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Adam LaChappelle
31 March 2020
Splitting vents, DIYing facemask, and having a blanket DNR are nuclear options that agencies and providers cannot immediatly jump to because there is a shortage or pandemic. Organizations and providers that carte blanche change the standards of care without strong planning and consideration can face serious legal ramifications. The process to devel...
Tyler Christifulli
28 March 2020
In the midst of the COVID-19 pandemic, hospitals and healthcare providers may experience shortages of critical equipment needed to treat their patients. Many have already begun to search for alternative methods to provide high quality care to patients despite such a shortage.After watching a YouTube video posted by Scott Weingart of EMCrit on how t...
Brian King
25 March 2020
The nurse approaches you as you're taking off your helmet and wheeling the stretcher into the ED from the helipad. "We can't get his pulse ox up! We have tried EVERYTHING!" This is a small outlying community access hospital and they rarely meet you at the door. Original page was a 43 year old male who is being transferred back to a tertia...
Austin Quillet
12 March 2020
 No one in emergency medicine wakes up in the morning and plans on going out of their way to make errors in patient care. We strive for perfection when treating our patients, at least most of us. We make clinical decisions to the best of our ability from what we have accrued in education, what resources we have at our disposal and what mistake...
Bryan Winchell
10 March 2020
If your "ventilator resume" looks like mine, you started with something like an AutoVent, and progressively upgraded to the critical care ventilator you are using now. Having not been through formal respiratory therapist training, understanding ventilator waveforms was not something I was taught initially. Thankfully, they are not nearly as difficu...
Tyler Christifulli
04 March 2020
You walk into the ED to find your septic patient has a MAP of 50 and heart rate bouncing between 110 and 140. As you walk closer to the hospital monitor, your suspicion of atrial fibrillation with rapid ventricular (RVR) response is confirmed. At some point in your career you may have asked yourself: "is the rate causing the hypotension, or is the ...
Tyler Christifulli
22 February 2020
If an alien were to come down from space and ask you to describe what the term pH means, you would probably state one of the following:1. It measures the acidity of a solution.2. It is a measure of the hydrogen concentration within a solution.3. OMG AN ALIEN!I recently taught a class on acid base interpretation utilzing the Stewart approach. The st...
Courtney Graham
02 February 2020
Note from Tyler: Courtney and I were chatting the other day about the fact that both of us had, at one point, a goal to work as  animation artists at Disney. The longer I have known Courtney the more I realize how gifted she is to bring science and art together so flawlessly. I asked her to illustrate some of the pediatric heart defects in an ...
Tom Latosek
17 January 2020
Whether you are a brand-new paramedic or nurse or a seasoned critical care provider, chances are you have started or maintained a patient on vasopressors.  They are considered to be one of the hallmark drugs of resuscitation and what we consider to be “life support” drugs.  There are a few key drugs on the market that have falle...
Jared Patterson
30 December 2019
If I click baited you into reading this with my cover art, I assume you are an educator looking to "spruce" up your presentation skills; or maybe you're a newbie looking to enter the world of teaching and education. I, too, was in the same spot, and while I think I still am a newbie, I have found many ways to improve my lectures and presentations o...
Brian Behn
29 December 2019
 In a sudden moment of clarity, I realize I’ve made a huge mistake.It is too late to do anything about it now; we are committed and past the point of no return. Dark thoughts come creeping into my head. I can envision a very long night ahead of us now, ending with us pulled over on the side of the road in this dark canyon, in a snowstorm, with...
Natalie Zink
28 December 2019
In a world where Ketamine rules all FOAMed, services without access to this “miraKle drug” often get left out of the conversation on safe chemical restraint. So, Ketamine Warriors, I humbly ask that you imagine for a moment that you don’t have your secret sauce, and you must rely upon……BENZOS AND ANTIPSYCHOTICS.I will leave the “favorite benzo flav...
