University Hospitals EMS Institute

10/26/2026

10/19/2026

Behavioral health patients come with a wide variety of presentations: from the calm and cooperative, to the manic but redirectable, to the floridly psychotic that is a danger to themselves and others. The UH EMSI protocol addresses each of these scenarios, and that is what I would like to discuss this week.

Mental health is a national crisis, and we as a nation are ill-equipped to provide these patients the long-term care they need; hence, they often end up on the streets, in the emergency departments, and in the back of your squads. There has been a lot of attention in the news over the past several years regarding the use of ketamine for psychotic patients with adverse outcomes. Our protocols are designed to protect you and the patient while providing appropriate medication escalations for each type of behavioral call.

The protocol is divided into three indications:

Agitation - Not combative: These are the patients who are redirectable. They are “experiencing a period of high anxiety…not a threat to self or others.” While we often transport these patients without the need for medications, both oral olanzapine (Zyprexa) and IV/IM/IN/IO midazolam (Versed) are options. These are patients to whom I offer medications but only provide if they wish.
Combative - not violent: Next escalation: these patients are a “threat to self or other; however, can be controlled with restraint with appropriate help without significant risk to the providers”. These patients require more than just a benzodiazepine; haloperidol (Haldol) is indicated for these patients. Colloquially known as a “B52” in the emergency department, our protocols allow for 5 mg IM haloperidol and/or midazolam (2.5 mg IV/IO 5 mg IM/IN). Diphenhydramine (Benadryl) is only indicated if patients experience fasciculations, dystonia, or other extrapyramidal symptoms.
Combative - violent: The highest escalation of the protocol; this is the patient who is in a violent state that puts providers at significant risk despite appropriate help. Ketamine is indicated here. 250 mg IM ONLY, with a repeat IM dose in 5 minutes if no response, for a maximum dosage of 500 mg. If the patient shows signs of emergence after ketamine, consider benzodiazepines as well.

Documentation is key in each of these scenarios for both continuity of care and protection in the event of an adverse outcome. Ideally, document the indication and rationale for why a medication was chosen, as well as any de-escalation techniques and demonstration of the ability to administer the medication without causing harm to yourself or the patient. The protocol notes the patient must be “out of control and may cause harm to self or others.”

As always, ensure scene safety before entering a potentially dangerous situation. Utilize law enforcement to ensure there are no weapons, as well as for assistance in restraint if indicated. Even if this is a patient you are familiar with, do not overlook potentially underlying medical or traumatic causes for their behavior, as well as the possibility of abuse.
Stay safe out there,

Erin Fenoff, DO, MPH

10/12/2026

Message

While there are several great off-label uses for the antipsychotic medications in our drug box, olanzapine and haloperidol are only indicated for acute agitation from a seemingly psychiatric condition. Haloperidol and droperidol can be used interchangeably within the protocol; this was purposely written. In the event of a drug shortage, the alternative medication can be supplied without need for re-training, similar to lorazepam and midazolam, calcium chloride and gluconate. While antipsychotics may be given in any “aggressive, violent, or severely agitated patients in the setting of psychosis or alcohol intoxication,” there are several key precautions we must watch for. Good luck getting an EKG on these patients before medication administration! All antipsychotics may increase the QTc, leading to life-threatening ventricular arrhythmias. We must watch for sedation and dystonic reactions; while uncommon from a single dose, patients may be on these medications chronically, which may increase the risk of side effects. Personally, if I suspect the patient may be agitated from an ingestion, I tend to reach for a benzodiazepine first. There is less risk of interactions from whatever they took, and Poison Control almost always recommends benzodiazepines as first-line for symptoms in the setting of overdose.

Remember, you cannot mix midazolam, diphenhydramine, and haloperidol together in the same syringe. I had a crew tell me they did it once and it looked like a “lava lamp.” Similarly, there must be three separate administrations at three separate sites at least one inch away from each other. Imagine that lava lamp necrosing in the soft tissue because they were administered too closely together. I recommend one injection per thigh, with the third injection (if needed) at least one inch away from the first. As noted last week, diphenhydramine is not automatic - it is only given if the patient experiences EPS symptoms after the haloperidol administration. Capnography should be monitored, especially if the patient becomes overly sedated from these medications.

