RamMD Winter Issue 2021: Emergency Medicine

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Table of Contents Ambulance Medicine Alexandra Paul ‘23 Amputations and Major Bleeds Noa Haron ‘23 Interview with Dr. Boris Khodorkovsky Ariella Goloborodsky ‘23 Barcode Scanning in the ER Evie Rosenfeld ‘24 Pocket-sized Ultrasounds Chloe Gad ‘23 CPR Rebecca Kalimi ‘23 Difference Between EMR, EMT, AEMT and Paramedic Rebecca Kalimi ‘22 Delivering a Baby Rebecca Kalimi ‘23 Interview with Certified EMT Simeon Dicker Sophia Rein ‘21 Dr. Gail Anderson: “The Father of Emergency Medicine” Finley Horowitz ‘22 The Modern Resolution To Systemic Toxicity Lani Kahn ‘23 Pain Management Daniel Kalimi ‘23 Paramedic Protocols for a Heart Attack Daniel Kalimi ‘23

Portable MRIs: Tali Sitruk ‘22 The Doctor Will See You Now Rachel Freilich ’22 Covid in the ER Naomi Hanna ’23 Diabetes Syndrome During Emergencies Rebecca Paikin ‘23 Seizure Safety Julia Feit ‘22 The Evolution of Emergency Medicine Daniel Kalimi ‘23 What to do When Someone Passes Out Rebecca Kalimi ’23

Be sure to check out ​Let’s Talk To The Doc! Let’s Talk to the Doc is a podcast created for aspiring healthcare professionals. Listen as Emily Rosenfeld and Alexa Gribetz interview various doctors in diverse specialties to acquire insight into the experience of working in the medical field. Head over to Spotify to listen to the third episode, featuring Dr. Katz, an emergency room physician!

Ambulance Medicine Alexandra Paul “If you’re ever in trouble, just dial 911.” Every child in the United States has heard this sentence before, whether it be from their parents, older siblings, or emergency authorities.

However, what happens when 911 gets a call and sends an ambulance to a person in need? First, the ambulance needs to understand what exactly the emergency is. Someone could be calling for a myriad of reasons, ranging from heart attack to gunshot wounds to a stroke. The lines of treatment for those maladies are completely different, and many times the ambulance needs to prepare specific care for a situation. The ambulance receives that information from the police dispatcher who answers the 911 call. When the ambulance arrives at the scene, they make a crucial decision based on how severe the situation is: where they should treat the person who needs help. If the situation is life or death, they can treat the person on sight. If it is a little milder, the person can be treated both on sight and in the ambulance. If the emergency has essentially passed, the patient can be treated in the hospital.

Who works in an ambulance? Emergency personnel can include paramedics, emergency medical technicians (EMTs), nurses, or other medical professionals. There are different kinds of treatments that EMS (emergency medical services) can offer, but most lines of treatment fall under two categories: the Franco-German model and the Anglo-American model. The goal of the Franco-German model is to “bring the hospital to the patient, not to bring the patient to the hospital”, according to Penn State University. On the other hand, the Anglo-American model is more focused on bringing the patient to the hospital as quickly as possible. Ambulances in America follow the Anglo-American model, a system shared with England. The Franco-German model brings doctors straight to the scene, which can prove to be more efficient because it diminishes the need for an emergency room visit, and patients can go straight to the treatment floor. The Anglo-American model relies on EMTs more. The problem with this is that patients still have to be assessed by a doctor and go through the emergency room upon arrival at the hospital. This adds more time to the ordeal and cuts down on productivity.

There are multiple levels of care that can be given inside an ambulance. EMTs and other ambulance technicians have to be prepared to give any kind of care that a patient may need. The first level of care that an EMT could provide is basic first aid care. This consists of CPR, bandaging and/or treating wounds, or anything else that is taught as basic first aid. The next level is Basic Life Support. People who work as BLS teams are the people commonly referred to as EMTs. They can administer care such as giving oxygen or practicing small necessary procedures on patients. Next comes Intermediate Life Support. ILS is the middle ground between BLS and the next level, Advanced Life Support. ALS is commonly given by paramedics, and its care can range from tracheal intubation, which helps someone breathe, to cardiac defibrillation, which helps someone’s heart start to beat again if it stopped.

All in all, ambulance medicine is riveting and requires critical thinking skills. Becoming an EMT or any other kind of ambulance technician is not for the faint-hearted, it can be a rewarding and fulfilling experience. ● ●

“Emergency Medical Services.” Wikipedia, Wikimedia Foundation, 10 Dec. 2020, en.wikipedia.org/wiki/Emergency_medical_services.

“What Is EMS?” EMS.gov | What Is EMS?, www.ems.gov/whatisems.html.

Amputations and Major Bleeds Noa Haron When dealing with an excessive amount of bleeding coming out of someone's body there are steps and actions that need to take place in order to ensure the persons safety, and to help guide them through an easy recovery process. Applying pressure with a sterilized wound to the opened wound will help control the bleeding, elevation is also another great factor that will help reduce blood loss. After applying pressure and elevation if the wound has other material and particles attached to it you should clean it, this prevents irritation and infection. If you start to notice an infection later on in the recovery process or if the residue is unable to be easily detached from the person's body then you should call a doctor, for a professional observation of the situation. These are ways to help the wound heal successfully.

Amputations are a lot more complicated than a major bleed. There are different degrees and types of amputations. There is a complete amputation, this is where the body part is completely detached from the body and there is nothing keeping it together. There is also the incomplete amputation, this is when there is something keeping this body part still attached to the rest of the body. The limb that is still attached does not have to be a functioning limb to be considered an incomplete amputation it just needs to have something keeping it attached to the rest of the body. When dealing with a complete amputation you should treat the body and the amputated body part as if it will be successfully reattached to the person's body. When someone has an amputated body part you have to treat both the amputated body part and the injured body part that is still attached to the body. For the amputated body part you should put the body part in a sterile bag and put it in ice.

There are different types of amputations, we have the crush amputation, ​avulsion amputation, and the guillotine Amputations. These are all different amputations that can occur and have different ways of treating and going about a situation in these three scenarios.Crush amputations usually occur during natural disasters like hurricanes or earthquakes, or if a car or building crashes. The crush injury is damage towards your arteries and soft tissue. The blood stops flowing to your limb cutting off circulations. This is usually when there is another object that is putting pressure on your limb, this is a very serious thing and if the object is placed on the body for a long period of time the injury will get worse and worse. How is this situation treated?

