settings should I use? I am by no means an expert on ECMO, in fact, I have only been on a handful of ECMO transports, but the concept fascinates me and I thought a blog breaking down a few concepts of ECMO physiology would be beneficial.

Before the July 4th weekend hits, I wanted to address two main questions whose answers may come in handy on a call you'll run very soon... Should EMS use a burn formula? What's the best way to manage pain for the burn patient? For a sense of a well-rounded blog on burns, I've included some quick facts about burn care at the end that are unrelated to these questions. Also, Erik Rima (CFRN and former burn center RN) left us his perspective at the end in a peer review. Be sure to check those out before you leave! Alright, on to question number one... should EMS even bother with a burn formula?

Invasive arterial blood pressure (IABP) monitoring techniques have enjoyed a rich history of use throughout the mid-to-late 20th century in the peri-operative setting and are now a standard of care intensive care units. While there are a variety of IABP monitoring options, one of the most common techniques is percutaneous radial arterial catheterization. Although monitoring of radial arterial lines is a widely accepted skill in the critical care transport (CCT) world, placement by CCT providers is less common. Concerns over safety and logistical management have contributed to the perceived difficulty in arterial lines; however, this article aims to demonstrate that arterial lines can be placed safely and effectively in the pre-hospital setting. www.foamfrat.com

Ok, here's the thing.. there really is no anion gap. We pretend there is because the things we routinely measure leave something to be desired on the anion side. Sam put out a killer blog and this is a follow-up conversation. Enjoy!

Traditionally transcutaneous pacing involves a paramedic placing pads anterior/posterior (preferred), and turning up the milliamps until electrical capture is obtained. Electrical capture is obtained when a pacing spike is followed by a wide complex. The clinician will then try to palpate a pulse to confirm mechanical capture. Because the contractions of the pectoral muscles can tug on the muscles of the neck as well, AHA recommends palpating a femoral pulse versus a carotid (3) to avoid thinking you feel a pulse (false mechanical capture). Not only are events of false capture common, but there are even situations in which the paramedic swears they feel a pulse and observes the patient becoming more alert, and they never had mechanical capture. I believe most of us are using SPO2 pleth wave to confirm mechanical capture versus the subjectivity of palpating a pulse, but even patients with a pulse can have poor pleth wave readings. I believe ultrasound-guided pacing is ideal and should become mainstream. I typically find I can get a parasternal long view on ultrasound with the pads placed as illustrated below. However, there are other views if your pad sweet spot is obstructing where you wanna put the probe. This is nothing profound and is definitely not a new concept in emergency medicine. It is however a new concept for paramedics and another feather in the cap of prehospital ultrasound. This is a conversation between myself and Dr. Eydelman discussing this topic. Enjoy!