Tyler Christifulli
22 December 2019
Pelvic fractures (PFs) can be one of the most devasting injuries. They can happen with simple falls in the elderly to the more prevalent young males involved in high energy motor vehicle accidents (MVA). PFs that arise from falls tend to be less severe as those in high energy trauma. Stable pelvic fractures have mortality rates as high as 19%....
Tom Latosek
19 December 2019
Every cardiac arrest you choose to begin resuscitating, has the potential to achieve ROSC. A Change in MindsetMost of us in the EMS profession are used to managing the adult out of hospital cardiac arrest. When I was a paramedic student, the ability to terminate resuscitation in the field was just beginning to make its way into my area and was...
Jace Mullen
16 December 2019
Serotonin Syndrome (or Serotonin Toxicity) is an uncommon and complex life threatening condition that is caused by too much serotonin in the synapses (either due to increased release, or decreased reuptake). It is important for EMS providers to be aware of this condition for two reasons. Firstly, the diagnosis is purely a clinical one. This rare di...
Adam LaChappelle
12 December 2019
As a kid I loved getting into the cookie jar. I thought I was pretty sneaky, but I would always get caught. To make it worse, when mom asked me if I had gotten into the cookie jar - I lied and said no. As a result of fibbing I got a paddling. Really mom just used a plastic spoon until one day it broke when she was paddling my brother (he deserved i...
Tyler Christifulli
05 December 2019
My experience with non-invasive positive pressure ventilation (NIPPV) is occasionally made up of the following issues: 1. Mask fitting properly (we always guess a size too big).2. Increased 02 Consumption (@bryanwinchell has a wicked app for this).3. Comfort level of the patient  There is limited literature to support the ideal agent...
Tyler Christifulli
30 November 2019
I notice when I am charting after a call, there occasionally appears to be more time between interventions, diagnostics, and assessments than I remember. The tendency is to fill this space to avoid the chart reading as if you had long periods of time in which you sat twiddling your thumbs. The fascinanting part about retrospective reflection, ...
Tyler Christifulli
28 November 2019
Much to my paramedic student’s chagrin, I spend some time talking through some topics I think would best be categorized as the “philosophy of paramedicine”. One of the things that I have been chewing over recently has been the idea of paramedic-as-translator being an essential skill of the profession. I usually open the conversation by telling...
Tyler Christifulli
27 November 2019
When I was initially taught acid base interpretation, we would start by drawing a tic-tac-toe grid.As we read off the values of the ABG, an X would be made in the corresponding box. In this graph above, we see a primary metabolic acidosis with respiratory compensation. After you did this a few times in class, you could easily do it in your hea...
Tyler Christifulli
20 November 2019
We’ve all heard that old adage: if it walks like a duck, swims like a duck, and quacks like a duck, it must be a duck. This is most definitely abductive reasoning. Abductive reasoning is defined as this: A chosen hypothesis that best fits the facts available. This is a logical process which best describes how we determine our field diagnoses of pat...
Tyler Christifulli
15 November 2019
I think we all have a good understanding of how to identify AV blocks. In your static cardiology station you probably identified one in something of a “cold read” with a strip of Lead II. As time goes on we learn what we need to put this in clinical context.When we add 12 leads and clinical presentation, the tracks start to come together. We just n...
Tyler Christifulli
06 November 2019
Early in my paramedic career I remember being told that propofol was the “white assassin” and had no role in the back of an ambulance or helicopter. The common quotes bounced around the web like a beach ball at a NickelBack concert.“You can either have a patient properly sedated or a patient with an adequate blood pressure.”“Propofol is meant for d...
Tyler Christifulli
03 November 2019
 “Did you just, uh... Did you just grunt? You really shouldn’t be, you know, grunting while intubating.” The paramedic in the back of the ambulance with me is a tired, sweaty mess. We are going through DSI training and working on intubation. “My shoulder is burning,” he says. “I need to take a break.”I tell him, “Listen, you have to ...