You should give the patient pain medication without removing any of the objects compressing the body part. Also apply oxygen to the patient and repeatedly test their heart rate. After these protocols you should check to see if the victim has any other injuries. It can be more complicated to reattach body parts if it is considered a crush injury. An ​avulsion amputation is another type of amputation. This amputation is when tissue is tord away from the body, this usually happens to smaller body parts like ears, eyelids, fingers, teeth etc. Guillotine Amputations these amputations are usually caused by knives or other sharp objects. It is easier to reattach an amputated limb when it is severed off by a sharp object. They are easier than the amputations involving car crashes and building collapses because they are a lot less complicated and less material involved in most cases.

All of these examples of amputations occur from outside forces but Amputations are also performed because of things that happen in your body. You can get an Amputation like an infection, cancer or other things that your body can cause. When doctors are amputating a body part they remove all the unhealthy tissue doctors will also remove severely damaged bones.

When reattaching a body part lots of factors are to be considered, nerve damage, how long the body part was unattached, and background health that would not involve the amputation itself are now factors and unhealthy eating or other disorders can lead to the loss of that body part.

Amputations are very complicated and lots of components go into decided whether a body part can be reattached to the person's body, but ​185,000 amputations occur yearly in the US and 90% of the complete amputations have been successfully reattached to the body. So it is not completely unlikely for the body part to be reattached and functioning properly. ● ● ● ● ● ●

https://www.amputee-coalition.org/resources/limb-loss-statistics/#2​ (2) https://www.ems1.com/patient-handling/articles/4-things-ems-providers-must-know-about-crushsyndrome-iGLMvsYAEi0JZael/ https://www.webmd.com/first-aid/bleeding-cuts-wounds https://www.jems.com/2018/10/22/managing-the-toxic-chemical-release-that-occurs-during-a-cru sh-injury/ https://www.webmd.com/a-to-z-guides/definition-amputation#2​ (1) https://www.emsworld.com/article/10322826/tramautic-amputations

Interview with Dr. Boris Khodorkovsky Ariella Goloborodsky Dr.Khodorkovsky works as an Attending Physician in the ER at Staten Island hospital.

What is your most memorable moment from this pandemic, both good and bad?

I recently recalled many memorable moments from the pandemic when one of the doctors at Staten Island hospital was collecting various recollections of what happened in the hospital during the pandemic. This triggered my memory and I began thinking about the hospital during the peak of the virus. During this time, most of the patients coming in had the same symptoms: Hard time breathing, horrible X-rays, and very low oxygen levels. That same week, four of my closest friends lost their loved ones. Mentally, it was an extremely hard week for me, because just like all other weeks everyday I had to wake up, go to work and treat patients. But this week, four of my friends were grieving or their loved ones and I wasn’t able to comfort them during their time of grief. Honestly, I felt extremely isolated during this time, and it was very hard for me to understand how to balance being there for my family and friends, and working long days treating patients with the coronavirus. It was really a time of despair and at that moment it felt like this virus would never end.

How many patients were you seeing on a daily basis during the peaks of the pandemic in NYC (March and April)? What was your daily schedule like? Did you go home every night?

Everyday, I used to get up, put on my regular clothes, drive to the hospital, change into scrubs, see many patients, go home, and change back into regular clothes. And I had to do all of this with the least social interaction as possible. I tried to keep my stamina running for as long as possible. On a daily basis, during the pandemic, I was actually seeing less patients but for a much longer time and with worse symptoms than regular patients. I saw about 20 patients a day, when on a regular day I would see 26-30. But, out of my 20 patients, 18 or 19 were always tough COVID cases.

How did you manage the situation of families not being able to visit their loved ones in the hospital? What was your communication plan with those families?

In the beginning of the pandemic, the Emergency Department immediately made the decision that we would allow no visitors. Honestly, I feel like this was the most inhumane decision that could have been made, but it was necessary. Sometimes, we need to hurt people to heal them.

Because there were no family or friends allowed to visit, the relationship between doctors, nurses, and the patients changed a lot. When you are a patient, speaking to a doctor alone, you feel like a number out of hundreds. But, when family and friends surround you,asking the doctors many questions, you feel love, warmth and care. Not allowing visitors was one of the hardest decisions we had to make, and I hope it will never happen again.

Since there were no visitors allowed, and no waiting room, we had to set up chairs outside the hospital where families could wait for the doctors to come and update them. To update the families, I ran outside of the hospital and spoke to the families there. We also updated the families by phone, or Ipad.

How did you balance the safety of the doctors and taking care of patients?

In terms of communication with the patients, we tried to spend the least time as possible in their rooms, unless we needed to. Everyone was afraid of the virus, but at the same time, we chose the profession as doctors and it was our responsibility to be on the front lines of the pandemic. We needed to do what needed to be done, while trying our best not to expose ourselves unnecessarily. We distributed Ipads to the patients and their family members outside so that they could communicate with each other.

We also bought baby monitors, which sounds humorous, but was how we communicated with many patients. Some rooms had phones, but the hospital was at 300% capacity so not each room that each patient was in had a phone. With the rooms that didn’t have phones, we distributed baby monitors and were able to update the patients through the monitors.

What did you wish you or the hospital would have done differently, knowing what you know now?

There are a few things that I wish we could’ve done differently if we knew more about the virus.

Honestly, this was, and still is a new virus and we had to learn many things on the fly.

Initially, we thought that we were going to treat this virus as a regular sepsis, so we injected the patients with many fluids and antibiotics. A couple of weeks later, we realized that we were injecting too many fluids into the patients, so we had to hold back. This was a new disease so we needed to test many things out before we found what worked and what didn’t.

Many patients were coming into the hospital short of breath. In their X-rays, we found big lung consolidations and their oxygen levels were extremely low. We acted as we would with regular patients who had low oxygen levels: we put them on ventilators. Around three-four weeks later, we realized we probably should not be putting so many people on ventilators, and instead, try to keep them on external oxygen as much as possible even if their oxygen levels are low. In this circumstance, patients being placed on ventilators were detrimental to them. We realized that you can recruit a lot more of lungs when you’re lying prone (lying on your stomach). When you’re lying supine (lying on your back), your heart and your chest are being pressed down and your lungs in the back are not being utilized. But when lying prone, your lungs are better utilized. We used to rotate certain patients in a prone position every half hour and their oxygen levels instantly shot up.

