Difference between revisions of "Category:Radio Medical Traffic (RMT)"

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|style="width:25%"|[[RMT Process]]
 
|style="width:25%"|[[RMT Process]]
 
|style="width:25%"|[[RMT Pearls]]
 
|style="width:25%"|[[RMT Pearls]]
|style="width:25%"|[[Regular (Outpatient) RMT]]
+
|style="width:25%"|
|style="width:25%"|[[Urgent RMT]]
+
[[media:SRC_Formulary.pdf|Subregional Clinics Formulary 2019]]
 +
<br/>&[[media:Village_Formulary.pdf|YKHC Village Clinics Formulary]]
 +
|style="width:25%"|[[Death in Village]]
 
|-style=text-align:center;height:50px;"
 
|-style=text-align:center;height:50px;"
 +
|
 +
[[Regular (Outpatient) RMT]]
 +
<br/>&[[Urgent RMT]]
 +
|[[OB RMT]]
 
|[[Emergency RMT Scenarios and Responses|Emergency RMT]]
 
|[[Emergency RMT Scenarios and Responses|Emergency RMT]]
 
|[[Emergency Medications Available in the Village]]
 
|[[Emergency Medications Available in the Village]]
|[[OB RMT]]
 
|[[Death in Village]]
 
 
|}
 
|}
  
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For more details about the process of RMT, urgent RMT, emergency RMT, and different scenarios, click on the Radio Medical Traffic Link at the top of this section.
 
For more details about the process of RMT, urgent RMT, emergency RMT, and different scenarios, click on the Radio Medical Traffic Link at the top of this section.
 
==Emergency RMT==
 
 
===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 [[media:Pediatric critical care guide.pdf|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.
 
 
''Resuscitation''
 
* Adult Dose=1mg IM
 
* Pediatric Dose 0.01 mg/kg IM = 0.01 ml/kg (using1mg/ml concentration epinephrine)
 
''Anaphylaxis''
 
* 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)
 
''Croup''
 
* 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
 
'''Dosing Chart'''
 
{| class="wikitable"
 
|-
 
! 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:
 
{| class="wikitable"
 
|-
 
! Weight (lbs) !! 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
 
 
==== Dexamethasone 10mg/ml ====
 
* 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
 
{| class="wikitable"
 
|-
 
| 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]]==
 
 
==OB Scenarios==
 
===Bleeding===
 
[[OB Triage Patients#Preterm and term vaginal bleeding evaluation|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.
 
 
===Labor===
 
[[media:Village OB Patient in Possible Labor.pdf|Village OB Patient in Possible Labor]]
 
 
===Abortion/Threatened Abortion===
 
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.
 
===Delivery===
 
[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.
 
==Death ==
 
===Expected===
 
[[Death in Village|Link to Death in Village]]
 
 
===Unexpected===
 
[[Death in Village|Link to Death in Village]]
 
 
==Links==
 
[[media:Village Formulary.pdf|Village Formulary]]
 
 
Link opens PDF file
 
 
[[media:SRC Formulary.pdf|SRC Formulary]]
 
 
Link opens PDF file
 

Revision as of 22:16, 16 June 2019

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).

RMT Process RMT Pearls

Subregional Clinics Formulary 2019
&YKHC Village Clinics Formulary

Death in Village

Regular (Outpatient) RMT
&Urgent RMT

OB RMT Emergency RMT Emergency Medications Available in the Village

Outpatient RMT Introduction

In the villages, patients are taken care of mostly by Health Aides (HAs) who consult with their assigned outpatient providers when patient care falls outside of their standing orders or expertise. These communications are called RMT’s (Radio Medical Traffic).

RMT’s are sent in by Health Aides through PowerChart/FirstNet where they come into message centers under the Proxies Tab as panels (i.e., Chronic Peds, Emergency, Kusko or Yukon). These proxies are set up for providers by IT, usually as part of the initial onboarding process.

At any given time there are assigned providers (some internal at YKHC and some remote providers) for each panel who will review the cases submitted and either discuss the care plan with the Health Aide via telephone, or send back the form with assessment/instructions. They will read the encounter, review orders from the appropriate power plan, modify the orders as needed, submit an addendum to the encounter with their plan, and send it back to the Health Aides.

Emergency cases who need Medevac or immediate attention to Bethel, are called in to the on-call Ward Docs in North Wing and sent to the Emergency Proxy panel.

When Telemed (media files) are reviewed as part of the RMT, providers should add a charge by selecting the order "Telemed Consult Level 1" and insert "..rmtmediareview" autotext (sampled below).

"Appreciate the photos of the _ that were sent to the Bethel provider so that the Health aide could get some help with the diagnosis and treatment plan.
Diagnosis: _
Plan: _
Please give immunizations that are due."

For more details about the process of RMT, urgent RMT, emergency RMT, and different scenarios, click on the Radio Medical Traffic Link at the top of this section.

Pages in category "Radio Medical Traffic (RMT)"

The following 6 pages are in this category, out of 6 total.