Finally, I would like to touch on appropriate restraint use. Restraining a patient is a high-risk procedure for both yourself, the patient, and anyone who may be assisting. We have all seen the coverage across the country from law enforcement restraints resulting in patient harm and death and the devastating consequences socially and legally. Restraint use is indicated to administer medications and to keep the patient and crew safe during transport. Documentation must show the indication for restraints, de-escalation attempts, patient positioning, response, and type of restraints used. Never restrain a patient face down and pay close attention to the airway for emesis or collapse, extremities for circulation and function, and the patient's condition overall. Vitals and neuromuscular checks should be performed every 15 minutes. These patients are often hypermetabolic - they are so worked up they can throw themselves into rhabdomyolysis (muscle breakdown), renal failure, hyperkalemia, hyperthermia, and arrhythmias. Medication use in addition to restraints may help decrease these complications by decreasing the physiologic demands on the body. If the patient is in law enforcement custody and handcuffs are applied, a member of that agency must accompany the patient in the back of the ambulance to adjust restraints as needed. If the patient is in 4-point restraints, ideally one arm is above the head of the bed, one below, and the head is at 30 degrees. Document, document, document! Make sure the receiving facility is aware of the need for restraints. Be prepared to address any change in patient condition immediately.
Stay safe out there,

Erin Fenoff, DO, MPH

10/09/2026

There are Leaders, Heroes, and Legends, Chief Reed was all three. We were lucky enough to Celebrate his retirement and unbelievable devotion to the Middlefield Fire Department for nearly 40 years just last week.

Today we mourn his loss. We are forever grateful for what Chief Reed represents! He was a proud and faithful leader who cared so deeply for the Men and Women of The Middlefield Fire Department and the people of his community. A proud U.S. Navy Veteran, and a prouder Father, Grandfather and Chief.

Chief Reed, your legacy will live on forever. We will take it from here boss!

10/09/2026

Red Alert 🚨 : We need help assisting one of our own firefighters!! Chardon Firefighter / Paramedic Dominic Shea (also a full-time Parma firefighter) has been battling melanoma since 2022. Despite his strong fight, the cancer has now metastasized to his brain and is considered stage IV. Please join us for a benefit dinner to help support Dominic and his wife, Jess, through their journey. All proceeds will go directly to the Shea family.

Dominic’s father, Kevin, was a Chardon firefighter for many years. They are all part of our “fire family”. Please help us help them. If you can’t attend the dinner in Parma, consider simply donating. Contact one of the firefighters on the flyer for more info.

City of Chardon, Ohio - Municipal Government Chardon Township, Geauga County Ohio Claridon Township - Geauga County, Ohio Parma Firefighters Local 639

10/09/2026

10/05/2026

This month’s continuing education lecture reviews the drug box medications for all ALS-level departments.

We'll start by covering the “Six Rights of Medication Administration," a topic covered in the Pharmacy Phriday series in December 2025: Right Patient, Right Medication, Right Dose, Right Route, Right Time, Right Documentation.1 Medication errors are the leading cause of preventable patient harm according to the World Health Organization. One out of 30 patients is harmed by medication errors, with 25% deemed severe or life-threatening.2 Errors may result from the wrong medication, the wrong patient, the wrong dose, a misreview of allergies, an inappropriate route, extravasation, or unintended side effects, among many other causes. In the U.S., medication errors are the third most common cause of death.3 Interestingly, the highest rate of preventable medication error is seen in the elderly population given multiple comorbidities, polypharmacy, and increased likelihood for adverse reactions to medications.3 Many emergency department organizations across the country have attempted to address this at the physician level.

What tool do we have in today’s technology that can help us reduce the risk of medication error? OneDose®! OneDose provides easy access to UH protocols with links to medications, dosing, and administration. If you input the patient’s age and weight (specifically for pediatrics), the output becomes even more specific. For example, inputting a 7-year-old patient will not allow review of aspirin dosing, as it is not indicated for children. It also helps decrease errors with med math and dosing calculations, especially after waking up at 2 AM for a critical patient. Scanning and verification of the medications also decreases the risk of accidentally drawing and giving a different medication than you were intending; OneDose can help with these potential errors. You will be alerted if you scan the incorrect medication, given appropriate mixing and administration instructions, as well as notified of warnings, contraindications, and the need for online medical control, all on the same screen. Nursing must scan all medications before administration across the hospital to increase safety and accuracy. The exception is time-critical medications, such as anaphylactic epinephrine, ACLS meds, etc.