Tyler Christifulli
30 October 2019
 STEMI equivalents have become a finding that many providers have either heard of or are familiar with, but how many can identify STEMI equivalents on the 12 lead ECG in your patients experiencing ACS-like symptoms? If you encountered bulky, tall, and disproportionate T waves with no ST-segment elevation seen anywhere on the ECG, would yo...
Tyler Christifulli
29 October 2019
Once upon a time I had a critical care paramedic as a trainee. This individual had been in EMS for approximately two years, and was an FTO at another local service. I was very surprised to learn of the providers complete lack of knowledge base and experience. Get ready for my list. It's scary. They had never run a code, never performed CP...
FOAMfrat
24 October 2019
Some time ago you probably read a post by Sam Ireland about how staying on scene can improve our time-to-intervention. If not, click the poop clock for a direct link. There is another side to this coin. ...
FOAMfrat
23 October 2019
The Laryngoscope:The tool many wield, but only a resuscitationist mastersIn the late 1800’s Alfred Kirstein developed the autoscope to directly visualize the glottis. Prior to this, mirrors were utilized to perform indirect laryngoscopy. Many of Alfred’s colleagues felt that there was not a need to directly view the glottis. Alfred stated “…Many a ...
FOAMfrat
15 October 2019
FOAMfrat
08 October 2019
Here on FOAMfrat we do a lot of thought experiments. I would like you to consider the pro's and con's of relatively fixed dose paralytics when performing an intubation. For the sake of this blog we will be referring to rocuronium as the primary agent. However, I feel you could substitute in succinylcholine with little variance. Rocuronium dosing ha...
FOAMfrat
05 October 2019
 Part 1 was a call to action, an opportunity to reflect on your current practice. Part 2 will be a commitment to action. A commitment to say ‘I am haven’t mastered resuscitation, yet, but we’re going to get there.’ This may be a commitment to be the example while working in a status quo department. This may be the commitment to say that ‘I can’t ch...
FOAMfrat
30 August 2019
 What is Harm Reduction? Harm reduction is the understanding that people who use drugs (PWUD) deserve to be treated with respect, dignity, and kindness. It is the understanding that one cannot recover from their drug addiction if they do not survive it. Thus, Harm reduction is a set of strategies aimed at making drug use as safe as possible, while ...
FOAMfrat
22 August 2019
There is an internal clock that begins ticking when I see a patient with a MAP below 65. That ticking gets even louder when the patient has a known head bleed. As clinicians we have several ways to raise someones mean arterial pressure: Fill The Tank: Fluids and blood products. Manipulate The Pump Dynamics: Inotropes and chronotropes ....
FOAMfrat
20 August 2019
 Airway management is NOT about passing a piece of plastic between the vocal cords. We can fool ourselves and get a clean kill with a laryngoscope if we fail to recognize the need to actively provide resuscitation throughout the procedure. No one ever died because they didn’t have a piece of plastic shoved down their throat. Pat...
FOAMfrat
10 August 2019
 I wanted to put a catchy introductory paragraph here—something to really suck the readers in and make them want to read this whole post. But I couldn’t think of anything, so let’s just get down to business here. A lot of blog posts are poorly written. A lot of my blog posts are poorly written, if we are being honest here. After a few years of bein...
FOAMfrat
07 August 2019
 Atelectasis is bad. Our job as a clinician is to prevent and treat alveolar collapse. Alveolar collapse is caused by a mix of different mechanisms. For this article we’ll focus on: Excessive fluid collection (obstructive) ...
FOAMfrat
02 August 2019
 Drop your highlighters, put down the textbook, and let’s talk about learning to learn.  If you are reading a FOAMed blog, you are either a dedicated EMS professional striving to continue your education or you are a student looking to expand your learning in new ways.  Either way, if you have arrived here you have realized that lifelong learning is...
