EMTpro Podcast

In this episode, the whole team is back for a spirited round of “EMS Jeopardy.” Steve takes on the role of game show host as Dan and Holly face off, answering questions across categories like airway and breathing, cardiology and resuscitation, medical emergencies, trauma and shock, EMS protocols and safety, and basic pharmacology. Tune in for a fun and informative review of EMS topics at all difficulty levels, brought to life by the lively banter of some of the field’s most respected and well-known professionals.

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EMS is notorious for the high stress, long hours, and repeated exposure to trauma that leave an alarming number of burned-out professionals in its wake. Whether you work for a private ambulance, fire department, or in a hospital setting, burnout is a real and pervasive threat to the well-being of any EMS provider. And, where burnout is often found, so is a toxic workplace. In this episode, Steve, Dan, and Holly talk about their experiences in toxic environments or around toxic individuals. They discuss how easy it is to become part of the toxic culture, and why that makes it crucial to recognize associated patterns of thoughts and behavior and rise above them. The team then walks through steps to prevent becoming entrenched in the thoughts and behaviors that lend themselves to toxicity. This episode provides an opportunity to reflect both on one’s environment and to look inward to examine if there are aspects of toxicity that have crept into our thoughts and practices. It also gives helpful tools to self-correct to preserve our mental health and support and improve our department’s culture.

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In this episode, Steve, Dan, and Holly are back in the studio as Holly leads the team through an in-depth discussion on the trauma death triad (diamond). They discuss each component – hypothermia, acidosis, coagulation – and that tricky final component that plays a role in all three, calcium. Holly provides a scientific breakdown of each component, and then the team discusses the practical implications of each component in the “real-life” management of a trauma patient in the field.  Holly also touches on some longer-term implications of trauma management for those providers who end up on scene with a patient for longer than they bargained for or who provide an interfacility transfer for a patient a few days after their initial incident.

This episode provides helpful insight for all providers in both the initial and ongoing assessments of any patient who has experienced a massive trauma, and what we can do in the field to mitigate mortality and positively impact their overall outcomes.

References

See Holly’s slides below!

Trauma Death Triad_PDF

In this episode, Steve, Dan, and Holly are joined by guest Matt Shamrell, a burn unit ICU nurse. Matt discusses treatment processes for burn patients, including fluid resuscitation, pain management, and wound care. Matt answers questions about risk factors for, and the in-hospital management of, compartment syndrome as well as the potential for severe and life-threatening infections in burn patients. The team discusses how EMS providers can best treat burn patients to ensure the transition of care from pre-hospital to in-hospital is as seamless as possible.

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.

Show Notes:

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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.