Category:Radio Medical Traffic (RMT)
- 1 Overview
- 2 RMT Process
- 3 RMT Pearls
- 4 Regular/Outpatient RMT
- 5 Urgent RMT
- 6 Emergency RMT
- 6.1 Emergency Medications Available in the Village
- 6.1.1 Epinephrine 1mg/ml Ampule
- 6.1.2 Ceftriaxone 1gm vials
- 6.1.3 Midazolam (Versed) 10mg/2ml
- 6.1.4 Diazepam (Valium) 10mg/2ml
- 6.1.5 Phenobarbital 130mg/ml (1 ampule)
- 6.1.6 Instaglucose 24 grams in a tube
- 6.1.7 Glucagon 1mg/ml (one ampule)
- 6.1.8 Morphine 10mg/ml (one ampule)
- 6.1.9 Naloxone 1mg/ml injectable solution
- 6.1.10 Dexamethasone 10mg/ml
- 6.1.11 Prednisone 10mg tablets
- 6.1.12 Albuterol 2.5 mg/3mL
- 6.1.13 Duo-nebs (ipratropium 0.5 mg and albuterol 3mg per 3 mL)
- 6.1.14 Racemic Epinephrine 2.25%
- 6.1 Emergency Medications Available in the Village
- 7 Emergency RMT Scenarios and Responses
- 7.1 Adrenal Crisis-Congenital Adrenal Hyperplasia (CAH)
- 7.2 Anaphylaxis
- 7.3 Angina/MI
- 7.4 Code-Resuscitation
- 7.5 Death In the Village
- 7.6 Drowning
- 7.7 Fever in Infants less than 90 days – Unstable
- 7.8 Hypoglycemia
- 7.9 Hypothermia
- 7.10 Respiratory distress
- 7.11 Seizures
- 7.12 Sepsis
- 7.13 Stroke (CVA)
- 7.14 SVT/Arrhythmia
- 7.15 Syncope (or near-Syncope)
- 7.16 Trauma
- 8 OB Scenarios
- 9 Death
- 10 Links
Radio medical traffic (RMT) is the most difficult clinical challenge that providers face in their jobs at YKHC. There are 50 villages/Subregional Clinics (SRCs) in the region staffed with Community Health Aides (CHAs) of varying degrees of training, limited formularies and supplies and weather and other challenges that make getting concerning patients into Bethel difficult. The SRC’s will often, but not always, have a NP/PA provider available to help assess and manage patients, and the SRC formulary and supplies are more expanded but still very limited. Often patients will have to be managed for long periods of time creatively in the village with the CHA’s and midlevels while awaiting an opportunity to get a patient in if the weather is down, there are no runway lights, the medevac team is tied up or timed out ....
Routine RMT evaluation, follow up, treatment, referrals, etc., is a challenge with this kind of distance delivery. It is a high risk interaction. You are managing the patient secondhand and depending on vitals, CHA exams and history. You will often be overwhelmed with the sheer volume of RMT and other clinical demands on your time. Be sure to not rush too much. Pay attention and address any ‘red flags’ in the patient history and exam. Take the time to look at the problem and medication lists when indicated (i.e., a patient with a chronic condition that requires daily meds but isn’t taking them or needs a f/u in Bethel; a patient with recurrent OM that was treated less than a month ago with Amoxicillin and therefore needs to now have Augmentin, etc.).
Villages are small communities. Often the patient that a CHA is caring for is a relative, friend or well known to them. This can place them in a difficult position socially and professionally. It adds a tremendous amount of stress to their job. It may be difficult for a CHA to make an OCS report (child protective services), resuscitate a loved one, and remain objective in evaluating some patients. RMT providers must remain sensitive to this challenge and assist the CHAs in any way possible.
Orientation for RMT will extend through your entire tenure at YKHC because there are so many different scenarios and new challenges that arise even daily. Work with others to figure out how best to manage RMT patients and don’t hesitate to ask for help repeatedly until you get more comfortable with different scenarios. It is better to ask and learn (remembering there is often more than one way to handle a particular situation).