FOAMfrat
30 July 2019
 Becoming intentional and cultivating a system of organization allowed me to become the husband, man, and paramedic I am today. In the Spring of 2016, at 25 years old, I was 240 lbs, dating someone who was not the right fit for me, and full of anger. I thought I was angry at the world for some perceived injustice. I felt like “I’ve scarified a lot ...
FOAMfrat
22 July 2019
All around the world opioid overdoses have become a bit of a routine. These patients are usually revived with some ventilatory assistance, O2 and naloxone. For the most part. they get better and go back to their lives following a brief period of monitoring in the ED. What about the cases that do not go so smoothly? What abo...
FOAMfrat
19 July 2019
 FOAMfrat is very excited to announce our online paramedic refreshers! It is our goal to make learning enjoyable, so we have taken a different approach to this online refresher. ...
FOAMfrat
09 July 2019
Many EMS services embrace and push for additional training. Personally I think EMS does a pretty good job at focusing on training and sees the value in it. Quite frankly EMS has no other option but to continually train due to the nature and variety of our work.Training is a bridge that allows the educator to facilitate the learners transport from t...
FOAMfrat
02 July 2019
As Leonard sits in the back of your ambulance, you ask him to describe his chest pain. He looks at you with small droplets of cold sweat on his forehead and says: " It feels... like .....someone.... is sitting on my chest." Your partner hands you four baby aspirin and you ask the patient to open up his mouth and chew these aspirin before swallowing...
FOAMfrat
01 July 2019
At some point in your career, you will probably teach something to somebody. These “Somebodies” could be EMT’s, paramedics, or nurses in training; or the newly hired individuals to your team. They could be the audience members at your conference presentation; or even your co-workers and staff. Your pupil could very well be a seasoned provider, who ...
FOAMfrat
27 June 2019
One handed face-mask EC seal SUCKS! Two handed EC seal is okay, but you’re better off to "Feel the Seal" and provide thumbs down face-mask seal to deliver appropriate ventilations to your apneic patients.Don’t be a monkey, be a sealBVM ventilation is a basic skill, mastered by few, and most likely to be delegated to the least experienced provider. ...
FOAMfrat
24 June 2019
Field Amputation: VLOG by Cynthia Griffin D.O., NRPVlog Notes!Indications for field AmputationThis is where we chose Life over Limb.1. Pt is unstable and there is no other way to extricate them2. Pt is somewhat stable yet there is no other way to extricate them, may have time sensitive injuries, may need time sensitive surgery, pt needs blood, pt h...
FOAMfrat
17 June 2019
The majority of EMS protocols utilize a systolic stopping point for the administration of nitroglycerin in a patient with suspected ACS.While not dumping their systolic pressure is important, I think an isolated focus on systole in a patient with ACS is the wrong move, and here's why..A-orta-know this by now!Let's start by reviewing how the coronar...
FOAMfrat
12 June 2019
Non-compressible torso hemorrhage (NCTH) is a leading cause of potentially survivable death.(1, 2)Stannard et al. described NCTH as vascular disruption in one or more of the following: named torso vessel, solid organ injury with grade 4 or greater with shock (systolic blood pressureOriginal author: Andrew Fisher & Zaffer Qasim...
FOAMfrat
05 June 2019
Being in EMS for about 3.5 years, I found myself in my first real rut of burnout this past December. I’vefound that in the midst of chaos, human nature urges you to seek order, like illogical patterns of events.Well, after a series of the types of calls that linger in your subconscious a bit too much, I began to fearmy Saturday shifts. Every other ...
FOAMfrat
25 May 2019
You’re running a cardiac arrest and you notice the provider on the airway is struggling to deliver effective ventilations. You start trouble shooting and realize there isn’t an OPA to aid you. You hand him the OPA and ask one of the firefighters to provide a thumbs up technique + jaw thrust. You now note that the patient is ventilating appropriate ...
FOAMfrat
23 May 2019
How unstable of a patient should an EMS crew take on an interfacility transport? What criteria should we be looking at to determine if a patient is appropriate for a transfer? How much risk is too much risk? My phone is ringing. I have no idea what time it is other than the middle of the night. My wife looks at me, shaking her head and mouths “you’...
