In this episode of the Pre-Hospital Care Podcast, we're joined by Dr Jo Mildenhall to explore a critical and often under-discussed issue in pre-hospital medicine: burnout.

Frontline ambulance staff experience some of the highest rates of sickness absence in the NHS, with stress, anxiety, and depression frequently cited as the cause. While much attention has traditionally focused on the impact of major traumatic incidents, Jo's research has consistently challenged this narrative, highlighting that the cumulative burden of daily hassles, operational pressures, organisational friction, resource constraints, moral distress, and relentless demand may be equally, if not more, damaging to psychological wellbeing.

Drawing on her latest work on the social psychological dynamics within ambulance service culture, Jo examines how group identity, workplace relationships, and collective experiences of adversity shape the way ambulance clinicians perceive, process, and respond to stress and trauma. Her research suggests that the cultures we work within profoundly influence our emotional responses, coping behaviours, and willingness to seek support. We unpack the informal coping mechanisms paramedics often turn to, including cognitive strategies, gallows humour, and peer support, and examine what it is about these strategies that they find particularly helpful.

With Jo's extensive experience in both clinical and educational settings, we reflect on how workplace culture, leadership, social identity, and peer relationships shape how paramedics manage stress, and what more can be done to protect psychological wellbeing on the front line. Ultimately, this episode asks an important question: if burnout is driven as much by the accumulation of everyday pressures as by extraordinary events, how do we build ambulance services that are not only operationally effective but also psychologically sustainable?

Please find Jo's latest research here: https://www.researchgate.net/publication/272449530_Occupational_stress_paramedic_informal_coping_strategies_a_review_of_the_literature

On the Pre-Hospital Care Podcast, we spend a lot of time discussing clinical decision-making, operational challenges, and the science that underpins emergency medicine. But now and again, it's important to step back and remember why we do what we do. Behind every dispatch is a person. Behind every set of observations is a family. And behind every successful mission is a story that often continues long after the helicopter has landed and the ambulance has left.

Today's guest is Shane Bradley. On the 27th of July 2025, what began as an ordinary day quickly became a fight for survival when Shane suffered a heart attack. Thanks to the rapid response of the emergency services, including the Devon Air Ambulance, he was transported to definitive care. His consultant later told him something few patients ever hear: that the helicopter almost certainly made the difference between life and death.Nearly a year later, Shane isn't simply reflecting on what happened. He's determined to give something back. To mark the anniversary of what he calls his "second chance at life," he's embarking on an extraordinary challenge: riding his motorcycle 1,000 miles in under 24 hours to raise funds for the charity that helped save him.

This is a conversation about survival, gratitude, recovery, and the profound impact that pre-hospital care can have, not just on a patient's outcome, but on the rest of their life. To give to Shane's challenge for Devon's Air Ambulance, please see here: https://www.justgiving.com/page/shanes1000mileride

The illicit drug market is evolving faster than ever before. Novel psychoactive substances (NPS), synthetic opioids and increasingly potent club drugs are creating new challenges for pre-hospital clinicians, emergency departments and critical care teams. Patients are presenting with unfamiliar toxidromes, unpredictable physiology, and rapidly deteriorating clinical conditions that demand evidence-based assessment and management.

The episode begins with insights from Dr Caroline Copeland, Senior Lecturer in Pharmacology and Toxicology at King's College London and Director of the National Programme on Substance Use Mortality. Caroline explains how the illicit drug market has transformed over the past decade, discussing the emergence of synthetic opioids, nitazenes, novel benzodiazepines and the ever-expanding range of novel psychoactive substances. Drawing on national surveillance data and forensic toxicology, she highlights the trends every frontline clinician should understand and the public health implications of these rapidly evolving substances.

Building on that foundation, Owen Bowden-Jones, Consultant Psychiatrist and one of the UK's leading experts in club drugs and addiction medicine, takes us into the practical realities of managing patients who have taken MDMA, ketamine, GHB/GBL, synthetic cathinones, synthetic cannabinoids ("Spice"), nitrous oxide and other emerging recreational drugs. The discussion focuses on recognising toxidromes, avoiding common pitfalls and delivering safe, evidence-based supportive care in the pre-hospital and emergency setting.

• How the illicit drug landscape has changed over the last decade.
• Novel psychoactive substances (NPS) and why they continue to emerge.
• Synthetic opioids, nitazenes and the growing public health threat.
• MDMA toxicity and serotonin syndrome.
• Ketamine: recreational use, toxicity and chronic complications.
• GHB/GBL overdose and withdrawal.
• Synthetic cathinones ("bath salts") and severe behavioural disturbance.
• Synthetic cannabinoids ("Spice") and unpredictable toxicity.
• Nitrous oxide misuse and neurological injury.
• Recognising toxidromes rather than chasing an exact drug diagnosis.
• Managing agitation, hyperthermia and cardiovascular instability.
• Harm reduction and communicating with patients who use recreational drugs.
• Emerging drug trends every pre-hospital clinician should know.

