Category Archives: Uncategorized

Active Shooter

sources from Dr. Marc Kanter’s All NYC EM Conference lecture, enjoy:

** EM:RAP 12/2013 segment with Ilene Claudius interviewing Active Shooter expert Mike Clumpner **

1) Active Shooter Planning and Response in a Healthcare Setting

2) NYPD Active Shooter Recommendations and Analysis for Risk Mitigation

3) Hospital-Based Shootings in the US: 2000-2011 Kelen GD, Catlett CL, Kubit JG, Hsieh YH. Ann Emerg Med. 2012 Dec;60(6):790-798.e1. doi

4) Violence in the Health Care Setting – JAMA Commentary December 8, 2019 Vol 304

5) Dept of Homeland Security First Responder Guide for Improving Survivability in Improvised Explosive Device and/or Active Shooter incidents

6) Hartford Consensus Compendium – American College of Surgeons

7) Dept of Homeland Security Letter – Active Shooter and Complex Attack Resources

8) Tactical Emergency Combat Care Guidelines

9) FBI/Dept of Justice – A study of active shooter incidents in the US between 2000-2013

10) The San Bernardino, California, Terror Attack: Two Emergency Departments’ Respons Lee C., Walters E, et al. Western Journal of Emergency Medicine January 2016

11) Handbook Tactical Combat Casualty Care Lessons Learned No. 13-21



Bradycardia Recap

by John Marshall, MD

– Bradycardia (HR <60) can be caused by SA & AV nodal disease

In patients with symptoms of instability (chest pain, AMS, hypotension)… remember: ABC’s, IV, O2, monitor.

  • 1st.) Atropine 0.5mg q3-5 min, for a maximum of 3mg (can cause paradoxical bradycardia)
  • 2nd.) TransCutaneous pacing, or… Pressors (Epinephrine & Dopamine: Beta 1 activity increases AV node flow and SA conductivity)
  • 3rd.) TransVenous pacing + expert consultation

Mobitz type 2 or greater are dispo’ed to CCU (AV blocks may deteriorate into complete block).

Only people to send home are people without comorbidity and received no urgent intervention



  • – identifying a block, but missing inferior MI
  • not having pacer pads ready while giving atropine
  • – sending someone home that appears better
  • atropine may worsen ischemia in someone with ischemic disease
  • – atropine may not work in infra-nodal blocks

Chaser before tPA shots?

by Andrew Summersgill, M.D.

Before taking shots of tPA, don’t forget your CHASER: a mnemonic for when NOT to give tPA in Stroke/MI patients:

  • C: Cancer
  • H: Hemorrhagic stroke in past. Hypertension>180/>110*
  • A: Aortic dissection, AV malformations
  • S: Stroke (ischemic within the last 3 months). Sugar (glucose 400mg/dL )*
  • E: Exsanguination/active bleeding
  • R: Relative contraindications

This is a quick outline to consider before pushing lytics. There is overlap between these two subsets, and obviously the list is more comprehensive, so be sure to look up the latest guidlines.

*stroke specific (ischemic, hemorrhagic, etc)

An Interview with Paul Thistle

by Jonathan Lee, MD

I hate pigeon-holing Africa into a giant monolithic entity but I couldn’t help looking out into the foliage and thinking to myself, “if this isn’t Africa, I don’t know what is”? In the northeastern corner of Zimbabwe less than a hundred kilometers from Mozambique and a three hour bumpy ride from its capital, Harare, which I was pre-warned about with a “this is the part where your teeth fall out!” is Karanda Mission Hospital. It sits on top of a hill nestled in lush vegetation serving the very community it looks over. I spoke with Dr. Paul Thistle, an OB/GYN physician from Canada about his lifelong work in the country. Since graduating residency he has worked in Afghan refugee camps in Pakistan in the 1980’s and has also worked in Indonesia as well. But for most of his career he has worked in Zimbabwe, serving 19 years in rural communities not only performing surgeries but also treating patients with HIV and tuberculosis, arguably the number one killer of adults in Zimbabwe and Subsaharan Africa. I discuss what emergency medical care in rural Zimbabwe is like and how he has learned to adapt to an inadequate healthcare system.


So you’ve worked for the last nineteen years in Zimbabwe. What made you want to work here versus Canada or the United States?

“Well, I had always known that I wanted to work in a resource poor area of the world. It’s a different environment here. People need help here. And to be honest the work is more satisfying as well.”

Tell me about Zimbabwe’s healthcare system.