FOAMfrat
16 May 2019
Date: May 25th, 2017Location: High DesertAmbient Temperature: ~75Altitude: ~4400Evidence: See AttachmentSuspects: Mother NatureBackground: It was a beautiful, sunny, day. It was that weird time of the year when the heater was needed in the aircraft at night, but the air conditioning was needed during the day. During the early morning checks, the vi...
FOAMfrat
16 May 2019
This is a non-medical post, so if you do not have interest in audio / video recording, you can save some time and stop here.Once I tell people that I invested in some sound dampening, the first question I've been getting is about the cost and setup. So why stop with the sound dampening? I'm going to show you guys what products I use and what result...
FOAMfrat
30 April 2019
Recently I transported a child who was diagnosed with acute lymphoblastic leukemia (ALL). I realized within a few minutes of conversing with the physician that I needed to improve my understanding of cancer, and the nomenclature that surrounds it. I will openly admit that it is somewhat depressing to discuss, and is typically not a topic amongst th...
FOAMfrat
17 April 2019
A few months ago Sam and I launched a course called "The Speaker's Atlas". The ideas was to create an online course for providers who wanted to successfully launch into the world of public speaking and educating. The students would meet in an online classroom one night a week as Sam and I presented what we believe to be the "need to know" fundament...
FOAMfrat
09 April 2019
I was given a vial of epi, a bag of D5w to mix it in and instructions to titrate as needed. I sent patients on a blood pressure roller coaster ride. Over the course of a few hours there would easily be 100mmhg swings in their systolic blood pressure.Action is comfort. Action fixes things, and you are a fixer. You were trained to be a fixer, to be a...
FOAMfrat
09 April 2019
We are only human, right? Some of the cool features that come with be being “Only human” include: forgetfulness, loss of situational awareness, and an amazing ability to make stupid mistakes. Oh right, let’s not forget about loss of concentration and freezing up, either.All of these are equally as awful; in a world where the expectation is that we ...
FOAMfrat
08 April 2019
I was invited by Chip Lange (@the_TOTAL_EM) of TotalEM to be a guest on his show a couple months ago. We had a great discussion about acute and impending ventilatory failure. This was really a closure of the series I did on NPPV (see below for the vodcasts that started off this series). This is where I answer the question that I left you all with: ...
FOAMfrat
04 April 2019
Typically if I engage someone with a particular question, it’s because I perceive they have a knowledge base or experiences that I can learn from. My brain often gets frustrated when someone answers a specific question with an unsatisfying and vague response. This happens ALL the time on panels at medical conferences and on social media.These often...
FOAMfrat
17 March 2019
Imagine you are sitting at your desk and one of your friends runs into your office, pins an article to your wall, and then runs away. You look at the title of the article, and wonder why your friend felt the need to share this article. A few minutes later, another one of your friends does the same thing. You finally grab a hold of the third friend,...
FOAMfrat
14 March 2019
Recently Chris Meeks put out a podcast onMind Body Medic discussing sedation during non-invasive positive pressure ventilation (NIPPV). He did a great job discussing his thoughts on the topic and gave some sound advice. Here are a few thoughts.My general experience with NIPPV patient's has been made up of the following issues:1. Mask fitting proper...
Tyler Christifulli
12 February 2019
Over the course of the last week I’ve stumbled upon a twitter thread full of misconceptions regarding anaphylaxis amongst medical professionals. I also recently spoke with a paramedic student who had been taught outdated information about anaphylaxis. When I pressed the paramedic student about indications for administering epine...
Tyler Christifulli
18 May 2018
I once worked with a prehospital practitioner who at one time worked for a service that drilled 20 minute scene times in their head. If they didn't make a 20 minute or less scene time, the service would question the crew as to why it 'took them so long.' I was never a fan of this. I would frequently be internally irritated when someone would remind...
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