We also learned a lot about how to protect ourselves and patients. We learned what PPE (Personal Protective Equipment) we needed, how to put it on, when to take it off, and how to maintain the least amount of contact possible with patients.

Did you work with Non-ER doctors in the ER during the height of the pandemic?

In the ER, there were mostly only ER doctors. Doctors in different specialties, such as surgeons, usually were working in the ICU since they did not have many surgeries at that time. I didn’t have to work with any untrained doctors during this time.

Did you see a difference in how many non-corona regular ER patients were coming or were corona patients just adding on to them? How did you prioritize which patients to take care of?

During the peak of the pandemic, most of the patients coming in were corona patients in horrible condition. We probably had 20 non-COVID patients in total during the peak. These days, we are seeing probably around only 11 COVID patients, and many regular patients are returning to the ER. The COVID patients coming in recently are not at all like the patients we were seeing in April and May. The people coming in now are sick, but thankfully, their symptoms are much less serious.

On a daily basis, during the peak of the pandemic, how many patients did you see?

Probably around 20 patients. I'm also not the only doctor and I supervise other doctors. Out of the 20 we saw, 18 were COVID patients. On average, I see about 26-30 patients a day, but again, I also have a managing position in the hospital. During the pandemic, we saw less patients, but the patients we saw came in with horrible conditions.

Note from Dr. Khodorkovsky: I don't regret any parts in becoming a doctor, or the specialty I chose. I love what I do, and I find fun in doing it. Speaking to patients, looking through their cases, and trying to solve the mystery of what is wrong with them is what I love doing. Honestly, at work, I feel like Sherlock Holmes.

I believe that anyone thinking about going into medicine should really think about if they love it, because if you do, all else, including money, will be irrelevant to you. Working on the front lines during this pandemic was one of the hardest things I’ve had to do, but I chose this profession, and it was my duty.

Barcode Scanning in the ER Evie Rosenfeld

Technology changes our everyday lives and shapes the way we live. One such way is through technological advancements in medicine that can improve the health care system by making it more efficient and accurate. One example is barcode-assisted medication administration, or BCMA is a process of scanning barcodes to reduce the number of human errors in the medical field making it overall a safer environment for patients. Since the Emergency Room is more prone to error due to the quick decisions that need to be made, it may benefit from having a similar system that has been proven successful in other medical fields.

Implementing this barcode scanning system can decrease the percentage of mistakes made in the Emergency Room. A study about BCMA used in an Emergency Room department was conducted to record the difference in errors when using barcodes. This research was executed at the Emergency department of University Hospital at Ohio State University Wexner Medical Center. This first-level trauma center sees approximately 75,000 patients annually.

Throughout the study, 1,978 distributions of medication were documented, 996 before and 982 after the system was used, registering and grouping errors. The most common mistakes being the wrong dosage of medication, wrong medication, mistaken path of administration, and administering of medicine with no order from a physician. The results were extremely successful, reducing the rate of errors from 6.3% to 1.2%, an 80.7% decrease. In conclusion, putting this barcode scanning system into action will considerably lower the number of missteps in the Emergency Room Department, making this a more secure space for hospitalized patients. ● ●

https://pubmed.ncbi.nlm.nih.gov/24033623/ https://onlinelibrary.wiley.com/doi/full/10.1111/acem.12189

Pocket-sized Ultrasounds Chloe Gad Dr. Rothberg is the CEO of “Butterfly Networks” and helped create the first Pocket-Sized ultrasound: The Butterfly IQ. It is a US-based tech product that scans your body to see what’s inside, just like a digital camera. The primary reason behind the creation of The Butterfly IQ was to provide an affordable way to scan the body without having to visit the hospital. The average ultrasound costs between $100 to $1000 and is far too large to transport easily. Due to the Butterfly IQ’s superior price point and the ability to be transported, it is much more accessible than the traditional ultrasound. The availability of the Butterfly IQ allows doctors to operate scans faster.

The pocket-sized ultrasound is powered with the use of just one silicon chip which can identify considerably more than the fragile piezo crystals that are used in the original ultrasound. The chip is controlled by the IQ app and can be used with just a click of a button. The device also has artificial intelligence capabilities that create more descriptive

images. In addition to those benefits, medical professionals say, it works much quicker than the regular ultrasound and as a result.

Dr. Jonathan Rothberg and his team will keep working on the Butterfly IQ to make the technology even easier and more accessible for patients, doctors, and hospitals around the world. Not only will they try and improve the technology, but they hope to make it possible for the 4.7 billion people around the world who are not able to afford medical care, to be able to obtain the Butterfly IQ, and many more products created by the Butterfly Network. ● ●

https://www.medicaldevice-network.com/features/pocket-ultrasound/ https://thejournalofmhealth.com/the-butterfly-effect-the-pocket-sized-ultrasound-thats-changing-b edside-diagnosis/

CPR Rebecca Kalimi Cardiopulmonary resuscitation, or CPR, is one of the most well-known medical procedures. But what is it really and how does it work? CPR is an emergency procedure performed when someone goes into cardiac arrest. CPR was invented in 1956 by Peter Safar and James Elam and ​combines chest compressions with artificial ventilation, through mouth to mouth resuscitation, to preserve brain function until the patient can get more help from a medical professional. Its main purpose is to restore blood flow to the brain and heart and delay tissue death.

CPR is a procedure that both doctors and regular people have the ability to master. CPR certification does not even have a minimum age! People all over the world have saved millions of lives just because of knowing how to perform CPR on someone who has gone into cardiac arrest.

With millions of people certified in CPR, why do only one-third of people who go into cardiac arrest receive bystander CPR? Some people forget how to perform the procedure and don’t want to risk the person’s life, while others find it unsanitary to perform a mouth to mouth procedure on a stranger. This does not have to be the case. ​Two major studies published in The New England Journal of Medicine in July 2010 showed that chest compressions alone, even without mouth to mouth contact could be just as effective or even better. As it turns out when someone suddenly collapses because the heart’s electrical function stops, there is enough air in the lungs to sustain heart and brain function for a few minutes. Additionally, some people even take gasps of breath before collapsing, providing them with extra air. Some studies even suggest that interrupting the chest compressions to administer oxygen to the patient via mouth to mouth can be detrimental and diminishes the effectiveness of the CPR.

