April 2018 ISSUE: 8
The Prehospital Gazette Committed to the care and improvement of human life in our facilities and the communities we serve.
April is Child Abuse Awareness MonthKnow the Signs
IN THIS ISSUE Child Abuse Awareness Swedish trauma case review Stroke case from P/ SL Intra-arterial stroke coming to Sky Ridge
care
Aurora’s SANE expansion MI case study at Rose North Sub discusses how to safely treat agitated patients Learn about AirLife’s mentorship program and Much More!
FIND US ON THE WEB
WORTH A LISTEN ‘The Emergency Medical Minute’ Podcast
Do You Know the Signs of Child Abuse and Neglect? Did you know that younger children are most Age matters: infants less than 6 months vulnerable to maltreatment, especially old rarely have bruises/no cruise=no bruise. children between 0-3 yrs of age? Older infants frequently have “normal” bruises, but they are likely to be confined to As health care professionals, we are bony prominences on the front of the body. mandated reporters. Requirements to report Unexpected bruises (in small infants) or are a reasonable cause to know or suspect unusual locations or patterns of bruises (in that a child has been subjected to abuse or older infants and children) demand an neglect OR observed the child being explanation. Any bruising on the torso, ear, subjected to circumstances or conditions that neck, and face in children < 4 months is a red would reasonably result in abuse or flag for child abuse (TEN 4 Rule). neglect. A mandatory report is to be made to the county department, the local law For an interactive and educational learning enforcement agency, or through the child experience, visit abuse reporting hotline system. Call 1-844www.identifychildabuse.org. This website provides an electronic module with vignettes CO-4-Kids to report your concerns. and images during which the learner submits an answer regarding need to notify social work.
Areas of Expertise
Level I Trauma Center
Burn Critical Care
Comprehensive Stroke Center
Chest Pain Center with Primary PCI
Rocky Mountain Heart Rhythm Institute
Epilepsy Center
High Risk OB Services
Level III NICU
Pediatric Care provided by RMHC
Geriatric Trauma Case Review EMS arrived to find a pleasant 70’s female who had been hit by a car going 5mph in a parking lot. Patient complained only of leg pain and had no LOC, or obvious injuries. Bilateral legs demonstrated full range of motion without evidence of trauma or increasing pain with movement. Patient was mildly confused but PD on scene reported this individual was a resident of a nearby memory care unit. Patient was fully immobilized and transported non-emergent to a trauma center.
EMS Liaison’s Message
Jordan Ourada
Spring is an exciting time in EMS! Not only is EMS Week just around the corner but it’s the perfect time to sit in your rig and enjoy the beautiful weather before we hit the triple digit temps of summer. Take time to enjoy it and relax when you can! As always if there is anything you need, just let me know– I am here for you! -Jordan
Jordan.Ourada@HealthONEcares.com 303-330-4757
At the hospital, this patient was found to have bilateral hip fractures, a 10mm subdural hemorrhage with 4mm of midline shift, a subarachnoid hemorrhage, an olecranon fracture and right ICA dissection. Furthermore, the patient was not a memory care resident and was previously independent. PEARLS: -Maintain a high index of suspicion with all geriatric trauma patients due to their general frailty and high incidence of comorbidities -Use extreme caution in gathering information on scene and always do your best to verify any ‘previous conditions’ -When time permits, repeat physical exams on trauma patients to look for any changes. Even a small hematoma can be a significant indicator of underlying injuries and developing issues.
Stroke alert success story At 11:39am on December 4, 2017, EMS was dispatched to E. Colfax Avenue in Denver for an “unknown medical” patient. Those EMS providers who have worked in Denver are all too familiar with this Colfax dispatch category and can often predict the type of patient they are likely to encounter when they arrive.
AirLife arrived to the ED via helicopter, packaged the patient, and departed P/SL at 13:09. They arrived at Swedish at 13:15 and transported the patient directly to interventional radiology. The neuroradiology team achieved vascular access at 13:51 and removed the clot via mechanical
Adult & Pediatric ER services.