In the villages, patients are taken care of by Health Aides/Practitioners (CHAs), who consult with their assigned outpatient providers when patient care falls outside of their standing orders. They complete a preformatted Health Aide Encounter document through Raven that the panel provider will review and then either discuss the care plan with the CHA via telephone or send back the RAVEN RMT with a modification attached.
Every afternoon 2-4 providers from clinic will review through Message Center approximately 200 RMTs (radio medical traffic) a day for the 50 villages through the Yukon and Kusko Proxy boxes. Chronic Peds patients are sent to the Chronic Peds proxy box. Eye and Dental RMTS are sent to the respective Eye Doc and Dental proxy boxes.
At this time we have several long distance providers who are also doing RMT – Helen Hancken PAC in Kenai, Lois Rockcastle FNP in Eagle River, Anne Marie Narog in Kodiak and Bud Vermeire, Sze Pang.
Routine RMT: For routine village encounters that fall outside a CHA’s standing orders, the health aide will complete a RAVEN encounter form and send it to Delta, Yukon RMT or CPP box. An assigned medical provider will then review the encounter and send back their assessment and plan.
Emergency RMT: For urgent and emergency village patient encounters, i.e. sick or critical patients who need immediate treatment or to be sent in quickly via a commercial or medevac flight, the CHA should complete an Health Aide Encounter RAVEN form (if time allows), send it to the "Emergency, RMT" or "Chronic Peds, RMT" proxy box and have the ward doctor paged for an urgent or emergency consult.
Occasionally the ER physician will take urgent or Emergency RMT calls if the ward doctor is too busy to answer the call or requests assistance.
All RMT providers need to review documentation paying close attention to the vitals and “Note to RMT” section. It is important to also look at "other history" as important clinical history can often be found there as well. The RMT provider will either discuss the care plan with the Health Aide via telephone and/or send back the modified RMT with the plan of care.
How to do RMT on RAVEN
- Go to Message Center (RPG Page 16)
- Go to Proxies tab on upper left– hit arrow – Select the appropriate RMT box: Yukon/Kusko/Emergency/CPP/Optometry/Dental
- Select 1st document in the list appearing on the Right side and open it.
- Read RMT- then to review orders
- Locate patient’s name in right upper corner and select the downward arrow to open the patient’s chart within orders
- Scroll on the Order’s View box (lite blue box on the left side) to see the village clinic powerplans located at the top.
- Review the Village Powerplan selected in the right window.
- If no orders added, just close the chart.
- If you check additional order boxes, sign (NOT INITIATE)
- For orders not on the powerplans, choose ADD to PHASE. Then hit sign (NOT INITIATE)
- Close the patient’s chart; MESSAGE CENTER should automatically become visible with the RMT document you were working on.
- Now to Modify and add addendum – right click within the body of the RMT document and choose modify.
- The area for you to add the addendum will appear at the bottom of the RMT document.
- Type in your comments.
- Now at bottom of RMT document Hit Additional Forward Action box –
- In the To: field - Select the Health aide who sent the RMT document to you (delete previous RMT health aide’s name).
- Then Click "OK and Close" – (DO NOT HIT NEXT)
- If a patient needs a medication to be sent from Bethel pharmacy – Order it from the blue Plus from the left side of the screen and select "mail to" when ordering it. New meds can be written on either form.
Heading links to page
- See guideline Fever – Infants 0-90 days.
- FUO→children < 5 should be sent to SRC or Bethel for UA
- Viral URI→supportive care w/ reevaluation in ~ 2 days or sooner if any concerns
- Stomatitis→tx options are magic mouth wash, aggressive hydration with a sippy cup or syringe, cold fluids, Tylenol, Motrin and frequent reassessment for dehydration→to Bethel or SRC if significant concerns. Usually worsens over 3 days and then gradually improves.
- Group A Strep pharyngitis—Children under 3 do not suffer the adverse sequelae of GAS so don’t test / treat
- Rapid strep may remain + for up to 1 month of tx** consider GAS eradication w/ Clindamycin or Augmentin for carriers w/ recurrent symptoms
- see ENT referral guidelines for recurrent GAS (Jane, I have these and will bring them next time for inclusion as a link)
- AOM→ See peds OM guideline.