Cardiac arrest takes more lives per year than multiple types of cancers and various other types of diseases combined. In 2015, sudden cardiac arrest mortality in the US was 366,807.

CPR, especially if given immediately after cardiac arrest, can double or triple a person’s chance of survival. About 90% of people who experience out-of-hospital cardiac arrest die. But, according to 2014 data, nearly 45 % of out-of-hospital cardiac arrest victims survived when bystander CPR was given. Most out of hospital cardiac arrests occur in homes, public settings, and nursing homes.

In 2011, a 9-year-old kid saved his baby sister’s life with CPR. He said that he learned how to administer CPR from watching TV and gave it to her after she fell in a pool. His grandmother went looking for his baby sister and they found her floating in a pool. While his mom and grandma went to call for help, he began the procedure while administering mouth to mouth resuscitation. He told the reporters he “knew what he was doing”.

So, although many people believe saving lives should be left to the “professionals”, any ordinary person can learn exactly how to save someone’s life. ● ● ●

https://well.blogs.nytimes.com/2013/12/23/taking-life-into-your-own-hands/ https://cpr.heart.org/en/resources/history-of-cpr https://abcnews.go.com/Health/HeartHealth/year-boy-saves-baby-sister-cpr/story?id=13408947

Difference Between EMR, EMT, AEMT and Paramedic Rebecca Kalimi Different terminologies in the medical field can often become extremely confusing. In particular, people frequently confuse EMR, EMT, AEMT, and paramedics. Most have to do with emergency medicine but they can be very easily confused due to the fact that they’re all relatively the same profession. What is the difference between them?

An EMR is an emergency medical responder, who provides immediate care to critical patients. They provide assistance to higher-level personnel at a scene. They are limited in what they can do and they need about 8 hours of work to be certified. They are certified in CPR and can provide splints, and conduct patient assessments. They are the “lowest” level of emergency patient care.

Paramedics are health care professionals that respond to emergency calls, usually alongside an EMT. They are a link between the scene and the health care system. ​The basic difference between EMTs and paramedics lies in their level of education and the kind of procedures they are allowed to perform. While EMTs can administer CPR, glucose, and oxygen, paramedics can perform more complex procedures such as inserting IV lines, administering drugs, and inserting pacemakers.

EMT stands for Emergency Medical Technician. They are also known as ambulance technicians. An EMT is a trained healthcare professional that works in an ambulance. They

sometimes assist paramedics, depending on where they work. Some EMTs are paid employees but most are volunteers. So, although we often confuse the two, paramedics and EMTs are similar but different, professions.

An AEMT is even more similar to an EMT than a paramedic is! AEMT stands for Advanced Emergency Medical Technician. An AEMT is an EMT with more advanced training.

The AEMT scope includes care for both critical and emergent patients. Although they work in ambulances alongside EMTs and Paramedics, many work in Fire Departments. ​All things considered, an EMR, EMT, AEMT, and Paramedic are similar professions which require different levels of training. ● ● ● ● ●

https://www.cpc.mednet.ucla.edu/node/27 https://www.nremt.org/rwd/public/document/advancedemt https://en.wikipedia.org/wiki/Advanced_emergency_medical_technician https://med.stanford.edu/emt/what-is-an-emt.html https://www.ems1.com/ems-products/education/articles/what-do-paramedics-do-av5C8MG7jiwB 4VpC/

Delivering a Baby Rebecca Kalimi I pride myself on the fact that I have watched both natural and cesarean section births in person while “shadowing” a resident in a hospital. I have always been infatuated with childbirth and was really interested in what to do in the case of emergency childbirth.

Starting with the basics, call an ambulance! Delivering a baby is literally bringing a life into this world, and the best thing to do is to call a medical professional to do his or her job.

In the case where you don’t have access to a medical professional and need to deliver a baby yourself, welcome to an instruction manual! First off, don’t panic! Billions of people have delivered babies, many have been inexperienced. Make sure the mother is taking breaths and panting through her contractions. If you are traveling in a car, pull over and turn on your hazard lights, there is no need to risk an accident. If it’s possible, call your doctor and ask them to help walk you through the delivery.

Put the mother in the correct position. Make sure she is either on the floor or lying on a steady surface. The next step is to gather some supplies. The baby will need to be wrapped up after it’s been delivered. So you’ll need things like pillows, towels, and blankets, or just things that can be used as cushions or blankets. Make sure, if possible, that you wash your hands.

Babies will be very susceptible to diseases because of their undeveloped immune system. Make sure to provide the baby’s head with support after it is delivered. Don’t pull on the baby’s head or body. Gently guide the baby out.

Once the baby comes out, make sure to clean off the baby’s nose to clear the excess amniotic fluid and mucus. Then, place the baby on their mother, skin to skin. Try to put the baby’s head slightly lower than its body to help drain the mucus.

One part of childbirth many people don’t know about is that after the baby is born, you need to deliver the placenta. The placenta is tissue that develops in the uterus during pregnancy.

It provides nutrients and oxygen to the growing baby and removes waste products from the baby’s blood. It attaches to the wall of the uterus, and the umbilical cord arises from it.

Delivering the placenta is an integral part of childbirth, but it might just deliver itself within around 30 minutes after the baby is born. If it is born before help arrives, put it next to the baby and don’t cut the cord.

Many mothers have a fear of an emergency delivery, but it occurs very rarely - about 1.3% of babies in the United States are born outside of the hospital. Luckily, if you are ever in this situation, you’ll know what to do. Good luck! ● ●

https://www.whattoexpect.com/pregnancy/emergency-labor https://www.verywellfamily.com/how-to-deliver-a-baby-in-an-emergency-childbirth-2758998

Interview with Certified EMT Simeon Dicker Sophia Rein How did you become an EMT this past summer?

“I was actually thinking about becoming an EMT for over a year now, but it never fit into a busy Ramaz schedule. So the one good thing to come out of Covid was that all my other summer plans were cancelled and I was finally able to take an EMT course. Luckily, I found an EMT course through YU that lasted only one month, even though courses usually take about 3-5 months. I didn’t want to miss this great opportunity, so I signed up right away.”