Level IV Trauma Center
Primary Stroke Center
Chest Pain Center
Hyperbaric Medicine
Limb Preservation Center
High Risk OB Services
thrombembolectomy at 14:00.
However, on this occasion, EMS arrived on scene to find a 29-year-old female lying on the sidewalk that did not fit one of those quintessential categories. They noted she was in business attire, which was unusual for a patient lying on the side of Colfax. There were no bystanders available to provide a patient history and the patient was aphasic with uncoordinated extremity movements. She exhibited right sided facial droop, right sided hemiparesis, and right sided neglect. There was no evidence of trauma or other noteworthy exam findings. She had a blood pressure of 128/80, a heartrate of 92, a respiratory rate of 24, and a blood glucose level of 116. The crew suspected a stroke and transported her emergently to Presbyterian/ St. Luke’s Medical Center. The attending paramedic provided a very articulate biophone call, underscoring the unique presentation of this particular patient. Based on the call, a stroke alert was activated and the teleneurologist was on camera when the EMS crew arrived in the ED at 11:57am. A large vessel occlusion (LVO) was identified with neurological exam (Stroke Scale of 27), the patient was transported to CT, and AirLife was dispatched to P/SL. CTA showed a largevessel occlusion of the proximal left cervical ICA. TPA was not given because her ‘last known normal’ time was unknown.
Areas of Expertise
Before
She also received a left internal carotid artery stent due to the presence of dissection with occlusion. The patient was discharged two days later, her only neurological deficit being a minor tremor of her right hand with the expectation of complete resolution. This patient story emphasized how well EMS, flight crews, and hospital personnel work together every day to improve the quality of life for patients they serve. Nice work to all involved! You should be proud.
After
EMS Liaison’s Message EMS Week 2018 (May 20th –26th) Ben Dunn
EMS week is quickly approaching! Thank you for your hard work, collegiality, and commitment to quality care. Stop by during EMS week for food trucks, EMS week gifts, and our appreciation for all that you do. Look forward to seeing you there.
IA Stroke Treatment is Coming to Sky Ridge Sky Ridge Medical Center is proud to launch 24/7 Intra Arterial (IA) Thrombectomy on April 18!
IA is the surgical removal of a blood clot during a stroke, an advanced treatment now available at Sky Ridge. 87% of strokes occur when blood vessels to the brain become narrowed or clogged with fatty deposits, cutting off blood flow to brain cells. Nearly 800,000 people in the US have strokes every year and it is the #5 cause of death in the US, killing nearly 130,000 Americans every year. Through this advanced procedure that we can now offer, we hope to bring a greater depth and breadth of care to the community.
Babysitting Class/CPR Training Saves the Day
The parents of young Aidan Ward credit South Metro’s Safety Foundation’s babysitting class with saving his mom’s life. He performed CPR when his mother suffered a heart attack before EMS crews arrived and transported her to Sky Ridge. We are happy to report that mom is on the mend.
Areas of Expertise
Dedicated Pediatric ER
Level II Trauma Center
Chest Pain Center with Primary PCI
Primary Stroke Center
High Risk OB Services
Level III NICU
According to a recent Wall Street Journal article, Dr. Don Frei, one of our Neuro Interventional Radiologists, said, “This procedure has the same transformative effect on treating stroke as penicillin did for infections.” It further notes “stroke experts estimate that, as a general rule, thrombectomies should be going to 20% or more of patients with clot-causing strokes, helping pre-empt brain damage in many patients. Over the coming weeks, Sky Ridge will be providing education and case studies to highlight this technique.