- recheck ears in children only if not improving or worse
- see ENT guidelines for recurrent AOM / perforation for PE tubes and tympanoplasty are covered in the referral orders for these on RAVEN
- Sinusitis→see peds sinusitis guideline (usually requires Pediatric consult)
- For adults try to avoid antibiotics for at least 2.5 weeks. Use routine supportive measures; the villages have nasal saline, Sudafed, and Benadryl.
- Community Acquired Pneumonia→ Use routine clinical judgment in deciding to tx or not (i.e. fever, productive cough, pleuritic pain, duration of sxs) remembering that there is a large number of patients w/ bronchiectasis from recurrent respiratory infection→look at problem list and have a lower threshold of using antibiotics in someone w/ recurrent CAP.
- Adults—Doxycycline, Augmentin, and Ceftriaxone are all available in the village
- Peds—see peds guideline. If abnormal respiratory exam, see recommendations as above. REMEMBER, fever and dehydration can affect respiratory rate and O2 sat, so treat these before deciding on disposition
- Boils/cellulitis—see guidelines
- REMEMBER I&D is 1st line tx→many CHAs will perform I&Ds
- No running water in many villages so suprainfection is a common complication of many skin conditions (bug bites, scabies, eczema)→MRSA colonization is common so need to cover for MRSA
- Provide bleach bath education for recurrent MRSA / multiple boils (available in Patient Education Custom Templates)
- UTI→See guidelines in children.
- Adults request cx. Use best clinical judgment to decide on empiric antibiotic
- Pregnant and suspected pyelonephritis→to Bethel for evaluation
- Viral Gastro Enteritis→routine instructions. Close follow up for evaluation of dehydration
- Abdominal pain→if nothing about exam or vitals is concerning, try empiric GERD / constipation tx w/ careful warning signs and next day recheck vs commercial flight for evaluation if dx is unclear and clinical concern
- STD checks→CHAs have standing orders for labs and medications→tx if clinical concern warrants it; o/ wait for studies
- Lacerations→Some CHAs are comfortable placing sutures. Hair tying and steri strips are other options for wound closure
- Pregnancy Test→Start PNVs, calcium, and iron; have CHA schedule 1st Prenatal appt
- Medication Refills
If the health aide requests that a patient needs med refills please do the following.
- Review the documentation in the past few visits, problems, and the past labs that have been done.
- If the patient needs labs drawn- please select those from the Future Lab order folder- in the Regular Lab folder on your home page.
- If you feel comfortable giving the patient the refills -then go to the Medication tab- place the cursor on the med you want to refill and right click. You will get a variety of options. You can select one month with 1- refills or 1 month with no refills if they need labs done
- Sign orders.
- If they need a new med refilled- do not add it to the Village Powerplan. Go to the Blue plus sign on the left hand side of the of the orders screen and select it- then ideally pick the Med out of the Med order folders in your home page and complete the order in the usual fashion.
- WCCs-Review RMT closely to make sure all safety, developmental screening, anticipatory guidance, fluoride varnish and immunizations are updated. Also check growth curves for HC, weight and length and make sure CHAs know do this as well. Referral to dental, optometry and peds should be made as necessary.
- Pediatric Dental Pre-op Travel Clearance RMTs must be forwarded to CPP RMT
OB in possible labor
Refer immediately to inpatient emergency RMT provider
Other than the 3 recognized truly Orthopedic Emergencies
- compartment syndrome
- compound fracture
- knee dislocation
that should likely require both a call to ANMC Ortho + medevac activation, you can likely send an ortho patient to Bethel ER with splint-sling-ice-elevation-pain control-crutches as indicated once you establish an intact neuro-vascular exam. For some cases, like a hip fracture for example, the patient may go directly to ANMC. You might be able to save one leg of a medevac (instead of a ramp-to-ramp transfer) and send the patient directly to ANMC. To do this, get an accepting doc at ANMC and then you can have LifeMed activate the Anchorage team instead of the Bethel team.