Tell me about a typical day at the EMT training program.

“Well, because of Covid restrictions, the majority of the class was online. We had five hour zoom classes three times a week, and online lectures with quizzes available at any time. Because the course was so accelerated I had barely any time to do anything but study. There were 1500 pages in the textbook, and at least 20 hours of online lecturing to finish - not to mention the 10 tests that I took along the way.

Essentially, I was reading, watching, taking notes and completing exams all day every day for an entire month. Then, the last four days of the program was meant to teach us the actual skills we’d be doing on the job: giving oxygen, applying a splint, administering certain medications, and more.”

In your opinion, what qualities make a successful EMT?

“An EMT should have many team oriented attributes. To know that you are so essential in the pre-hospital chain is important, but there are so many levels above you that you must be able to take orders very well. Of course, you need a stomach for anything that can happen on the job - not all cases are pretty. An EMT should also be able to work well under pressure. Every case that you're called to is an emergency for that person and you must treat them with compassion and respect while giving them the best care that you can. The job also requires some amount of physical strength to lift and load patients into the ambulance.”

How do you avoid becoming emotional or panicked while working as an EMT? “On the job I always feel a lot of pressure during every case. It's normal to show your emotions and talk about it with your colleagues after the fact. But during the emergency, in order to give the patient the best care that you can, you have to be focused. I try really hard to just think about the fact that to save the patient's life I need to remain calm and that usually does the trick. I know that if I am too emotional or panicked the patient could suffer because of that and that's always enough for me to remain focused at those times.”

How do you think emergency medicine differs from general medicine?

“I read an article written by an emergency medicine doctor, and the physician stated “My job is to make [the patient’s] problem, someone else's problem. Emergency medicine’s true focus is to stabilize any and all life threatening injuries before transfering the patient to a physician who can medically give a definitive comprehensive diagnosis and treat longer-term. It is not my job to make any complex diagnoses; I am simply there to provide any treatment I can in a prehospital environment, often ignoring the minor injuries to focus on the bigger picture. Any internal medicine doctor would then take over my case and provide definitive care.”

Dr. Gail Anderson: “The Father of Emergency Medicine” Finley Horowitz Although emergency medicine is known to be a very important specialty in the medical field today, it was only recognized as such relatively recently—thanks to Dr. Gail Anderson. Dr. Anderson trained in obstetrics and gynecology and became the ​director of the OB-GYN service at Los Angeles County General Hospital in 1958. He was known as a very successful and accomplished surgeon and professor, specializing in diabetic pregnancy, and became the acting chair of the obstetrics and gynecology department at USC. While at USC, he became involved with their emergency medicine training program when it was created in 1971. He then founded the first physician assistant emergency medicine program at LAC and USC in the early 1970s and the American Board of Emergency Surgery with eleven others in 1976, serving as its president in 1987 and 1988. He also traveled around the world to meet with other physicians who were interested in emergency medicine. Because of his efforts, emergency medicine was

designated as an independent specialty in 1989. Dr. Anderson continued to practice medicine, see patients, and manage a very successful emergency medicine department until his retirement in 2002. He died in 2014 at the age of 88 and led a very impactful life. ●

https://hscnews.usc.edu/gail-anderson-emergency-medicine-pioneer-88

The Modern Resolution To Systemic Toxicity Lani Kahn Lipid Emulsion Therapy is a relatively unknown type of medical treatment. Lipids are organic compounds that include fatty acids. Emulsion is the act of dropping a liquid droplet into another insoluble liquid. This modern medical remedy includes the emulsion of lipids into the veins to stop cardiovascular collapse caused by local anesthetics. In other words, if a patient were to consume a drug used to suppress pain and it resulted in either a heart, vein, or artery dysfunction, there would be a loss of blood flow to the brain, and the body would become a victim to systemic toxicity. In that case, a physician would infuse lipid-plasma into the veins, which would then serve as an antidote in these toxic anesthetics.

In an effort to see its effects, scientists conducted a study on Lipid Emulsion therapy on rats who had been exposed to poison. The study concluded in a “rapid detoxifying effect of lipid emulsion, acting primarily on key end organs, including the heart and brain, dependent on the partitioning effect of the introduced lipid”(Saudi Medical Journal). After seeing the incredible results of many tests similar to these, the technique was approved in the United States in 2006. It has proven itself to be the most effective way of treating local toxicity.

The compound is injected through the veins as an extended plasma, and due to its size and sink-like shape, it is able to grasp the toxic anesthetics, ultimately removing them from the tissue and causing them to become useless. The way in which the lipid is able to inactivate the toxicant is unknown, however, various experiments have suggested multiple theories. One being that the lipid concentration in the drug as well as its volume of distribution allow for the plasma to bind to the drug. Another being that the emulsion provides the heart’s muscular tissue with energy, for anesthetics which interfere with the fatty acids being transported to the cardiac mitochondria cause a loss of energy in the heart’s muscle tissue. The undiscovered reasoning provided for this treatment suggests to us its modernity and the extremely short amount of time that it has been used on patients.

Records show that in 2018, almost 70,000 people died from drug overdose (CDC). The use of narcotics has been found to be an extremely common issue among today’s world, and Lipid Emulsion Therapy provides us with the positive reinforcement that there is a medical treatment that could save the body from narcotics. Although this medical technology is relatively new, it has proven itself to be incredibly reliable and to be an important breakthrough in the study of cardiovascular collapse caused by local anesthetics. It seems miraculous that through

this new therapy, doctors can save a person’s physical body and provide a second chance to those who have stumbled upon the path of drug usage. ● ●

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5694647/ https://www.cdc.gov/injury/features/prescription-drug-overdose/index.html

Pain Management Daniel Kalimi Whether we like it or not, pain is a very important part of our lives. It is a way for our body to tell us what is wrong, where the problem is, and how severe the problem is. Pain is one of the most frequent reasons people call 9-1-1 so it is very important for EMTs and paramedics to know how to manage their patient’s pain. One would think pain medications help anyone in pain, but there is a huge moral dilemma in emergency medicine about when it is ok to use them.

Some say the point is to help end people’s suffering, but others say that it may not be effective for people with drug addictions and may even lead to addiction.