EMS Liaison’s Message How does everyone like the food and beverage selection in the Sky Ridge EMS lounge? We work hard to keep it stocked for you 24 hours a day and 7 days a week so we want to make sure we are meeting your needs. I am always open to new ideas so let me know if you have any thoughts, questions or comments. Thank you for all you do! Caroline Dullien
—Caroline.Dullien@HealthONEcares.com
SANE service expansion at Saddle Rock ER
Areas of Expertise Level II Trauma Center Chest Pain Center with Primary PCI Primary Stroke Center
SANE Coordinator 303-525-5639
Our SANE Mission: We are pleased to announce the arrival of our 24/7 SANE program at Saddle Rock ER (Gartrell/ E-470) We have seen a significant increase of SANE patients over the past few months and feel that adding another program site location in southeast Aurora at our free-standing ER will be beneficial to our community. We have 15 SANE nurses on staff for TMCA/SRER. Please reach out our SANE Coordinator with any questions.
With our community partners, we strive to promote safety, justice, alleviate fear, and facilitate, healing by providing timely compassionate, culturally sensitive forensic evaluation and treatment by trained sexual assault nurse examiners.
Rocky Mountain Heart Rhythm Institute High Risk OB Services Level III NICU
We embrace a team approach to provide compassionate, comprehensive care and education for victims of sexual assault. Utilizing community partnerships, this will result in healing and lead to justice.
Operating Room REMODEL Increase in average square footage in each OR suite. Investment in state of the art equipment for treatment of surgical patients. Recruitment of new subspecialist surgeons to offer comprehensive care. Surgeons and surgical care team trained in the latest advancements in medical technique and technology.
Why Focus on Sepsis?
NAME THAT RHYTHM…
-The one year all-cause mortality of patients treated with severe sepsis or septic shock may be as high as44%
We appreciate ALL that you do! We LOVE our EMS partners! Please don’t hesitate to call/text/ email me at any time if you need anything.
-Patients who have septic episodes are at a risk of death for upt to five years after the acute event.
Brian Marshall, EMS/ED Manager 303-475-9544
-In 2008 only 2% of hospital patients were diagnosed with sepsis in the US, but it was responsible for 17% of hospital deaths.
New Useful Tool in Determining LVO Our ED physician and RN staff at Rose Medical Center have started using a new scale to determine large vessel occlusions. If your patient has a fast score of 0-1, likelihood of LVO is < 15%. If the score is 2-3, the patient is around 30% diagnostic for LVO, and any score above 4 is 60-85% likely to be a large vessel occlusion. Our physicians and neurologists have determined it is reasonable to suspect an LVO for any FAST-ED score of 2 in the following categories: speech change, eye deviation, or denial/neglect. Symptoms inside the 6 hour window will activate a stroke alert protocol, and the patient will be treated for LVO. Symptoms outside the 6 hour window will initiate a stroke notification, prompting neuro consult.
Areas of Expertise
Chest Pain Center with Primary PCI
Atrial Fibrillation Center
Primary Stroke Center
High Risk OB Services
Level III NICU
Level IV Trauma Center
Rocky Mountain Heart Rhythm Institute
Case Study: Inferior Wall MI Last month, we recognized Denver Heath Paramedics Justin Loera and Dave Nieberlein, for their early recognition and treatment of a patient experiencing and inferior wall STEMI. DHPD responded to the patient’s residence earlier the same morning, only this time it was for the patient’s spouse, who was in cardiac arrest. Unfortunately resuscitation efforts were unsuccessful and she was pronounced on scene. Emotionally distraught after losing his wife, the patient soon developed shortness of breath and left sided numbness. Luckily, a DPD officer was still on scene and initiated another call to EMS. Justin and Dave arrived to find the patient much like a typical anxiety patient. The patient was hyperventilating and complaining of carpal pedal spasms, he had no complaints of chest pain. Despite an atypical presentation, the crew maintained a high index of suspicion and immediately obtained a 12 lead EKG. It was quickly revealed the patient
was having a massive inferior wall STEMI. The patient was transported to the Rose Medical Center Cath Lab where is was found to have a 100% occluded RCA. The cath lab successfully deployed 1 stent, the patient was transferred to the ICU in stable condition and discharged days later! Despite an unfortunate situation, the patient is expected to make a full recovery. He and his family are forever grateful for the outstanding care rendered by the Denver Health Paramedic Division!