Sick patients that probably need to come in
These patients either have a compelling initial presentation or they have worsened in village follow-up. If vitals and exam are reassuring and spO2 is not <90%, they can probably come to Bethel ER or clinic on the next commercial flight or boat-ice road vehicle. If transport is unlikely or the clinical situation does not allow it, the next decision that needs to be made in conjunction with the CHA’s comfort level and resources available as well as weather conditions, is whether a medevac or more local treatment is indicated. Sometimes weather forces decision-making.
These patients can usually go in to Bethel ER commercially, sometimes requiring an escort after the pain is treated neither with IM morphine or PO TC3 or Tylenol-Motrin.
Fever in Infants less than 90 days
Infants under 3 months of age with a fever of 100.4° or greater must be evaluated in Bethel for a sepsis and/or meningitis work up and treatment if indicated. Infants with fevers 100.4° or greater with a normal exam, who are clinically stable, need to be evaluated within 12 hours in Bethel. These patients can come in by commercial flight, if there is one available in less than 8-10 hours. If it is after hours the patient can be monitored closely by the family at home and be rechecked by a CHA in the morning (or sooner if worse) to make sure the patient is still stable for commercial flight in. It is best not to pretreat these infants with Ceftriaxone unless there are weather delays or the patient is getting worse. Please consult the pediatrician on call if there is any question about what to do in these challenging RMT cases.
If the patient gets worse in the village…see emergency RMT section
Need more examples of sick patients that need to come in here…
Emergency Medications Available in the Village
NOTE: Health Aides can NOT give any medications via IV route, even if ordered by a physician.
Remember to use the Pediatric Critical Care Guide for weight-based dosing if available
Epinephrine 1mg/ml Ampule
NOTE: In the absence of standard IV/IO route of administration, epinephrine may be given IM if it does not compromise CPR. Efficacy is unknown for this route in humans.
- Adult Dose=1mg IM
- Pediatric Dose 0.01 mg/kg IM = 0.01 ml/kg (using1mg/ml concentration epinephrine)
- Adults and peds > 30kg = 0.3mg IM anterolateral thigh (0.3ml)
- Pediatric <30kg = 0.01mg/kg IM anterolateral thigh (0.01ml/kg using 1mg/ml concentration epinephrine) (Max 0.3mg=0.3ml)
- If no racemic epinephrine available, mix 1 ampule of epinephrine 1 mg/ml with 3 mL NS bullet and then nebulize.
Ceftriaxone 1gm vials
- Adult Dose=2 grams IM
- Pediatric Dose = 100mg/kg IM (max dose= 2grams)
Midazolam (Versed) 10mg/2ml
NOTE: If dosing intranasal, divide dose equally between both nares
- Adults 0.2mg/kg IM or IN
- Pediatric 0.2 mg/kg IM or IN
|Weight Range in pounds||Intranasal midazolam dose|
|less than 17 lbs||Ask provider for dose|
|17-20 lbs||2 mg = 0.4 mL =0.2 mL/naris|
|21-24 lbs||2.5 mg = 0.5 mL = 0.3 mL ro one naris and 0.2 mL to other naris|
|25-31 lbs||3 mg = 0.6 mL = 0.3 mL/naris|
|32-40 lbs||4 mg = 0.8 mL = 0.4 mL/naris|
|41-51 lbs||4.5 mg = 0.9 mL = 0.5 mL to one naris and 0.4 mL to other naris|
|52-64 lbs||5.5 mg = 1.1 mL = 0.6 mL to one naris and 0.5 mL to other naris|
|>65 lbs||6.5 mg = 1.3 mL = 0.7 mL to one naris and 0.6 mL to other naris|
Diazepam (Valium) 10mg/2ml
- Adult Dose=10mg rectally or IM. (total max dose = 20 mg)
- May repeat once in 10-15 minutes
- Pediatric Dose=0.5mg/kg rectally or IM. (total max dose = 20 mg)
- May repeat q 5-10 minutes prn
Phenobarbital 130mg/ml (1 ampule)
- Adult Dose=10-20 mg/kg IM q 20 min prn
- Pediatric Dose=20mg/kg IM
- May give another 5-10mg/kg q 15-30 min prn up to a total dose of 40mg/kg
- Pay close attention to respiratory rate if repeating phenobarb doses
Instaglucose 24 grams in a tube
NOTE: Use care in administering to an unconscious patient to prevent aspiration. Use small amounts in the buccal area bilaterally or smear on gums and cheeks. Glucose is not rectally absorbed.