Managing pain was never a priority for hospitals until the mid-1990s. At the time there were a good deal of research papers showing that a lack of good pain management in hospitals increases the chances for patients to develop chronic pain conditions, post-traumatic stress, depression, and other physical and psychological problems. They showed the benefits of having an effective way to manage pain in the form of faster wound healing andfaster discharges from the hospital. Pharmaceutical companies took advantage of this and provided alternative pain relief medications. After this, there became a standard for pain management required for all hospitals, but with this came a significant increase in overdoses and addiction. Doctors started throwing drugs at any problem having to do with pain and didn’t explore alternative pain management strategies, like physical therapy and psychosocial support.

In emergency medicine, there is no standard for pain management and it isn’t a major part of EMS (Emergency Medical Services) training. Studies have shown that EMTs and paramedics are very reluctant to give pain medications to patients. One of the most common reasons is because it will make it harder for a physician to make a proper diagnosis, but in reality it can sometimes help them because it prevents them from moving around during the medical exams. Another reason for the unwillingness to administer pain medication is that they are afraid to give them too high a dose of painkiller, but a one-time dose in an ambulance has a very low chance of causing an overdose. In the case of someone dependent on painkillers, they say it is extremely hard to know when someone is faking a symptom or not to get narcotics. Ultimately, it is very understandable that times of crisis put EMTs and paramedics in moral dilemmas without a straightforward answer. ●

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548151/

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https://www.hindawi.com/journals/isrn/2013/583132/ https://www.washingtonpost.com/outlook/some-patients-are-in-pain-some-just-want-drugs-how-d o-i-tell-them-apart/2018/03/09/1c1b66d2-20b7-11e8-badd-7c9f29a55815_story.html

Paramedic Protocols for a Heart Attack Daniel Kalimi Every year hundreds of thousands of people die from heart conditions. It is the number one leading cause of death in the United States. The heart condition that most people are familiar with is a heart attack, also known as a myocardial infarction. Often, people get a heart attack, seemingly out of nowhere, and have to be rushed to the hospital. In that case, EMTs and paramedics have to know how to diagnose and temporarily treat heart attacks to keep the patient alive and prevent further heart damage.

Once the ambulance crew arrives, the diagnosing process begins. Paramedics start by asking different questions about symptoms, and if the patient shows signs of a heart attack, they do an electrocardiogram (ECG) to check the heart’s rhythm and find out if the symptoms are because of a heart attack. If the paramedics read the ECG and believe that it is in fact a heart attack, then they send the ECG to the hospital so that a doctor can evaluate it. Although the final diagnosis is up to the doctors, the preliminary diagnosis is necessary because it allows paramedics to start treatment right away. The importance of sending in the ECG is also to prepare the doctors for the incoming patient, which decreases the door-to-balloon time.

Door-to-balloon time is the time from when the patient enters the hospital to the time they place the stent in the patient’s heart to fix the heart attack. It is a fundamental measurement for hospitals regarding the treatment of heart attacks.

After doing an ECG and making a preliminary diagnosis, the paramedics treat the patient in multiple ways. First, to ease the pain, they administer morphine through the vein and glyceryl trinitrate (GTN) as a tablet under the tongue or as a spray. To prevent the heart attack from getting worse, they give the patient aspirin which thins the blood. A heart attack happens when blood clots in the coronary arteries so blood can’t reach parts of the heart. When on a blood thinner, the blood stops clotting so the original clot doesn’t keep building up. It is crucial that they give the patient aspirin because it prevents the situation from getting worse and can ultimately save their life.

To conclude, paramedics play a crucial role in today’s society and rescue millions of lives. Every second counts when in a life-and-death situation, and it is a privilege to have people working in emergency medicine willing to drop everything on a moment's notice to help a fellow human. ● ●

https://healthtalk.org/heart-attack/pre-hospital-care-in-the-ambulance-for-a-heart-attack https://www.ncbi.nlm.nih.gov/books/NBK321505/

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https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106

The Doctor Will See You Now Rachel Freilich The concept of telemedicine is not new to patients and physicians, although its rise in popularity has taken off as a result of the Coronavirus pandemic. Telemedicine was originally used as a tool to provide medical care and share medical knowledge with patients who were located in remote areas without access to primary care doctors or subspecialists. In addition, telemedicine was often used to help local physicians with complicated cases by providing advice or collaboration from doctors located in major medical centers, often hundreds or thousands of miles away.

In the most recent past, telemedicine has been used as a more rapid and economical way of seeing a doctor. Numerous apps and website platforms were created so that a patient, with just a few clicks and a credit card, could get expert medical advice from doctors. The downside to this was that these encounters often occurred with a doctor who had never seen this patient before and did not know the patient's full medical history. In addition, certain medical problems such as ear infections or heart murmurs are difficult to diagnose over a video call. Another issue dealing with malpractice existed, as well, because physicians have state licenses. A treating or prescribing doctor was often not in the same state as the video patient, so they were not licensed to practice or give advice to patients residing in another area.

In March 2020, this all changed. Sick patients were advised not to go to doctor's offices to minimize the possibility of transmitting the Coronavirus infection. Healthy patients in need of maintenance check-ups and routine procedures were also told to stay away so that they would not get infected. As a result, doctors honed their telemedicine skills and started providing as much care as possible over a video call. Malpractice insurance providers allowed doctors to provide care for people out of their home state. Other phone applications like pulse oximeters and remote EKGs were put into use to give the physicians as much information as possible.

Resourceful doctors visited patients over facetime or other video platforms.

While an in-person doctor visit is still the preferred method to have both routine check-ups and sick visits, telemedicine has proven to be a viable alternative for after hours and when it is not possible to go into the office.

Covid in the ER Naomi Hanna Dr. Samuel Maryles, MD is an Emergency Medicine Physician at Stamford hospital in Stamford, CT, and has over 21 years in the field. He graduated from Rosalind Franklin

University of Medicine and Science/The Chicago medical school in 1999. Dr. Maryles originally started out on track to become a surgeon. However, a year into his residency decided to change paths to Emergency Medicine, and switched hospitals from Boston City Hospital to New York Medical College. He then completed his residency in Emergency Medicine at New York Medical College.

