Global MedOps Command

The lips are swollen. The wheeze is loud. The family already used the patient's auto-injector.

Anaphylaxis is a recognition problem first. IM epinephrine is the intervention. Auto-injector sits at EMR and EMT. IM epinephrine by syringe sits at AEMT and Paramedic when protocol allows. Endotracheal intubation is Paramedic-only if the airway is lost.

The missed call is treating hives as a dermatology complaint while the blood pressure is still holding.

That being said, the sequence is learnable. Epi. Airway. Then antihistamine and fluids at the level that owns them. Simulation builds that pause before a talking allergic reaction becomes an obstructed airway.

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The family says stroke. The speech is slurred. The glucose is 38.

Hypoglycemia masquerades as a CVA until someone checks the number. EMTs acquire the glucose and the 12-lead. Oral glucose sits at EMT. IV dextrose is AEMT and Paramedic when protocol allows. The missed call is loading a talking, confused patient toward a stroke center before the sugar is known.

That being said, the sequence is learnable. Glucose. Mental status. Then destination. Simulation builds that pause before a metabolic problem is treated as a large-vessel occlusion.

emsmedsim.globalmedopscommand.com

The fall was from standing height. The patient is talking. The family wants a ride to the closest hospital.

A ground-level fall in an older adult is a head-injury problem until you prove it is not. Anticoagulants. New confusion. A headache that started after the hit. GCS that looks fine because the patient is still answering questions.

EMTs own spinal motion restriction, oxygen, and 12-lead acquisition. Paramedics interpret the tracing and decide whether this is a medical masquerader riding under a trauma complaint. The missed call is treating conversation as clearance.

That being said, the sequence is learnable. Mechanism. Meds. Mental status. Then destination. Simulation builds that pause before a talking fall becomes a delayed intracranial bleed.

emsmedsim.globalmedopscommand.com

The respirations are 6. Pinpoint pupils. The first dose of naloxone does nothing.

Do not treat that as a failed opioid call.

Mixed toxidromes are common. Stimulant plus opioid. Sedative plus opioid. The pupils can lie. Naloxone that does not restore ventilation is information, not a reason to stop supporting the airway.

EMTs and EMRs can give unit-dosed naloxone and bag. AEMTs may give IM or IN naloxone and start IV or IO when protocol allows. Repeat dosing sits with AEMT and Paramedic per protocol. Endotracheal intubation is Paramedic-only.

That being said, the sequence is learnable. Airway. Naloxone. Recheck the toxidrome. Simulation builds that pause before a non-opioid overdose is treated as a naloxone problem.

emsmedsim.globalmedopscommand.com

The toddler is retracting. Sat 88 on a non-rebreather. The parent wants you to look in the throat.

Do not look in the throat.

Pediatric respiratory distress on the street starts with positioning, high-flow oxygen, and a seal that actually works. Endotracheal intubation is Paramedic-only. EMTs do not intubate. AEMTs may place a supraglottic airway when protocol allows. The child who later needs a tube still needs a BVM that works while that decision is made.

This is a recognition problem for every provider on the truck. Drooling, stridor, and worsening work of breathing are reasons to stop stimulating the airway, not reasons to take a look.

That being said, the sequence is learnable. Position. Oxygen. Seal. Then escalate only to the level that owns the next skill. Simulation builds that stack before a pediatric airway becomes an unnecessary look.

emsmedsim.globalmedopscommand.com

The slab is still on the legs. The patient is talking. The 12-lead already looks ugly.

Crush is not only a trauma packaging problem. Prolonged compression dumps potassium. The field trap is treating a talking, trapped patient as stable until extrication, then discovering a wide QRS after the load comes off.

EMTs own hemorrhage control, oxygen, and 12-lead acquisition. 12-lead interpretation and hyperkalemia treatment sit at the Paramedic level. The missed call is waiting for hypotension before anyone asks whether this is a potassium problem.

That being said, the sequence is learnable. Scene. Compression time. 12-lead before release when you can get it. Then treat the tracing, not the conversation. Simulation builds that pause before a talking crush becomes a sudden arrest.

emsmedsim.globalmedopscommand.com

People still talk about Mississippi like the state never left 1960.

Then you remember:

NASA’s rocket-propulsion test center is at Stennis.

The world’s largest auto plant built from scratch is in Canton.

Dr. Arthur Guyton wrote Textbook of Medical Physiology at UMMC, still the standard around the world.

Dr. James Hardy performed the first heart transplant, first lung transplant, and first kidney autotransplant.

The blues, country, and rock ’n’ roll all have Mississippi birth certificates.

Per capita, we give more than almost any other state.

The ads have been saying it for years. The facts have been here longer.

Mississippi. You better believe it.

MISSISSIPPI… Believe It!
https://mississippibelieveit.com/campaign/

The 28-year-old was 34 weeks. Abdominal trauma from a low-speed MVC. She was talking. Blood pressure 108/70. Heart rate 118.

The crew documented stable pregnant trauma and transported without priority notification.

That blood pressure is not stable in late pregnancy.

Maternal circulating volume is up. Compensated shock hides longer. The fetus is the canary. Persistent maternal tachycardia with a pressure that would be acceptable in a non-pregnant adult is already a perfusion problem. The placenta does not wait for maternal hypotension to declare itself.

This is a recognition and destination problem for every provider on the truck. Left lateral tilt. High-flow oxygen. Rapid transport to a facility that can do both trauma and obstetrics. Magnesium, tocolysis, and advanced airway decisions sit at the Paramedic level when protocols allow. The missed call happens earlier, when the crew treats a talking third-trimester patient like a talking medical call.

That being said, the pattern is learnable. Mechanism plus gestation plus maternal tachycardia is a high-acuity transport even when she is conversational. Simulation builds that priority before a reassuring scene becomes a dual resuscitation.

emsmedsim.globalmedopscommand.com

The MVC patient was talking. Blood pressure 128/82. Heart rate 108. Breath sounds present on both sides, a little quieter on the right.

The crew called it chest wall contusion and loaded.

Fifteen minutes later he was hypotensive and the right chest was silent.

Occult tension pneumothorax does not wait for the textbook triad. Distended neck veins, tracheal deviation, and absent breath sounds arrive late, if they arrive at all. In a noisy ambulance, a quiet hemithorax is easy to miss. Compensated patients stay talking until venous return collapses.

The provider who waits for hypotension before raising the differential has waited for the compensation to fail.

That being said, the recognition is mechanism plus trend. Penetrating or blunt chest trauma, progressive tachycardia, increasing work of breathing, unequal rise. Needle decompression is a Paramedic-level intervention. The recognition that this chest is changing belongs to every provider on the truck. Destination and priority change before the procedure does.

Simulation builds that trend recognition before a talking trauma patient becomes a silent one.

emsmedsim.globalmedopscommand.com

I have worked the overnight shift as a full time nocturnist the last 8 years. I have been studying the literature associated with "the night shift" for almost that same duration. I have lectured our residents formerly, had many discussions while on shift with medical students and nurses, and more recently began writing a book that encompasses my lessons learned paired with the literature on how to survive a career that requires night shift work. I read a recent article in ACEPNow and it prompted me to write the following article. https://www.acepnow.com/article/night-shift-is-an-occupational-exposure-treat-it-like-one/