- Adult Dose: 15-20 gm
- Pediatric Dose:
|Less than 11 lbs||1 ml|
|11-20 lbs||4 ml|
|21-30 lbs||8 ml|
|31-40 lbs||12 ml|
|> 41 lbs||20 ml|
Glucagon 1mg/ml (one ampule)
Note: Glucagon is only effective if hypoglycemia is due to hyperinsulinism-either because of insulin administration or endogenous insulin production. It is not rectally absorbed
- Adults and Peds > 20kg Dose=1mg SC/IM. May repeat q15 minutes
- Pediatric Dose= 0.5mg SC/IM. May repeat q15 minutes
Morphine 10mg/ml (one ampule)
- Adult Dose=10-30mg PO, 2 to 10 mg IM
- Pediatric Dose=0.05-0.2mg/kg IM (max dose=10 mg)
Naloxone 1mg/ml injectable solution
- Adult Dose=0.4-2mg IM/SQ or 2-4mg intranasal-may repeat q2-3 minutes
- Pediatric Dose=0.1mg/kg IM/SQ (Max dose=2 mg IM or 2-4mg intranasal) May repeat q2-3 minutes
- Adult Dose=depends on condition IM
- Pediatric Dose
- Croup/Stridor 0.6 mg/kg IM or PO. (Max 10mg)
- Congenital Adrenal Hyperplasia 0.7 mg/kg/dose IM (1.5-2 mg/m2/dose)
Home supply of emergency Solu Cortef should be given preferentially according to directions OR use the following table
|Solu Cortef Act-O-Vial||100mg/2ml IM dose|
|Under 4yo||25mg = 0.5ml|
|4-12 yo||50mg = 1ml|
|Over 12yo||100mg = 2ml (whole vial)|
May repeat in 12-24 hrs (give sooner if sicker) if not able to get to a higher level of care
Prednisone 10mg tablets
- Adult Dose=40-60mg PO
- Pediatric Dose=2mg/kg PO (tablets crushed and mixed with palatable substance)
Albuterol 2.5 mg/3mL
- Adult Dose=1 unit dose
- Pediatric Dose=1 unit dose
Duo-nebs (ipratropium 0.5 mg and albuterol 3mg per 3 mL)
- Adult Dose=1 unit dose
- Pediatric Dose=1 unit dose
Racemic Epinephrine 2.25%
- Adult Dose=1 unit dose in nebulizer (0.5ml) diluted with 3 mls NS bullet
- Pediatric Dose= Give nebulized racemic epinephrine:
<10 kg: 0.25 mL mixed with 3 mL NS
>10 kg: 0.5 mL mixed with 3 mL NS
Note: Monitor pulse during and after administration.
If no racemic epinephrine available, mix 1 ampule of epinephrine 1 mg/ml with 3 mL NS bullet and then nebulize.
Emergency RMT Scenarios and Responses
Adrenal Crisis-Congenital Adrenal Hyperplasia (CAH)
Acute adrenal crisis presents as vomiting, diarrhea, dehydration, hypotension and shock. Crisis can be precipitated by illness, trauma and hyperthermia. If you get a call on a pediatric patient with CAH who is in crisis, find out if the caretakers have a dose of IM Solucortef for emergencies and give this ASAP. Make arrangements for medevac.If the patient has no emergency solucortef available, you can give dexamethasone from the village formulary
For patients who present with wheezing/stridor, hives, lip or facial swelling, abnormal vitals, abdominal pain, vomiting, diarrhea
Give epinephrine without delay!
- Adults and peds greater than 25kg give 0.3 mg IM
- Peds less than 25 kg give 0.15 mg IM
- See emergency meds section (link to this section)
Repeat Epinephrine q 5-15 minutes as needed ABCs and Nasal Cannula O2
Lay patient down with feet up
- Adult =50mg po
- Peds=1.25 mg/kg po (12.5mg/5mls)
- Adult= 60 mg prednisone
- Peds=2mg/kg prednisone crushed tabs OR Dexamethasone IV solution 0.6 mg/kg IM or po
Establish an IV
Give IV fluid boluses (20mg/kg for peds and 1L for adults) as fast as possible.
