Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Thoracentesis

Thoracentesis is a percutaneous procedure during which a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. When performed using real-time ultrasound (US) guidance, thoracentesis has an extremely low rate of complications. Anatomy The thoracic cavity is lined by thin serous membranes: the visceral pleura, which wraps around the lungs, and the parietal pleura, which lines the inner surface of…

Mechanical Ventilation

Introduction Mechanical ventilation (MV) is an important tool for resuscitation of critically ill patients in the emergency department (ED). It is vital that ED practitioners have a thorough understanding of the basics of MV and to know when to apply these principles and how to support patients in respiratory or cardiac failure. Hospital overcrowding has led to a delay in transfer of mechanically ventilated patients out…

Tracheostomy Care

Introduction Placement of a tracheostomy tube is a common procedure in critically ill patients. Common indications for this procedure include upper airway obstruction, head or neck trauma, and prolonged respiratory failure. Approximately one fourth of patients in the intensive care unit (ICU) will require a tracheostomy tube for prolonged respiratory support or weaning from mechanical ventilation. Advances in health care allow many patients with tracheostomies to…

Cricothyrotomy and Percutaneous Translaryngeal Ventilation

Few clinical scenarios are as critical as when a patient's airway cannot be controlled with traditional endotracheal (ET) intubation. Although cricothyrotomy is rarely required, the incidence of surgical airways has decreased even further since the advent of adjunctive intubation techniques. The conditions accompanying an airway emergency are often stressful and chaotic and require the emergency department (ED) physician to be intimately familiar with this procedure. When…

Pharmacologic Adjuncts to Intubation

Endotracheal (ET) intubation in the emergency setting presents a challenge distinct from that associated with intubation of fasted, premedicated patients in the operating room (OR). Patients in the emergency department (ED) are frequently uncooperative and unstable and may have medical problems or anatomic abnormalities that are completely unknown to the treating clinician. It is challenging that within a matter of minutes and with scant data the…

Tracheal Intubation

Intubation is often the pivotal procedure in the emergency management of critically ill patients. There are several new devices that can improve the likelihood of successful intubation, and it is important to put the intubation procedure in perspective, understanding that intubation is just one part of airway management. The primary objective of airway management is to maintain adequate ventilation and oxygenation, and intubation only allows ventilation…

Basic Airway Management and Decision Making

Basic airway procedures are often overlooked in favor of more exciting intubation devices and techniques, but basic procedures are critically important and often lifesaving. Establishment of a patent airway, oxygenation, and bag-mask ventilation (BMV) remain the cornerstones of good emergency airway management ( Videos 3.1 – 3.11 ). These techniques can be used quickly and in any setting. They allow practitioners to keep apneic patients alive…

Devices for Assessing Oxygenation and Ventilation

Spirometry For patients with acute exacerbations of asthma and chronic obstructive pulmonary disease (COPD), accurately estimating the severity of airflow obstruction is a critical component of their care. A focused history plus physical examination is the cornerstone of this assessment in the practice of emergency medicine. Wide variation exists in the ability to accurately diagnose airway obstruction, and a significant proportion of patients with marked airflow…

Vital Signs Measurement

Measuring the temperature, pulse, respiratory rate (RR), blood pressure, and pulse oximetry is generally recommended for all emergency department (ED) patients, in addition to assessment of pain in the appropriate patient population. For very minor problems or for some fast-track patients (e.g., suture removal), a full set of vital signs may not be required, and this is best decided on a case-by-case basis rather than by…

Transport of Patients with Highly Hazardous Communicable Diseases

Questions and Answers 1 Your crew arrives on scene to a call dispatched as a “sick person.” They find a 35-year-old male who recently returned from Saudi Arabia and is complaining of feeling unwell and has a cough. What measures can be taken by the crew to protect themselves and minimize exposure to others? Emergency responders should adopt an identify, isolate, and inform strategy to ensure…

Telemedicine and Emerging Telecommunications

Questions and Answers Case: You arrive on scene to a 55-year-old male with chest pain. While on scene, you take vitals, obtain a history, and perform a 12-lead electrocardiogram (EKG). The patient asks you how his EKG looks and after telling him that it looks ok, he does not want to go to the hospital. How might telemedicine influence your ability to treat and transport this…

Procedures in the Trauma Patient

Questions and Answers 1 What is one of the most important things to remember before performing any prehospital procedures? The most important thing to remember in any patient encounter is your safety and health. The patients that you encounter in the prehospital environment could possibly have any number of communicable diseases. This means that for every patient encounter, proper BSI (body substance isolation) is required. At…

EMS Point-of-Care Testing

Questions and Answers 1 What is “point-of-care” testing? Point-of-care testing (POCT) is medical diagnostic testing done in a setting remote from a centralized laboratory facility. These tests are generally simple and can be performed at the bedside. This is in contrast to centralized laboratory facilities that perform a variety of testing in one location that does not perform patient care. 2 Which POCT has been performed…

Perimortem Caesarian Section

Questions and Answers 1 What is a perimortem caesarian section (PMCS)? PMCS is the delivery of a baby by means of a surgical incision into the uterus, in the event the mother is in cardiac arrest. The steps to perform a perimortem C-section are essentially the same as those done in a normal caesarian section. The main difference between PMCS and a normal caesarean section is…

Hemorrhage Control

Questions and Answers Case: You are dispatched to a call for “hemorrhage”; you arrive to find a woman who is pale and diaphoretic and looks to be in distress with a large pulsatile bleed from a left arm fistula site. 1 How is massive or life-threatening hemorrhage defined? There is not a universally accepted definition of massive hemorrhage. It is bleeding that is rapid, large volume,…

Field Amputation

Questions and Answers 1 Who can perform a field amputation? Field amputation is a rare procedure; therefore, preplanning is necessary. EMS providers in some areas may be faced with the prospect of having to perform a field amputation. It would be desirable to be in contact with medical control to discuss the procedure before proceeding. Having multiple trained providers will also facilitate a smooth procedure. Additional…

CPR, AED, and Mechanical Compression

Questions and Answers CPR and Manual Compressions 1 What is meant by cardiopulmonary resuscitation (CPR)? CPR is a lifesaving intervention performed when an individual’s heart stops beating in order to maintain blood flow and promote oxygen delivery to one’s vital organs. To most, “CPR” refers to basic life support (BLS), consisting of chest compressions and rescue breathing. To other healthcare providers, it can also encompass advanced…

Care of the Agitated/Suicidal Patient

Questions and Answers Case: A 911 call comes in for a suicidal patient. The basic life support (BLS) unit is dispatched. They arrive at a residence where police are already on the scene. You learn that the mother called for assistance when she arrived home from work 30 minutes ago to find her 18-year-old daughter locked in the bathroom after discovering a suicide note on the…