The goal of Montgomery County Hospital District’s Department of Clinical Services is to provide a consistent and superior system of emergency and non-emergency services to our community and provide support for our employees through leadership and professional management.  This includes protocol development, oversight of the electronic Patient Care Record (PCR), quality improvement process, professional development, continuing education, provider credentialing, community education, and integration of the care MCHD provides with the healthcare community

The Clinical team employs the following tools to improve MCHD’s success:

  • Review and analysis of all reports related to strokes, cardiac events, and trauma
  • Regular attendance at local emergency department meetings to foster clear lines of communication and quality improvement
  • Regular case reviews with emergency department personnel and the paramedics on those cases
  • Procedural review, changes and/or training as called for by the case reviews
  • Studies on the implementation and effectiveness of best practices
  • Published research papers


A critical role of the department is ensuring MCHD’s paramedics are trained and best positioned to utilize their knowledge, abilities, and talents in the field.  MCHD creates an environment where our paramedics continuously develop their skills as a provider while growing within the agency and are trusted with more responsibility.  The following are the different levels of credentialing utilized by MCHD.  In order to maintain the current level of authorization, the paramedic must successfully pass a re-credentialing exam every other year.

  • PI – Attendant: This is an emergency medical provider who has passed credentialing exams and holds a TDSHS EMT-Intermediate or EMT-Paramedic certification or license.
  • PII – In Charge: This is a paramedic who has shown clinical proficiency through multiple written and scenario evaluations. They have limited clinical authority and consults with higher-authorized provider prior to performing certain skills.
  • PIII – In Charge: An In Charge who has demonstrated enhanced clinical proficiency beyond that of a PII. This paramedic has an expanded level of clinical authority and is no longer required to consult with a higher-authorized provider prior to performing certain skills.
  • PIV – Supervisor: The highest level of authorization for MCHD is a PIV. This employee has shown excellent operational and clinical proficiency. They are authorized to provide medical direction through consults to paramedics at lower levels of authorization.

MCHD Department of Clinical Services shares our best practices and lessons learned and often publishes our findings through professional journals and magazines. Below are a few of our most recent publications:




Dr. Dickson is a native Texan and graduated from the University of Texas San Antonio medical school in 1997. He did emergency medicine post – graduate training at Indiana University and has worked as a practicing emergency physician and educator in Texas and NZ. He is board certified in emergency medicine, EMS medicine and holds fellowship in both the American and Australasian Colleges of Emergency Medicine. His academic interests include   acute neurologic emergencies, EMS and systems of care in time sensitive emergencies. He has authored multiple articles on these topics and has lectured regionally, nationally and internationally. In his spare time he enjoys cycling, travel and swimming.






Casey Patrick grew up in Williamsburg, KY and graduated from The University of the Cumberlands in 2000.  Following his undergraduate studies, Patrick received his MD from The University of Kentucky College of Medicine in 2004. In 2007, he completed residency training in Emergency Medicine at Indiana University.  Since residency he has practiced EM in both Indiana and Texas. Currently, Dr. Patrick is Assistant Medical Director for the Montgomery County Hospital District EMS service and works in multiple community emergency departments in the Greater Houston area.  His EMS educational  focus is on innovative paramedic teaching via the MCHD Paramedic Podcast  Dr. Patrick’s prehospital clinical research involves using bolus intravenous nitroglycerin for acute pulmonary edema and implementation of lung protective ventilation strategies for EMS patients. Casey and his wife, Alyssa, work and live in Conroe, TX and Spokane, WA. Together they have five children: Mia, Ainsley, Brock, Dean and Will.





MCHD Department of Clinical Services utilizes evidence-based medicine to develop Clinical Guideline and ensure excellent patient care.  Below is some of the literature utilized for recent internal education and Clinical Guideline updates:


  1. Holcomb JB, et al, PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015 Feb 3;313(5)
  2. Stein et al. Reduction of massive transfusion in major trauma patients Anaesthesia 2017, 72, 1317–1326
  3. Pusateri AE, et al. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg. 2020 Feb 1;155(2)
  4. Moore HB, et al. Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial. Lancet. 2018 Jul 28;392(10144):283-291.
  5. Sperry JL, et all; PAMPer Study Group. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326.
  6. Guyette FX, et al. Prehospital Low Titer Group O Whole Blood Is Feasible And Safe: Results Of A Prospective Randomized Pilot Trial. J Trauma Acute Care Surg. 2022 Jan 25.
  7. Braverman MA, et al. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion. 2021 Jul;61 Suppl 1:S15-S21.
  8. Sayre MR, et al. Providing whole blood for an urban paramedical ambulance system. Transfusion. 2022 Jan;62(1):82-86.
  9. Harmsen AM, et al. The influence of prehospital time on trauma patients outcome: a systematic review. Injury. 2015 Apr;46(4):602-9.
  10. Wandling MW, et al. Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System–Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services. JAMA Surg. 2018;153(2):107–113
  11. Zur M, et al. Freeze-dried plasma stability under prehospital field conditions. Transfusion. 2019 Nov;59(11):3485-3490.
  12. Nadler R, et al. The Israel Defense Forces experience with freeze-dried plasma for the resuscitation of traumatized pediatric patients. J Trauma Acute Care Surg. 2019 Dec;87(6):1315-1320.
  13. Nguyen C, et al. Use of French lyophilized plasma transfusion in severe trauma patients is associated with an early plasma transfusion and early transfusion ratio improvement. J Trauma Acute Care Surg. 2018 May;84(5):780-785.
  14. Garrigue D, et al. French lyophilized plasma versus fresh frozen plasma for the initial management of trauma-induced coagulopathy: a randomized open-label trial. J Thromb Haemost 2018; 16: 481–9.
  15. Oakeshott JE, et al; Kent Surrey Sussex Air Ambulance Trust. Feasibility of prehospital freeze-dried plasma administration in a UK Helicopter Emergency Medical Service. Eur J Emerg Med. 2019 Oct;26(5):373-378.
  16. Ditzel RM Jr, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020 Mar;88(3):434-439.
  17. Sanders S, et al. Fibrinogen Concentrate in the Special Operations Forces Environment. Mil Med. 2018 Jan 1;183(1-2):e45-e50.
  18. Akbari E, Safari S, Hatamabadi H. The effect of fibrinogen concentrate and fresh frozen plasma on the outcome of patients with acute traumatic coagulopathy: A quasi-experimental study. Am J Emerg Med. 2018 Nov;36(11):1947-1950.
  19. Ziegler B, et al; FIinTIC study group. Efficacy of prehospital administration of fibrinogen concentrate in trauma patients bleeding or presumed to bleed (FIinTIC): A multicentre, double-blind, placebo-controlled, randomised pilot study. Eur J Anaesthesiol. 2021 Apr 1;38(4):348-357.


  1.  Gayet-Ageron A et al. Effect of Treatment Delay on the Effectiveness and Safety of Antifibrinolytics in Acute Severe Haemorrhage: A Meta-Analysis of Individual Patient-Level Data From 40138 Bleeding Patients. Lancet 2017.
  2.  Effects of Tranexamic Acid on Death, Vascular Occlusive Events, And Blood Transfusion in Trauma Patients With Significant Haemorrhage (CRASH-2): A Randomised, Placebo-Controlled Trial. Lancet 2010.
  3.  Morrison J.J., Dubose J.J., Rasmussen T.E., Midwinter M.J. (2012). Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study.  Arch Surg, 2012 Feb;147(2):113-9.


IV Nitrates in APE

  1.  Cotter G, Metzkor E, Kaluski E, et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998;351(9100):389-93.
  2.  Levy P, Compton S, Welch R, et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007;50(2):144-52.
  3.  Wilson SS, Kwiatkowski GM, Millis SR, et al. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med.2017;35(1):126-31.

Ventilator Mgmt

  1.  Fuller BM, Ferguson I, Mohr NM, et al. Lung-protective ventilation initiated in the emergency department (LOV-ED): a study protocol for a quasi-experimental, before-after trial aimed at reducing pulmonary complications BMJ Open 2016;6:
  2.  Boyer AF, Schoenberg N, Babcock H, et al. A prospective evaluation of ventilator-associated conditions and infection-related ventilator-associated conditions. Chest 2015;147:68–81.
  3.  Ranieri VM, Rubenfeld GD, Thompson BT, et al., The ARDS definition task force. Acute respiratory distress syndrome. JAMA 2012;307:2526–2533.
  4.  (No authors listed). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301–1308.
  5.  Austin Michael A, Wills Karen E, Blizzard Leigh, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial BMJ 2010; 341
  6.  Turner JS, et al, Feasibility of upright patient positioning and intubation success rates at two academic emergency departments, American Journal of Emergency Medicine 2017.



  1.  Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed Sequence Intubation: A Prospective Observational Study. Ann Emerg Med. DOI:
  2. Weingart SD. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. J Emerg Med. 2011 Jun;40(6):661-7. Epub 2010 Apr 8. Review.
  3.  Christodoulou, C, Mullen, T, Tran, T, Rohald, P, Hiebert, B & Sharma, S. 2013. Apneic oxygenation via nasal prongs at 10L/min prevents hypoxemia during elective tracheal intubation. Chest, 144(4- Meeting Abstracts): 890A
  4.  Weingart, SD & Levitan, RM. 2012. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med, 59(3): 165-75.
  5.  Ramachandran, SK, Cosnowski, A, Shanks, A & Turner, CR. 2010. Apneic oxygenation during prolonged laryngoscopy in obese patients: A randomized, controlled trial of nasal oxygen administration. J Clin Anesth, 22(3): 164-8.



  1.  Angus DC, Barnato AE, Bell D. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive care medicine. 41(9):1549-60. 2015
  2.  Brewer JM, et al. Can Vasopressors Safely Be Administered Through Peripheral Intravenous Catheters Compared With Central Venous Catheters? Ann Emerg Med 2015.
  3.  De Backer D, Aldecoa C, Njimi H, Vincent JL. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis*. Critical care medicine. 40(3):725-30. 2012.