Albuterol nebs as needed.
Most clinics have AFHCAN TeleHEALTH 12-lead ECG capability available to help in the evaluation of ischemic chest pain symptoms. ECG confirmation of concerning symptoms in a middle-aged to elderly patient with cardiac risk factors might warrant medevacking such a patient to the Bethel ER for further evaluation including risk assessment for possible thrombolytics within the 12 hour treatment window. Morphine, Oxygen, Nitroglycerin and Aspirin (MONA) are all available in the village clinic if needed. If chest pain does not appear ischemic, a patient is often commercially transported to the ER in Bethel for further more likely atypical chest pain.
There are times when you will get a call from a CHA who is doing CPR on a patient in the home or in the clinic.
- Have the CHA call for more help
- Get as much information as you can about what happened.
- Find out exactly what they are doing and who is there to help them.
- Do not activate a medevac for CPR in progress unless there is a spontaneous return to circulation OR it is a pediatric patient and, in consultation with the pediatrician on call, a decision is made to medevac the patient. CPR in the field without advanced life support is almost never successful. Most CHAs know this. Do the things listed below, keeping in mind that this is generally a futile process, but very necessary for the patient’s family and the CHA.
- Airway open
- Appropriate sized BVM with a good fit and seal
- Patient on O2 with tank O2
- AED placed (even peds)
- Determine if CPR is adequate (fast, effective and can palpate a pulse) and make sure CHA/s are reassessing for this regularly.
- Get glucose and HGB
- Place IV if possible
- Get the patient’s name and DOB, so you can look up the patient’s history.
- VTC Video monitoring if able
- Get the CHA contact number/s in case you get disconnected.
- Stay calm and as reassuring as you can.
- Reassess frequently-Confirm what has been done and let them know they are doing a good job
- Take good notes with times, medications given, interventions done and responses
- Prepare the CHA’s, family and helpers (keep in mind that you are often on speaker phone) for next steps depending on how resuscitation is going.
- If a patient responds to resuscitation , a medevac needs to be activated.
- If the patient is not in the clinic, they should be taken to clinic if safe transportation is possible.
- If resuscitation appears futile (ie effective CPR for > 20 minutes) you will need to go over everything that has been done and make sure there is nothing else that you and the CHAs thinks can be done.
- Prepare the CHAs and family for calling the code.
- It may be necessary to continue CPR longer than you would normally to give the family time to gather and adjust.
- Have the lead CHA step away and talk to you privately for a moment to help them prepare for stopping CPR.
- Epinephrine 1:1000 (1 ampule vials).
- NS Fluid resuscitation
If a code is called you will need to follow the protocol for a Village Death * Link here.
- Fax Village death form to Medical Examiner office (if this was an expected death (ie. Palliative care, comfort measures), this form may have already been faxed)
- Call medical examiner’s office
- Notifly Life Alaska (number is on bulletin board on northwing)
- Call state Trooper
- Write free text note documenting events, time of death, etc. And send to Ellen Hodges and Rebecca Tunuchak.
Death In the Village
CPR should be continued as safe and able in the field or village clinic. In the latter environment, re-warming with blankets and heated IV bags for likely additional hypothermia will help the resuscitation effort. Generally, without a confirmed pulse, a medevac should not be activated with the possible exception of drowning involving hypothermia in a nearby village.
Fever in Infants less than 90 days – Unstable
Infants with fevers 100.4° or greater are at risk for sepsis and meningitis. Any infant with fever who appears ill, i.e. is irritable, lethargic, tachycardic, tachypneic, vomiting or has a rash needs to be medevaced to Bethel ASAP. IM ceftriaxone at 100mg/kg should be given in the village while awaiting a medevac. A blood culture should be obtained prior to Ceftriaxone if the patient is in a SRC. Have the blood culture sent in with the patient. Please consult peds on call for any questions or assistance in managing these patients.