Documentation is just as important. Good documentation shows the medication being administered, which the ePCR will often do automatically with the patient, dose, route, and time. Great documentation includes the rationale for why (or why not) a medication was used per protocol. This is equally important when protocol recommends a medication, but circumstances recommended against, such as “nitroglycerin was considered for this patient; however, given borderline blood pressures, medication was withheld.” This will also provide protection in the event of adverse outcomes. In the event of an error or adverse response, be honest, document well, and learn from the incident.

You deal with enough stress, critical decision-making, and quick thinking on a daily basis. Use OneDose to take some of the burden off to help decrease the risk of harm to the patient and yourself. As always, reach out to online medical control, your medical director, and each other for help, questions, and guidance.
Stay safe out there,

Erin Fenoff, DO, MPH

09/28/2026

Measles is a highly contagious viral illness that can cause serious complications, particularly in young children. The disease is spread through the air when an infected person coughs or sneezes, and the virus can remain suspended in the air for up to two hours. Although measles can lead to severe illness, it is largely preventable through vaccination. Two doses of the measles, mumps, and rubella (MMR) vaccine are ~97% effective at preventing measles infection.

Common symptoms include fever, cough, runny nose, and red or irritated eyes. As the illness progresses, a characteristic rash usually develops two to four days after the initial symptoms begin. The rash typically starts along the hairline and spreads downward across the face, neck, trunk, and the rest of the body. Some individuals also develop small white spots inside the mouth, known as Koplik spots, which may appear two to three days before the rash develops. The virus spreads through the air when an infected person breathes, coughs, or sneezes and may survive in the environment for up to two hours. Individuals who have not been vaccinated and have not previously had measles have more than a 90% chance of becoming ill after exposure. A person with measles is contagious four days before the rash appears until four days after the rash develops.

Complications of measles can range from having ear infections, pneumonia, diarrhea with dehydration, to life-threatening seizures, encephalitis, and death. Because of these potentially severe outcomes, prevention through vaccination and infection control measures is essential.

All first responders should have documented evidence of immunity against measles and should follow their EMS agency’s policies regarding proof of immunity. Evidence of immunity may include documentation of two valid doses of live measles or MMR vaccine administered at least 28 days apart, laboratory evidence of immunity, or laboratory confirmation of prior measles infection. Individuals born before 1957 who don't have laboratory evidence of immunity or previous disease should receive two doses of the MMR vaccine at the recommended interval.

Appropriate Personal Protective Equipment (PPE) is important when caring for patients with suspected or confirmed measles. First responders should wear an N-95 respirator, while patients should wear a surgical mask whenever possible. Only personnel known to be immune to measles should have direct contact with patients who may be infected. Healthcare facilities should be notified before the arrival of any patient with known or suspected measles. Advance notification allows facilities to prepare appropriate infection prevention measures, including placement of patients in negative-pressure rooms or rooms equipped with HEPA filtration systems. During ambulance transport, the patient compartment exhaust vent should be operated on a high setting, and the driver compartment should be isolated from the patient area whenever possible. The driver compartment ventilation system should also be set to high airflow without recirculation to reduce the risk of airborne transmission.
That is all for September. Keep up the great work and stay safe!

Regina A. Yaskey, MD

09/23/2026

Great job by all involved and especially Mickey Smith and staff at NWFRG!!!!

09/23/2026

🚒 SAVE THE DATE! 📆

Join us for an Open House at Strongsville Fire Station 4 on October 4th from 1–4 PM!

As we kick off Fire Prevention Week, come meet the members of Strongsville Fire & Emergency Services, get a behind-the-scenes look at life in the firehouse, explore our equipment, and take part in fun and educational fire safety activities for the whole family! 👨‍🚒🔥

Bring the family and come spend the afternoon with us!

We hope to see you there! 🚒