“In the rural areas, 60 percent of hospitals are being run by churches and 40 percent by the government. In Harare, it’s more like 10 percent mission and 90 percent government. Currently about 15 percent of the population gets medical aid but that still leaves the majority without any access to healthcare. The government hospitals are expensive and so a lot of people even from Harare end up coming all the way up to Karanda hospital for their medical care because it is much more affordable.

Zimbabwe has had a bumpy past. There is a lot of discontent, there are no jobs, there’s certainly no health care system to speak of. There is a lot of disillusionment in the country and in the end, the people suffer.”

So, Zimbabwe has had a lot of violence in the past, most recently in 2008 during the elections. What was it like working as a physician during that time? Did you see a lot of injuries?

“We saw a lot but we didn’t see as much as you think. At Howard Hospital where I used to work we saw about 30 traumas related to the violence in our catchment of 300,000 and of those, 2 people died. Is that a lot? Well more people die in Toronto of car accidents in one day so by volume it’s not. A lot of what was on the news was sensationalized but at the same time those weren’t accidents. It was politically charged violence which is always bad but at the same time you have to stay neutral.”

I would have expected there to be a lot more. What is the prehospital medical infrastructure in Zimbabwe? Is there an EMS system here?

“In theory yes. In Zimbabwe, we have private healthcare and then there’s public healthcare. In private, they may have an ambulance service depending on your insurance. Maybe you can pick up the phone and they’ll pick you up. But in the public medical system, which almost all Zimbabweans utilize, there is no emergency medical system, even in Harare. You would have to put the person in the back of the taxi and rush them in somehow.”

What about rural areas?

“Nothing, no.”

So if someone doesn’t have a car and there aren’t any taxis around which is typical in rural Zimbabwe and lets say you have some acute illness that needs to be managed, what happens?

“Well, as long as we’re talking acute, they’ll die on the way to the hospital. Or they may not even make it that far, they’ll just die at home. Or they will come in with complications, like a ruptured appendix for example. So most people can hire a car if there are vehicles around. But there isn’t a guaranteed emergency medical system. We do happen to have an ambulance truck in the hospital, but then again we can’t staff it. We don’t have a driver to go out. If somebody calls us, then we might look around for a driver and a nurse, then send it out.”

How often do you receive calls?

“Not very often, most people just walk in.”

And this isn’t a special 3 digit phone number, it’s the number to the hospital?

“That’s correct. Because nobody pays for the service, right? You’d have to have a driver on stand-by for emergency services. A nursing team would have to be available. And then there is the mileage of the vehicle. Who pays for all of this? The hospital can’t afford it. So we do have an ambulance but its the logistics of getting it out in the fields. And plus the roads are rough. Even if you have an MI or a stroke, you’re not gonna get to them within thirty minutes. And also we don’t have an intensive care unit. We’re trying to intensify our emergency response but in reality, the hospital doesn’t have a cardiac care unit or neurosurgical care. So if there is an acute cardiac or neurological emergency, what are we going to do about it? So it’s more than just one link that’s broken in the system. So if they survive an MI and make it to the hospital, we’re looking at morphine and heparin. We can’t do coagulation studies studies either so you have to make the best judgement. Normally you give morphine and an aspirin and try to reduce long term complications. So you will see it all first hand.”

So then you diagnose the MI wIth just an EKG? Can you test cardiac enzymes?

“Last time I checked, we needed to fix our EKG machine. It wasn’t working the last time I heard. And no we can’t do cardiac enzymes. So if someone comes in with crushing chest pain, you have to rely on your clinical judgement and experience.”

“Most young doctor, if you can’t make a diagnosis, you order more lab tests or imaging tests but you have to learn to make decisions based on what you have. We don’t have the luxury for extra tests.”

Doesn’t that become frustrating as a physician when you can’t diagnose?

“Yes but being a doctor isn’t just about that. You do the best you can with what you have. But kindness and compassion goes a long way. The medicine part you won’t have trouble figuring it out.”

Do you envision yourself staying in Zimbabwe in the future?

“Well we’re working it out one day at a time. You can never predict the future. Some things about home I miss and something’s about Zimbabwe I would miss. The work is better here. The job is more satisfying. The income is much lower, but that’s not the reason I would decide.”

Dr. Thistle is married to his Zimbabwean wife Pedrinah who is a nurse-midwife and has two sons, James and Alex. He lives within the compounds of Karanda Mission Hospital and frequents the “bumpy ride” to and from Harare to visit his sons and pick up groceries of which his guilty pleasure is potato chips.