This episode brings together and expands on two previous conversations from the Pre-Hospital Care Podcast:

• Novel Psychoactives and The New Drug Landscape: A Conversation with Dr Caroline Copeland
  https://podcasts.apple.com/gb/podcast/novel-psychoactives-and-the-new-drug/id1441215901?i=1000748836782
• Club Drugs, Illegal Highs and Novel Psycho-active Substances with Owen Bowden-Jones
  https://creators.spotify.com/pod/profile/phcp/episodes/Club-drugs--illegal-highs-and-Novel-Psycho-active-Substances-with-Owen-Bowden-Jones-ejk7rf

You can find excellent online eLearning resources on Club Drugs and NPS here: https://elearninghub.rcpsych.ac.uk/products/Module_1_Introduction_to_club_drugs_and_NPS

These are empirical studies conducted and published by Caroline Copland: https://www.kcl.ac.uk/people/caroline-copeland

Pain is one of the most immediate and universal experiences of trauma, yet in emergency and pre-hospital care, it remains surprisingly under-treated. Despite decades of awareness, oligoanalgesia, the inadequate treatment of acute pain, continues to affect patients in the very moments when compassionate, effective care matters most. Too often, the focus in emergency systems has been on processes: whether a drug was given, which medication was used, or how quickly it was administered. But from the patient’s perspective, the real question is much simpler: did their pain actually get better?

In this episode, we explore a powerful shift in thinking: what if pain management wasn’t something that happened later in care, but something that started immediately, from the very first patient contact? What if analgesia were treated as a core patient-centred outcome rather than an optional add-on?

Joining us today are Luca Carenzo and Urs Pietsch, whose recent editorial challenges us to rethink how and when we deliver analgesia in trauma. We’ll discuss the concept of “pain first,” the growing role of non-intravenous analgesics such as transmucosal fentanyl and inhaled agents, and what this means for paramedics, HEMS teams, and pre-hospital systems worldwide. Find the editorial here: https://pubmed.ncbi.nlm.nih.gov/41673878/

This episode is sponsored by PAX: The gold standard in emergency response bags.

When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.

PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.

PAX – built to perform, made to last.

Learn more at ⁠https://www.pax-bags.com/en/⁠

In this episode, we welcome Dr Abigail Pamich, an experienced Clinical Psychologist with more than 20 years of experience working in mental health and psychological therapy. Dr Abigail leads a private psychology practice in the UK, overseeing a team of 12 highly skilled therapists who provide evidence-based therapy remotely to clients across the UK and internationally.

Together, we explore Eye Movement Desensitisation and Reprocessing (EMDR), one of the most researched and effective psychological therapies for trauma, post-traumatic stress disorder (PTSD), anxiety and other distressing psychological conditions. Dr Abigail explains what EMDR is, how it works, and why it has become an increasingly important treatment within trauma-informed care. We unpack the theory underpinning EMDR, including the Adaptive Information Processing (AIP) model and the role of bilateral stimulation, before discussing what patients can expect during an EMDR session and how traumatic memories can be processed safely and in a structured way.

We also discuss Dr Abigail's journey into EMDR, what first inspired her to specialise in the therapy, and how her clinical experience has shaped her understanding of psychological recovery. The conversation examines the growing empirical evidence supporting EMDR, the conditions for which it is recommended, and how it compares with other established psychological treatments, including cognitive behavioural therapy (CBT) and other trauma-focused therapies.

Using compelling clinical examples and anonymised case studies, Dr Abigail demonstrates how EMDR can help individuals recover from traumatic experiences, reduce anxiety, overcome phobias and process difficult life events that continue to affect everyday functioning. Finally, we discuss the evolution of remote psychological therapy and how EMDR can be delivered effectively through secure online consultations, improving access to specialist trauma care for patients regardless of their location.

Whether you're a healthcare professional interested in trauma-informed care, someone considering EMDR therapy, or simply curious about the neuroscience of psychological recovery, this episode offers an accessible, evidence-based introduction to one of the most influential developments in modern psychotherapy.

• What EMDR therapy is and how it works.
• The science behind bilateral stimulation and the Adaptive Information Processing model.
• The evidence base supporting EMDR for PTSD, trauma, and anxiety.
• How EMDR compares with CBT and other psychological therapies.
• Common misconceptions about EMDR.
• Real-world clinical case examples demonstrating its impact.
• Delivering EMDR safely and effectively through remote therapy.
• Why trauma-informed care is becoming increasingly important across healthcare.

This episode is sponsored by PAX: The gold standard in emergency response bags.

When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.

PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.

PAX – built to perform, made to last.

Learn more at ⁠https://www.pax-bags.com/en/⁠

On today’s episode, we’re diving into a case study that captures the reality of modern prehospital care at its most demanding: a high-speed road traffic collision resulting in major trauma, an evolving shock presentation, and tension between competing priorities in the field. This case comes from Dr Michael DeFilippo, an Emergency Medicine and EMS physician, and it challenges us to think beyond protocols, to physiology, pattern recognition, and decision-making under pressure.

In this episode, we’re going to slow this case down and unpack it, drawing out the key learning points, clinical decision-making frameworks, and practical prehospital strategies that shaped the outcome. From early shock recognition to fluid strategy, analgesia, and transport decisions, this is a case packed with insights for anyone working in high-acuity, time-critical care.