Any seizing patient should get a glucose accucheck as soon as possible to evaluate for hypoglycemia as this is a correctable cause of seizures. Additionally, patients with a history of diabetes or patients with symptoms of AMS or acute illness including sepsis might also be tested as appropriate for low blood sugar. Instaglucose, administered via the mucous membranes, is available in the village clinic to treat this. Also be aware that carnitine palmitoyltransferase (CPT) 1 deficiency is relatively common in our population and during periods of fasting or during an illness can present as hypoglycemia.
See drowning above Correct hypothermia any way possible. If the patient fully recovers in the village clinic, transport to Bethel may not be necessary.
While assuring that the patient has sufficient supplemental O2 available in the clinic, inquire if he/she normally has Home O2, is an Expected Home Death or Palliation patient to better meet both the needs and planned desires of this patient. Once full treatment of the patient is established, at least one trial of a nebulized bronchodilator with clinical progression of treatment as is indicated. Consider PO prednisone 40-60 mg x1 for broncho-constricted adult patients. Also consider medevac if after a trial of treatment, spO2 remains <90% or moderate to severe respiratory distress persists.
- Give Two back-to-back albuterol nebs
- O2 administered –preferably with NC, but blow by ok to start with
- If patient is febrile, give Tylenol and/or Motrin
- Find out who else is helping the CHAs, where the patient is and patient’s name and DOB
- Make sure the CHA calls for at least two more people to help.
- Move patient to clinic if they are at home or another site
- Make sure bag and good fitting mask is available
- Get patient information to look up past history medications etc
- Frequent reassessment and keep good documentation of times and interventions
- If patient improves with these interventions then reassess O2 requirement, RR and WOB.
- Consider close monitoring and possibly regular flight to Bethel
- Activate medevac if not improving
- VTC video monitoring if able
- Increase nasal cannula O2 to 3-5 L as needed
- Frequent nebs or continuous Albuterol if required
- Try Atrovent nebs or racemic or nebulized epinephrine (IV solution)
- Call peds or a pediatric partner for help
- Consider prednisone 2mg/kg of crushed tablet in liquid/pudding or syrup.
Stridor at Rest
Remember Supportive Measures
- Keep child upright
- May take child outside for cool air
- Minimize invasive measures – keep child CALM!
- Do NOT give albuterol; this can worsen croup
- May give NS neb
Activate a medevac immediately if patient develops signs or symptoms of severe croup or impending airway obstruction: drooling, lethargy, tripod position, marked retractions, tachycardia, cyanosis or pallor
- Start nebulized racemic epinephrine neb
- Give Dexamethasone by least invasive method possible
- Follow stridor guidelines for ongoing management
- Stay as calm and reassuring as you can
- Get the CHA contact number/s in case you get disconnected.
- Determine if the patient is still seizing and whether the patient is in the clinic or at another site
- Get the patient’s name/DOB and last weight (for peds).
- Find out who else is helping the CHA and where the patient is
- CHA must call for more help
- Move patient to clinic if they are at home or another site AND bring all patient’s meds to the clinic
- Follow your CAB/ABCs and make sure
- They have on O2
- A bag and good fitting mask is available and
- The CHAs are ready to do CPR if needed.
- VTC Video monitoring if able
- If the patient is a known seizure patient find out if the patient has any rectal Diastat available to give. If they don’t it is good to have an Rx sent to the village by pharmacy in case of future episodes.
- Place IV if possible and give NS bolus
- Get an accucheck glucose as soon as possible (low glucose is a reversible cause of seizures)
For low blood glucose you can smear Instaglucose on mucous membranes or give glucacon SC/IM/IV If Instaglucose or glucacon are not available you use a slurry of sugar water to coat oropharynx or give per NG (may use IV tubing as makeshift NG). The rectum does not absorb glucose well, but can be used if no other options available.
- Confirm what has been done and let health aides know they are doing a good job
- If seizure does not resolve or is prolonged, get help for yourself and get a medevac activated ASAP
- Before giving or stopping anti-seizure medications, determine if the patient is still seizing. This can be very subtle at times and VTC is helpful. The CHA may no longer see tonic-clonic movements, but the patient may still be stiff, have fine tremors or eye deviation, poor O2 sats etc.