EMS Liaison's Message:
Bryce Anderson
Our ED renovation is quickly coming to an end! The final phases will include 8 brand new patient exam rooms and 2 large resuscitation rooms. By the end of our project, we will have a state of the art cath lab in the back of the ED, as well as an in house CT suite. We have also have new additions to our executive team. Ryan Tobin, our former COO has been promoted to CEO, Hollie Seeley will be replacing Ryan as our COO. As always, feel free to reach out to me directly for any questions or comments regarding your experience at Rose. bryce.anderson@healthonecares.com
Introducing our New CEO Areas of Expertise I would like to thank you all for the warm welcome you have shown me since I arrived at North Daphne David, CEO Suburban Medical Center in early January! I am very excited to be a part of the team and I look forward to meeting each and every one of you in the near future. I have been with HCA since 1999 and have worked in various capacities throughout the organization. I spent 16 years at Garden Park Medical Center in Gulfport, MS with the last six years as the Chief Operating Officer. In 2015, my family and I decided to move to Jacksonville, Florida as I assumed the role of Chief Operating Officer at Orange Park Medical Center. Our move to Colorado was an easy decision as my husband, Eric, and two sons, Noah (7) and Joshua (3) and I love the Denver area and are very excited about settling in and making this community our home for years to come.
The whole organization at North Suburban is united in their commitment to teamwork, quality outcomes, compassion for our patients, service to our community and desire for excellence. It is clear North Suburban has a strong foundation and even stronger future. The senior leadership team is committed to embracing all North Suburban has to offer and to work with our EMS partners to ensure teamwork and collaboration as we work together to build a strong future for our facility and community.
Recognizing, Treating and Safely Transporting Confused and Agitated Patients You are called to respond to the scene of an anxious patient. On arrival, you encounter a 25 year old male who is restless and not willing to answer your questions. His “friend” states that they had been smoking marijuana and relaxing. The patient became progressively agitated and confused. His friend noticed him going in and out of the bathroom on multiple occasions. He adamantly denies witnessing any cocaine use tonight, but states patient has used previously. The patient is now pacing, patting himself on the abdomen and muttering in an unintelligible manner. He doesn’t want to answer your questions and it looks like any intervention might set him off. He needs medical attention, but how will you be able to transport this patient to the hospital? What is a rapid and safe way to restrain the patient?
Excited delirium syndrome is a unique state that is only recently being recognized in the medical literature. It is defined as a potentially fatal syndrome of excitation and altered level of consciousness often accompanied by violent behavior, superhuman strength and perceptual disturbances. It is most commonly caused by cocaine ingestion, closely followed by amphetamines, PCP and synthetic marijuana. These patients can progress rapidly to hyperthermia, metabolic acidosis, rhabdomyolysis, acute kidney injury and death, with estimates of mortality rates approaching 10%.
Verbal de-escalation techniques and physical restraint are first line techniques. It is important to avoid “hog
Level III Trauma Center
Primary Stroke Center
Chest Pain Center with Primary PCI
Comprehensive OB Services
Level II NICU
tie” or prone positioning to allow for adequate respirations. Chemical restraint is also vital. Usually, IV access will not be obtainable so intramuscular injections are preferred. Benzodiazepines have traditionally been employed and are well tolerated, but require 15-20 minutes to take effect. Ketamine has emerged as a viable alternative and is now on many EMS protocols. Advantages include a 3-5 minute time of onset, preserved airway reflexes and no effect on blood pressure. Despite this, there is a high rate of prehospital or ED intubation so preparation for airway interventions is key. Fortunately, these patients tend to recover rapidly and rarely suffer from any permanent sequelae when managed appropriately.
-Dr. Chris Bannigan is an ED physician with Carepoint and has been practicing at North Suburban for the past 3 years after joining us from Chicago,.