Dr. Maryles was interviewed to discuss his experience with COVID-19 in the Emergency Room, how COVID has affected those that work there, and how it affected those that go for medical assistance. When asked about the new protocols adapted because of Covid, Dr. Maryles explained that before Covid, patients that came into the Emergency Room were allowed to have visitors and other people there with them. Having others to help explain what happened to the patient is very important especially if the patient doesn’t remember all of the details. Not having someone who could explain the medical history of the patient, for example if they take medications, makes it more difficult to begin treatment. This was a major adaptation for doctors to make because of Covid protocols. It now takes the doctors longer to obtain the patient’s medical history, and chief complaint which they need before they treat a patient. He explained that now this usually involves an extensive amount of phone calls to gather complete information, and is one of the biggest adaptations made in the Stamford Hospital ER. Dr. Maryles also added that the new personal protective equipment, also known as PPE, is another major modification made to the ER protocol. He explained that it now takes doctors a longer time to switch from patient to patient because they have to change most of their protective gear. When treating potential Covid patients, doctors have to be careful not to infect themselves or others with the possible germs on their PPE. Doctors at Stamford Hospital now try to do all necessary tests at once to avoid the long process of taking off and putting on the proper PPE. Maryles added that before Covid, people would come into the ER if they felt it necessary, now they don't because they are scared they may catch Covid from either the doctors or the patients.

Due to the patient delaying medical treatment, their condition would progress, and when they finally came into the ER their condition would be more complicated to treat. For example, if someone had severe stomach pains that weren’t going away, and they choose not to go into the ER due to Covid, their condition would get worse. Then one ends up with a patient that may have a burst appendix rather than a patient who just has appendicitis. When asked if he thought the new PPE used would continue in the years to come, Dr. Maryles said, “I think there will certainly be an elevated level of concern and awareness of it, so whether that means we’re going to wear masks for every single patient for the rest of time, I don't know for sure because I don't think we’ve gotten to the point where we know everything about this virus, and how it’s passed.

So, I think it’s to be determined, to what extent, but I think we now deal with each patient with more awareness, and that even patients who are not necessarily coming in with classic covid symptoms can wind up having it.” Maryles then continued to add that at this stage of Covid, and with the limited knowledge that we have, we still don’t know enough to say what protocols will continue into the future and what won’t.

Dr. Maryles gave a very thoughtful answer to the question of if he ever felt unsafe going into the ER. He answered by saying that personal safety and fear is not something you can think about in this field, you have to just go and do it. You have to focus on the task at hand and recognize that you are the only person between your patient and the virus, and you can’t think about the dangers of the unknown.

The final question Dr. Maryles answered was; if he could change one thing about the way the ER was run during the peak of Covid, what would you change? The main point in his answer was that he wished that we knew more about how Covid spread, and how quickly it spread. Then we might have been able to slow down the transmission . He also commented that had we known how serious and dangerous the infection was at the beginning of the Covid crisis, we may have been even more cautious which could've prevented some of the damage we saw in the early months. Maryles’ concluding thought was that we still don’t know enough about Covid, but had we known how quickly the virus spread, and that it is airborne, we could’ve educated people on protecting themselves and their families. If we had known and done all of that, then maybe there would’ve been a change in number of people affected by the virus.

Dr. Maryles provided thoughtful insight into the Covid pandemic and how it is affecting Stamford Hospital, and the medical community.

Diabetes Syndrome During Emergencies Rebecca Paikin Diabetes is a disease that causes a decrease in the production of the hormone, Insulin in the pancreas. .The function of Insulin is to move the glucose from the food that is eaten into the cells to be used as energy. Without enough Insulin, the glucose stays in the bloodstream and never makes it to the cells where it’s needed. The two most common types of diabetes are type one and type two. Type one stops the production of insulin completely and is congenital. Type two has trouble making or using insulin and generally exists in older people. High blood sugar caused by diabetes can later lead to other health problems such as heart, eye, and kidney disease, bladder issues, foot problems, etc. To avoid these health problems, diabetics have to learn to constantly check their blood pressure, maintain good cholesterol, follow strict meal plans, regulate physical activity, and take their medicine which includes insulin injections.

Although diabetics have ways to keep their disease under control, it can still lead to an emergency. There are two ways in which a diabetic would need emergent care. The first is Hypoglycemia​, low blood sugar. The symptoms include thirst, dry mouth, drowsiness, blurry vision, and a frequent need to use the restroom. This is caused by insulin moving too much sugar out of the blood which can happen after taking too much insulin, drinking excessive amounts of alcohol, or over exhilaration. Usually, ​Hypoglycemia is treated with a small amount of food or a drink with a high glucose concentration. If there are no signs of improvement or they start

experiencing harsher symptoms medical professionals are necessary. The medics will give a hormone by the name of glucagon to significantly raise blood sugar.

The second type of emergency is called Hyperglycemia high blood sugar. This occurs when there is next to none or no insulin to regulate the level of glucose being allowed into the bloodstream. The symptoms align very closely with regular diabetic symptoms which include hunger, nausea, weakness, sweating, tingling lips, and feeling irritable and shaky. The difference between normal diabetic symptoms and those of Hyperglycaemia is its abruptness. If left unattended, loss of consciousness is common which can eventually lead to death. Both Hyperglycaemia and ​Hypoglycaemia can happen to both types of diabetics.

When diabetes is left untreated, people go into Diabetic Ketoacidosis (DKA). This is a life-threatening complication that mostly occurs in type one diabetics. DKA is very similar to hyperglycemia with the exception of dehydration levels and specific enzymes from the liver.

During pregnancy and childhood, DKA can be lethal.

Over 400 million people suffer from diabetes worldwide. Although it is controllable, there is still no cure, and it is one of the leading causes of death. Knowing how to help a diabetic in a time of need could be extremely helpful and might even help save a life. ● ● ●

https://rcni.com/hosted-content/rcn/diabetes/emergency-treatment-diabetes https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes https://www.who.int/health-topics/diabetes#tab=tab_1

Seizure Safety Julia Feit Seizures are not uncommon and they are as scary for the patient as they are for everyone watching. About 1 in 10 people have a seizure during their lifetime. The key is not to panic.

