Dispatch systems are designed to get the right resources to the scene based on limited information, but the dispatch determinant is only the beginning of the patient assessment. Because dispatch decisions must be made before EMS arrives, some patients receive ALS resources that ultimately are not needed, while others may require a higher level of care than initially recognized. As a result, determining the appropriate level of transport depends on the assessment performed at the patient's side—not the dispatch determinant alone. In this episode, Maia Dorsett is joined by Roger Stone, Ben Kaufman, and Jeremy Cushman to discuss how EMS clinicians and systems can determine whether a patient requires ALS transport or can be safely transported by a BLS crew. Drawing on Montgomery County's pioneering work in developing and validating an ALS downgrade process, the panel explores common pitfalls, the importance of thorough assessment, strategies to avoid missed diagnoses, and the role of structured decision-making in improving patient safety while making the best use of limited ALS resources. Whether you are an EMT, paramedic, educator, quality leader, or medical director, this conversation offers practical insights into building systems that support consistent, patient-centered transport decisions.

Resources:

Montgomery County Resources: Checklist, posters, presentations

Monroe-Livingston policy on Determining the Appropriate Level of EMS Clinician for Patient Transport

Free CAPCE credit for CME available at Prodigy EMS for this episode until July 31st: https://frontend.prodigyems.com/class/CDB94B9A-6A2F-4DFD-A91F-C6F270700826?tab=overview

What happens when we fail to treat pain early in older adults? What unique considerations arise when managing pain in geriatric patients in the prehospital setting? In this episode of EMS Clinical Brief, Dr. Maia Dorsett is joined by Dr. Tony Rosen, Dr. Aaron Farney, and paramedic Kevin Gustina for a thoughtful conversation about prehospital pain management in older adults, particularly after falls and hip fractures. The discussion explores how untreated pain contributes to delirium, physiologic stress, and downstream complications, while also examining the cultural and operational barriers that often lead to under-treatment in EMS. Through practical examples and a discussion of a regional quality improvement initiative, the episode highlights how small changes in assessment and treatment can meaningfully improve patient outcomes. This is a clinically grounded and deeply human conversation about one of the most common yet overlooked aspects of EMS care.

Learning Objectives:

By the end of this episode, listeners should be able to:

1. Describe the physiologic and clinical consequences of untreated acute pain in older adults, including the relationship between pain and delirium.
2. Discuss unique considerations in geriatric pain management, including altered pharmacology, dementia, multimodal analgesia, and age-adjusted opioid dosing.
3. Identify operational, cultural, and systems-based barriers to effective prehospital pain management and strategies to improve care for older adults with suspected hip fractures.

Resources:

MLREMS Suspected Isolated Hip Fracture Care Bundle: https://www.mlrems.org/wp-content/uploads/2026/04/Care-Bundle-Suspected-Isolated-Geriatric-Hip-Fracture.pdf

CAPCE credit for this episode available for members of Prodigy EMS: https://frontend.prodigyems.com/class/E95419B8-E766-4FF2-B6AE-587EA3C2927C?tab=overview

References:

1. Thompson, C., Brienza, V. J., Sandre, A., Caine, S., Borgundvaag, B., & McLeod, S. (2018). Risk factors associated with acute in-hospital delirium for patients diagnosed with a hip fracture in the emergency department. Canadian Journal of Emergency Medicine, 20(6), 911-919.
2. Morrison, R. S., Magaziner, J., Gilbert, M., Koval, K. J., McLaughlin, M. A., Orosz, G., ... & Siu, A. L. (2003). Relationship between pain and opioid analgesics on the development of delirium following hip fracture. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 58(1), M76-M81.
3. De Simone, B., Chouillard, E., Podda, M., Pararas, N., de Carvalho Duarte, G., Fugazzola, P., ... & Catena, F. (2024). The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World journal of emergency surgery, 19(1), 18.
4. McGuire, S. S., Brown, C. S., Palmer, A. K., Jeffery, M. M., Mullan, A. F., Stanich, J. A., ... & Bellolio, F. (2026). The Downstream Effects of Prehospital Opioid Dosing in Older Adults: A Retrospective Cohort Study. Academic Emergency Medicine, 33(4), e70294.
5. Hughes, J. A., Alexander, K. E., Spencer, L., & Yates, P. (2021). Factors associated with time to first analgesic medication in the emergency department. Journal of Clinical Nursing, 30(13-14), 1973-1989.

In the inaugural episode of EMS Clinical Brief, Maia Dorsett and Shane O'Donnell are joined by Jeff Jarvis for a candid, high-level conversation on patient-centered airway management. Framed by lessons from the NEMSQA Airway Collaborative, the discussion challenges long-held assumptions about airway success—moving beyond “getting the tube” to asking what actually improves patient outcomes. Through real-world examples, debate, and reflection on past missteps, the group explores how EMS culture, training, and system design have historically prioritized procedures over physiology. They unpack the tension between clinician identity and patient need, examine the risks of hypoxia and hypotension during airway interventions, and highlight how thoughtful metrics and policies can reshape practice.

CAPCE-accredited CE for this episode is available via Prodigy EMS at https://www.prodigyems.com/

References discussed:

1. Dorsett, M., Cooper, R. J., Taira, B. R., Wilkes, E., & Hoffman, J. R. (2020). Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emergency Medicine Journal, 37(4), 240-245.
2. Jarvis, J. L., Panchal, A. R., Lyng, J. W., Bosson, N., Donofrio-Odmann, J. J., Braude, D. A., ... & Sholl, J. M. (2024).Evidenced Based Guidelines for Prehospital Airway Management Prehospital Emergency Care, 28(4), 545-557.
3. Spaite, D. W., Hu, C., Bobrow, B. J., Chikani, V., Gaither, J. B., Barnhart, B., ... & Keim, S. M. (2017). Effect of Prehospital Hypoxia “Depth-Duration Dose” on Mortality in Major Traumatic Brain Injury. Journal of Emergency Medicine, 53(3), 443.
4. Vithalani, V. D., Vlk, S., Davis, S. Q., & Richmond, N. J. (2017). Unrecognized failed airway management using a supraglottic airway device. Resuscitation, 119, 1-4.
5. Jarvis, J. L., Jarvis, S. E., & Kennel, J. (2025). The association between out-of-hospital drug-assisted airway management approach and intubation first-pass success. Annals of Emergency Medicine.
6. Robinson, A. E., Knack, S. K., Driver, B. E., Prekker, M. E., Perlmutter, M. C., Bunting, A. J., ... & Puskarich, M. A. (2025). Trends in Prehospital First-Attempt Use of Supraglottic Airways in Non-Cardiac Arrest Patients: A Descriptive Study. Prehospital Emergency Care, 1-8.
7. Jabre, P., Penaloza, A., Pinero, D., Duchateau, F. X., Borron, S. W., Javaudin, F., ... & Adnet, F. (2018). Effect of bag-mask ventilation vs endotracheal intubation during cardiopulmonary resuscitation on neurological outcome after out-of-hospital cardiorespiratory arrest: a randomized clinical trial. Jama, 319(8), 779-787.
8. Do it For Drew Foundation: https://www.doitfordrew.org/