EMS Liaison’s Message
Ben Tice
In January, I celebrated my 1-year anniversary as the EMS coordinator at North Suburban. It’s been an incredible honor to serve the men and women of our EMS, fire and police agencies over the past year. I am looking forward to get to know even more of you in 2018 and continue to share in the exciting growth at North Suburban Medical Center. YOU make our community a better and safer place to be, so please don’t hesitate to reach out if there is anything I can do to make your day better! –Ben
Benjamin.Tice@healthONEcares.com or (720)201-2637
The RMHC Mobile Training Center Rocky Mountain Hospital is here for you and our community. Together we can improve our children's medical outcomes with collaborative simulation training for a range of healthcare providers. We offer simulation training for schools, clinics, EMS and hospitals.
We bring the simulation lab to you! With our state-of-the-art mobile simulation lab, we can provide simulation training for a broad range of healthcare teams. Our simulation scenarios provide training for premature, newborn and pediatric patients. These scenarios will be tailored to your team's specific educational needs.
Meet our RMHC Family!
Our Network of Services
Acute Inpatient care at P/SL
Dedicated RMHC ER at P/SL and Sky Ridge
Pediatric Emergency Care at Swedish, The Medical Center of Aurora and North Suburban Medical Center
Affiliated NICU and Pediatric Care at all HealthONE Hospitals
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Ryan, our 16 year old full body adolescent Max, our 6 year old full body child Hope, our 1 month old full body newborn Chloe, our 25 week premature infant Our High Fidelity Simulation Mannequins offer a wide-range of clinical functionality to teach the stabilization skills for airway, breathing and circulation management. Our entire RMHC Family has accurate anatomy to provide the most realistic simulation training possible. They are great for practicing IV/IO placement, intubations, chest compressions, needle chest decompressions, catheterization skills and other great clinical benefits.
Welcome to Their Home 2 Bedrooms: A fully equipped Ambulance Room and Hospital Room with
39 square feet Wireless Mannequins Speaker System Patient Monitors
Tech Room Onboard Wi-Fi 4 Video Cameras Debriefing TV
Broad Casting Capability Hydraulic Gurneys Mechanical Lift ADA Accessible
Striving to be the paragon air and ground critical care transport service.
AirLife Mentorship Program
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The mentorship program is designed to help individual who are looking for professional guidance, critical care and transport continuing education, and for those potentially interested in a career in helicopter EMS. Real world experience, educational professional guidance, and free CEs in a relaxed and open format each quarter is a fun and interesting way to better understand the culture, safety and the advanced medical care of our program. You’ll learn side by side with pilots, flight nurses, flight paramedics, high risk OB and neonatal specialized medical crews. We also reserve opportunities for participating in a development plan, ride-along, and many of our conferences and events, just for our mentorship participants! Contact for further information or to RSVP AirLifeMentorship@gmail.com
2018 Mentorship
Workshops August 28th Mark Your Calendars! 21st Annual Friends of AirLife Memorial Celebration and Race!
May 12th, 2018
November 20th 10am– 2pm
Registration and further information always available at
www.AirLifeDenver.com
Friends of AirLife, a 501c non-profit, home-grown from grassroots organizers to memorialize, celebrate, support and grow the first responder community, is a proud sponsor of the Air Medical Memorial and Remembrance Ceremony that is hosted each year, right here in Littleton, Colorado. On July 29th, we were honored to represent a proud community “In remembering, there is healing”. To support or for more information visit airmedicalmemorial.com or friendsofairlife.org
HealthONE EMS Event Calendar
April 2018 Sun
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7 TMCA -Hugo 9-4
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20 TMCA 9-11
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26 SMC 12-1
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28 SWER family fun event
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18 TMCA 9-11
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12 AIRLIFE run and volleyball
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Donâ&#x20AC;&#x2122;t forget...
EMS Week is May 20th-26th