EMTpro Podcast

Steve and Dan co-host their first show without Holly as they welcome special guest Eric Jaeger. Eric is an RSI Paramedic and Attorney from New Hampshire who leads the discussion on best practices for physical restraint and chemical sedation and the legal ramifications these interventions carry. Eric shares his knowledge of the tragic circumstances surrounding George Floyd and Elijah McClain’s deaths and discusses improvements to consider when it comes to protocols and guidelines for these procedures.

In today’s episode, Steve, Dan, and Holly have the opportunity to discuss an interesting MCI call with guest, Firefighter/Paramedic Kyle Snider. At the time of the incident, Kyle was a new paramedic graduate with wilderness medicine training who was working in a rural department with limited resources. Kyle discusses the call from the point of dispatch to call completion and reviews what he felt went well and what he would have changed. This episode gives the team a chance to discuss how we often leave chaotic scenes feeling overwhelmed and discouraged; however, reviewing the call with others in the field can be helpful to see where we performed well and where or what we could do to make improvements if faced with a similar call in the future. When discussing this call, we see how Kyle managed as the PIC and only paid medic while ensuring all patients received care. He then took what he learned from this call to help make personal and departmental improvements moving forward.

It is no secret that we, as a nation, are experiencing extreme implications of opioid abuse. In this episode, Holly talks about a new program she is helping head, whose goal is to provide treatment to patients suffering from opioid addiction. This cutting-edge program utilizes a medication called buprenorphine to initiate treatment in the field and provide ongoing care for willing patients. While there is still much to learn, Holly discusses the research behind the foundation of this program, its successes thus far, and some learning points. The team discusses how this information is helping shape the current program and providing crucial data for future programs. This episode sheds light on current opioid abuse and overdose statistics, discussion around the steps of behavioral change, and relevant data on what treatment is proving most effective for individuals suffering from opioid addiction.

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In this follow-up episode, Bruce and the team continue discussing ventilation and airway management. This episode goes into greater depth on how ETCO2 can be used to manage an array of patients effectively and how a thorough understanding and monitoring of end-tidal during a resuscitation attempt can help ensure a patient remains neurologically intact, assuming ROSC is achieved. Bruce covers case studies on this topic, and the team has the opportunity to look at the “oscillations” in end-tidal and how they provide vital information on the efficacy of CPR and PPVs. This episode provides unique insight and information on the delivery of effective ventilations and how to best use the tools in our toolbox to ensure our patients receive the highest possible level of care. This episode highlights the central theme of part 1: that airway management should not be lightly handed over to the least experienced provider; instead, thorough training should be provided to all members of a crew to ensure all are competent and understand the weight and importance of the delivery of effective ventilations to not only the management of the patient while they are in crisis, but to their longevity following the incident.

Below are graphics and their descriptions provided by Bruce to help understand concepts discussed in the course.

This example shows “Oscillations, 30:2 Ventilations. This patient is intubated (Patent Airway). Tidal Volume is excellent, and compressions look high quality. You can see it all play out.  Also, notice that in the 30:2, the first end-tidal waveform is shortened.  That is because we are trying to give two really fast breaths, so we interrupt the first breath out with an immediate 2nd breath in, giving it a shortened waveform.  This is trained at TVFR to give your two breaths and then look for a shortened waveform, and the 2nd breath has the compressions.  Appreciate how consistently our variables work together, and the end-tidal is not wavering or all over the place.”

– Bruce Opsal

The above example “Is a crew that gave the bonus breaths that I discussed in the podcast. Rhythm Change (Sinus Bradycardia), not perfusing, and the end-tidal drastically is dropping breath by breath.  You might think, if I give 4 stacked breaths, wouldn’t that lower the end-tidal, and the answer is no.  You will not have a drastic change as that, where the first breath is around 50 and by their 5th breath, it’s at 20.  I would argue that it will just outright sustain if the heart is perfusing.  A student contested this, so I just had him put on an end-tidal and a monitor and watched him dry to drop his capnometry even one point from 1 – 5 breaths, and he couldn’t do it.”

In this episode, Steve, Dan, and Holly talk with Bruce Opsal, a long-time firefighter and paramedic who has spent years leading training programs centered on effective airway management and ventilation. Bruce first emphasizes the importance of airway management in any patient, especially those in cardiac arrest. The team talks about how the previous line of thought was to assign the airway to the least experienced provider and then forget about it. However, this is evolving in pre-hospital management as we better understand the importance of careful and attentive airway management. Bruce then introduces his 6-step process for confirming effective ventilations, and through this discussion, providers of all levels can glean helpful tools for effective airway management and successful delivery of ventilations. The team spends the most time on one step that is not often well understood, which is end-tidal (ETCO2). Throughout their discussion, Bruce and the team go through what end-tidal is measuring, how it can confirm effective PPVs and/or airway placement, and how it can be used to manage a patient successfully during cardiac arrest. This episode allows listeners to challenge the current thought processes around out-of-hospital airway management and gives a new perspective on effectively managing an airway.

Below is a graphic and description provided by Bruce that will help the listener understand some of the concepts discussed in this course.