- Have a health aide get Diazepam and Phenobarbital out of the village clinic lock box and ready for administering.
- If a patient has seized for more than 5-10 minutes, be prepared to start with either the patient’s rectal diastat prescription or village diazepam IM or rectal. The longer a patient seizes the harder it is to break the seizure.
- Before giving diazepam, make sure the CHA has obtained a good fitting bag and mask and is ready to provide assisted ventilation with bag-mask-valve device to support the patient if the patient becomes apneic. Diazepam can be repeated as often as every 10-15 minutes…waiting a little longer is often better as you must weigh the risk of apnea in the village against prolonged seizure activity.
- Your inpatient pharmacist is available in house or on call for assistance if needed.
- Take notes with times, medications given, interventions done and responses
- Reassess frequently.
- Get VTC set up for video monitoring if possible
- The second line medication will be phenobarbital IV or IM. For adults, the dose of IM phenobarb may exhaust the entire village supply.
If likely signs and symptoms of acute sepsis are present, IV fluids and available antibiotics should be initiated while activating an urgent medevac for transport to the ER in Bethel.
See YKHC Clinical Guidelines and Inpatient/Common Adult Admissions/Cerebrovascular Accident (CVA) (do we have guidelines for suspected stroke in the village? These would be really helpful because this comes up a lot) Consider an urgent medevac if a patient with acute stroke symptoms presents to a village clinic where there might be enough time from onset of symptoms to completion of a Head CT in the ER in Bethel to be within the 4.5 (or 3) hour limit to consider thrombolytics following evaluation with risk assessment. Otherwise commercial transport with an escort to the ER might be a more appropriate option in an otherwise stable patient with neurologic deficiency consistent with an acute or subacute process. While awaiting transport in the village clinic, supplemental O2 and IV fluids may be appropriate but not aspirin until a hemorrhagic process in the brain can be ruled out in the ER.
A pulse rate of >150/minute is usually consistent with this diagnosis but an AFHCAN TeleHEALTH 12-lead ECG is helpful for confirmation. In the village clinic,
- carotid artery massage
- Valsalva maneuver
- dive reflex (face in basin of ice water)
can all be attempted while evaluating the patient with CHA. If the above converts the arrhythmia, commercial transport to the Bethel ER is appropriate for further evaluation. If symptoms persist, activating a medevac is appropriate to bring this patient to the ER in Bethel, likely already chemically cardioverted by the medevac crew with adenosine.
Syncope (or near-Syncope)
Generally, this history is concerning and the patient is best sent to the ER in Bethel or an evaluation. In the clinic POC blood sugar and Hgb as well as an AFHCAN TeleHEALTH 12-lead ECG might all be helpful in this evaluation.
Follow ATLS with attention to ABCs as well as c-collar and back-boarding while transporting as indicated by history or severity of trauma. The “golden hour” should be considered and activating a village medevac from Anchorage (or ramp transfer in Bethel to Anchorage) with ANMC Surgery consultation may be the best plan for an acute and compelling major trauma. LifeMED can coordinate this type of medevac. Consultation with another YK physician, especially the ER attending can be helpful in decision-making.
Preterm and term vaginal bleeding evaluation Assess amount of hemorrhage by “pad” count and POC Hgb and transport commercial to Bethel OB Triage (if EGA > 20 weeks, otherwise to the ER) if vital signs stable and hemorrhaging allows. Consider IV fluids as needed.
If a POC HGB and vital signs are stable this patient may go to the ER in Bethel on the next available flight. She should be warned that she may in be in Bethel for at least 2-3 days as part of the evaluation. There is also a risk she may bleed to death if she remains in the village.
[Link to OB-Newborn/OB Special Circumstances/Labor in the Village]] If a (non-preterm) delivery is imminent in the village, encouraging the CHA to marshal resources in the clinic area for delivery is important including finding the most experienced (even former) CHA or traditional mid-wife. If the term laboring mother is unstable (or didn’t sign a BIB agreement) then activating a medevac to bring the patient to Bethel OB Triage is appropriate.
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