Most seizures will end on their own in just a matter of minutes and do not require an emergency call or visit. During an episode, a bystander should follow specific protocols to protect the patient from hurting himself. It is important to remain at the scene of the seizure and stay with the patient until the seizure ends and they are fully conscious. Once the person is awake and alert, someone at the scene should explain to him what happened, while comforting the patient and speaking calmly.

However, specific seizure scenarios warrant emergency medical attention. These cases include if the person has never had a seizure before, has trouble breathing or regaining consciousness after the seizure, or the seizure lasts longer than five minutes. These alarming scenarios may be an indication of brain damage and require further testing by medical professionals. Additionally, if the person has a second seizure soon after the first one, gets hurt during the seizure, the seizure happens in water, or the person has a preexisting health condition

like diabetes, heart disease, or is pregnant, the patient should immediately consult an emergency physician.

Generally, most seizures are not grand mal seizures in which the patient may scream, fall to the ground, shake vigorously, or jerk their head, becoming unaware of their surroundings. In the event of a grand mal seizure, a bystander should gently lay the person on the floor, turning their body to one side in order to facilitate breathing. They should place something soft and flat underneath the patient’s head, clearing the surroundings of anything potentially dangerous to the patients. Additionally, eyeglasses should be removed and tight shirts around the neck of the patient should be loosened. Lastly, the seizure should be timed and an ambulance called if the episode exceeds five minutes. Although seizures may seem frightening, they are manageable with specific protocols. ●

​https://www.cdc.gov/epilepsy/about/first-aid.htm

The Evolution of Emergency Medicine Daniel Kalimi Over the years, emergency medicine has changed significantly, and it is important to understand the evolution of this field so we can properly apply it to its future development. From the different techniques to the sheer idea of an ambulance, these are all things people take for granted. These resources were not always around, but after many years, idea after idea, they accumulated to become emergency medicine.

Julius Caesar was one of the first people in history to have doctors help injured people in a time of emergency. It was his idea to have medics on the battlefield who would help injured soldiers and bring them to a hospital-like facility for them to heal.The generals had to arrange transportation, medical care, and time to recover behind enemy lines. Those wounded were usually treated on the field, in their tents, or if in friendly territory, lodged in private houses or returned to their families.

Caesar’s medics were an example of emergency medicine in war, but there is also proof of emergency medicine techniques for everyday life. Interestingly enough, there is an instance of this in the new testament in the parable of the good Samaritan. It talks about a Samaritan who was travelling and saw a man on the street who was beat up almost to death. He poured oil and wine on his wounds, bandaged him up and took care of him. Although this isn’t the method we use today to sanitize wounds, it is interesting to see that they still saw the importance of cleaning and covering wounds.

The first time people used ambulances in an organized fashion was for Napoleon's wars.

A man by the name of Baron Dominique Jean Larrey, the French chief military surgeon, came up with a way to transport injured men on the battlefield to the hospital right outside in order to treat them. He called it the “flying ambulance”, a horse-drawn ambulance that could manoeuvre

rapidly across the battlefield, picking up wounded soldiers and taking them to field hospitals just outside the battle zone.

Next, there was the idea for the medical professional to go to the patient rather than the patient coming to them. Clara Barton proposed this idea during the civil war. The idea was so successful that it eventually became the foundation of the Emergency Medical Services System in Europe.

Even Though such an important field like emergency medicine has been around for a long time, it only became an independent medical specialty sometime between the 60s and 70s.

Before then, the doctors on staff ran the emergency department in hospitals on a rotating base of family physicians, general surgeons, and other specialties. ● ●

http://www.hkcem.com/html/publications/Journal/2001-2/84-89.pdf https://www.acep.org/patient-care/policy-statements/definition-of-emergency-medicine/

What To Do When Someone Passes Out Rebecca Kalimi Fainting is a common problem that accounts for 3% of emergency room visits and 6% of hospital visits. What exactly is fainting? Fainting normally erupts from a change in our circulatory or nervous system that causes a drop in the normal amount of blood, sugar, or oxygen that enters our brains. This interrupted supply to the brain causes loss of consciousness and causes a person to fall on the floor. Lying on the floor usually corrects the brain’s blood supply and the person regains consciousness after a couple of minutes. Most of the time, loss of consciousness doesn’t indicate any underlying issues, but it’s still important to consult with healthcare professionals to make sure.

There are several explanations as to why someone can lose consciousness.

Hyperventilation, also known as breathing rapidly, causes a reduction of carbon dioxide in the blood. Hyperventilation can occur if a person is extremely stressed, if they have anxiety disorders, or if they are in shock. Low blood sugar also very commonly causes fainting. Going without food for a long time is the most common cause of low blood sugar. During pregnancy, it’s common for women to faint since the body needs more fluid so it’s easy to become dehydrated and because there are hormonal and circulatory changes to the body. Also, as the uterus grows it can block larger blood vessels and decrease the amount of blood that gets to the brain. Having anemia is among the most common causes of fainting. Being anemic means one has fewer red blood cells than normal, decreasing the amount of oxygen in the blood supply that is delivered to the brain. Other physical triggers that cause someone to lose consciousness include being in poorly ventilated rooms, exercising in hot weather, allowing oneself to become dehydrated or too hungry, standing up too quickly after sitting for a long time, or just standing for a long time. And lastly, among teenagers, emotional stress is extremely common and can

cause fainting all the time. Fright, shock, anxiety, or pain all affect the body’s nervous system and can cause a drop in blood pressure, which results in fainting.

There are many reasons a person can faint, but there are just as many ways to treat it. If someone ​faints, it’s best to lie them on his or her back and make sure they are breathing. If possible, lift the person’s legs above their heart level to help their blood flow to the brain. If the person is not breathing, check their airway to make sure nothing is blocked, and make sure to watch them until professionals come, and if they have no pulse, start the process of CPR. Never forget to appoint someone to call 911. Continue with CPR until help arrives. When the person regains consciousness, let them rest instead of trying to get them up quickly. If they are diabetic and missed a meal, giving them some sweets will help raise their blood sugar levels. Stay away from shaking someone who fainted; although one might think it’ll help wake them up, it can disrupt their body’s attempt to regain consciousness. The most important thing is to call an ambulance to get professional help even if the person regains consciousness to make sure they are okay. ● ●

https://www.mayoclinic.org/first-aid/first-aid-fainting/basics/art-20056606 https://ercare24.com/what-should-you-do-when-someone-faints/