“[This] is a nice visual I found […] I like seeing the EtCo2 line and its relationship to CO2 in the blood. This helped me get to my soup analogy.”

– Bruce Opsal

Dr. Selbak joins Steve, Dan, and Holly to discuss a few unique case studies. The episode begins with Steve walking the team through a call that raises many questions for his crew. As the case is discussed, the listener is encouraged to critically consider the patient’s history, symptoms, presentation, and additional lab values as they are given. At the same time, Dr. Ramsay discusses his process for assessing and managing this patient and ultimately comes to a diagnosis.

The second half of this episode provides an overview of hyperkalemia – what it is, how it happens, how it often presents, and how it may be stabilized in the field and definitively treated in the hospital setting. Field providers do not often understand hyperkalemia and its field treatment, so the team breaks down the etiology of hyper-k and the mechanisms of action for the classic medications used to treat it in the field. The listener also gets insight into how these patients are managed in the hospital in the short and long term, which helps paint a complete picture of the hyper-k patient.

This episode demonstrates the importance of history gathering and provides a deeper insight into lab values and how they are used to diagnose patients with less obvious disease processes. Listeners should walk away feeling better equipped to identify both endocrine and electrolyte imbalances in patients with unique presentations.

In this episode, Steve presents two trauma case studies for the group to discuss. While patient care in both of these calls went well, and these scenarios provide an overview of successful extrication and patient management following both an MVA and significant blunt force trauma, the distinguishing factor in each is a particular element that caught Steve “off guard” and forced him to revisit the call days or weeks later. As first responders, we often arrive on scenes that we assume will be “routine” or similar to calls we have been to before; however, it is essential to understand that sometimes there are elements of a call that, while on scene, may not affect our patient care or ability to perform, but later they stick with us and prevent us from adequately processing the call. The element that sticks or “catches us off guard” will vary, but the result is often the same…the memory refuses to file itself into our mental Rolodex of calls properly. It is like a page of a book that has folded and torn, catching on the pages around it and preventing the book from closing properly. For these calls, we hope to recognize these “sticking points” and seek help from a trusted mental health professional to prevent these points from gumming up the surrounding mental space and preventing us from processing all incoming information and future calls.

This episode provides an interesting insight into trauma patient assessment, management, and transport. However, it also emphasizes the work we, as healthcare providers and first responders, must do to maintain pique mental health and continue to provide a high level of care to patients in unpredictable and ever-changing scenarios. 

In today’s episode, the team talks with Daniel Sundahl, a 20-year Firefighter/Paramedic, and artist. Daniel discusses how his experiences navigating PTSD led him to create powerful artwork, which is now helping open the conversation around mental health for first responders. For decades, mental health care was neglected for those working in the field, meaning responders were repeatedly exposed to traumatic events with little (if any) time to process what they saw, heard, treated, and experienced. While stigmas are still attached to seeking care for mental health, the concept that only the weak need help is slowly being dismantled. Therefore, the team takes the time to broach this sensitive subject with the hopes of helping first responders across the country, continent, and world seek help and care while recognizing they are not alone.

This episode delves into the evolution of mental health care with expanding research around mental health and traumas. It also emphasizes the value of those with years of experience using their history in the field to build a foundation of support and care for current and future first responders.

If you or someone you know is in crisis or having thoughts of suicide, please call 988 (U.S.) or go to https://988lifeline.org/.

If you want to view Daniel’s artwork, read more about his story, or see where his artwork will be on display, visit https://www.dansunphotos.com/.

In this episode, Steve, Dan, Holly, and Dr. Selbak review a few of their calls involving aortic dissections. Because aortic dissection is a relatively uncommon disease process, and many severe cases never make it to the hospital, reviewing these cases provides a unique opportunity for the listener to gather abundant knowledge in one sitting that may otherwise take years to gather in the field. The team also discusses how patient presentation, vital signs, and history gathering can point a provider towards aortic dissection over other cardiac or pulmonary conditions and how a few relatively simple tests in the ER can help confirm a field provider’s suspicions.

The goal of this episode is to encourage listeners to be on high alert for a few key phrases and to be cautious about falling into the classic trap of overlooking a patient simply because their signs and symptoms may not be glaringly obvious or particularly alarming. We all know that two patients with the same etiology can present drastically differently, and this podcast not only provides a few clear examples of this but also sheds light on why that might occur. 

In this episode, Steve, Dan, and Holly talk with Dr. Ramsey Selbak about the increasing prevalence of violence in healthcare. They each take a turn providing examples of dangerous situations they’ve been involved in, how they handled them, and how they have adjusted their tactics as providers since. This episode introduces a much-needed conversation about provider safety in healthcare and how it has long been neglected. The team touches on why violent incidents seem to be more commonplace, why they often go unreported, and the lack of debriefing many EMS providers have following these events.

The team goes on to explore how a lack of training on entering unsafe scenes often puts providers at risk, and how much of this is because, historically, EMS providers did not enter unsafe situations without law enforcement. However, this seems to be changing, and EMS providers often have to call for law enforcement after the situation has already devolved. This episode forces the listener to reflect on their own experiences and consider steps each of us may need to take to keep ourselves, our patients, our crews, and future EMS providers safe in an ever-changing field.