You can read Mike's Substack post here: https://emsdrmike.substack.com/p/c1-dcr-trauma

This episode is sponsored by PAX: The gold standard in emergency response bags.

When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.

PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.

PAX – built to perform, made to last.

Learn more at ⁠https://www.pax-bags.com/en/⁠

This special compilation brings together three of our most important episodes exploring the medico-legal aspects of pre-hospital care. From documentation and communication to legal responsibilities and ethical decision-making, this collection provides practical guidance to help clinicians navigate some of the most challenging situations they will encounter in practice.

We begin with Mark Faulkner, who was the Assistant Medical Director at the London Ambulance Service at the time of recording. Drawing on more than a decade of experience supporting and leading the organisation's pre-hospital legal department, Mark shares invaluable insights into the legal principles that underpin safe clinical practice and how clinicians can protect both their patients and themselves.

Across the series, we explore:

• High-quality documentation and effective clinical handovers
• Duty of care, negligence, and professional accountability
• Mandatory reporting and safeguarding
• Confidentiality and working alongside law enforcement
• Managing legal challenges during major incidents
• Patient autonomy, capacity, and refusal of treatment
• Advance decisions and end-of-life care
• Practical approaches to ethical and legal decision-making

The compilation concludes with Steve Bell, Consultant Paramedic and Consultant HEMS Paramedic, who discusses the complex intersection between ethics and law in pre-hospital care, providing practical strategies for navigating difficult decisions in the field.

Documentation and Communication: Medico-Legal Aspects of Care – Part 1 (Mark Faulkner)

Managing Complex Legal Scenarios: Medico-Legal Aspects of Pre-Hospital Care – Part 2 (Mark Faulkner)

Ethical and Legal Decision-Making: Medico-Legal Aspects of Pre-Hospital Care – Part 3 (Steve Bell)

Whether you're a student, paramedic, critical care practitioner or physician working in pre-hospital care, these conversations offer practical, evidence-informed advice to strengthen your clinical decision-making, improve patient safety and reduce medico-legal risk.

This episode is sponsored by PAX: The gold standard in emergency response bags.

When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.

PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.

PAX – built to perform, made to last.

Learn more at ⁠https://www.pax-bags.com/en/⁠

In pre-hospital care, few environments demand more precise and timely judgment than within a HEMS system. Decisions are made rapidly, often with incomplete information, within dynamic and unforgiving conditions. It is an operational space where clinical urgency intersects with aviation risk, and where each intervention requires a careful balance between decisive action and the principle of doing no harm.

Today’s guest, Adele Dobler, works at this exact interface. With thousands of flight hours spanning urban HEMS, remote medical evacuation, and high-risk environments, from central London to the deserts and high-altitude regions of Kenya, she brings exceptional depth of experience in high-stakes decision-making. Her operational background includes flying aircraft such as the H135 and H145, frequently at night, under night vision goggles (NVG), and within complex, evolving mission profiles across diverse global settings.

In this episode, we examine the realities of decision-making in HEMS, including cognitive load, inherent biases, operational trade-offs, and the critical inflection points that shape outcomes. The discussion focuses on dynamic judgment, risk management, and professional accountability in an environment where decisions must be made in real time, with minimal scope for error. 

This episode is sponsored by PAX: The gold standard in emergency response bags.

When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.

PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.

PAX – built to perform, made to last.

Learn more at ⁠https://www.pax-bags.com/en/⁠

What you do in the first few minutes after a burn injury can influence not only survival, but pain, healing, scarring, and long-term quality of life.

In this special compilation episode, we've brought together both parts of our conversation with burns specialist Krissie Stiles into one comprehensive masterclass. Whether you're revisiting these episodes or listening for the first time, this is an evidence-based guide to the assessment and management of burns in the pre-hospital environment.

Across the episode, we discuss:

• The pathophysiology of burn injury and why it matters clinically
• Evidence-based burns first aid, including optimal cooling strategies
• Assessing burn depth and total body surface area (TBSA)
• Airway assessment and recognising inhalation injury
• Analgesia and pre-hospital pain management
• Fluid resuscitation—who needs it and when
• Dressings, packaging and transport considerations
• Referral criteria and working with specialist burns services
• Common myths and pitfalls in burns management
• The lifelong physical and psychological impact of burn injuries

Krissie combines decades of clinical expertise with practical advice that can be applied immediately by paramedics, emergency physicians, nurses, and all clinicians involved in pre-hospital emergency care.

Listen to the original episodes:

Part 1 – Pre-Hospital Burns with Krissie Stiles
https://podcasts.apple.com/us/podcast/part-1-pre-hospital-burns-with-krissie-stiles/id1441215901?i=1000672971414

Part 2 – Pre-Hospital Burns with Krissie Stiles
https://podcasts.apple.com/us/podcast/part-2-pre-hospital-burns-with-krissie-stiles/id1441215901?i=1000673376119

Whether burns are a rare part of your clinical practice or something you encounter regularly, this episode is packed with practical pearls that will improve your confidence and your care.

If you enjoy this episode, please consider subscribing, leaving a review, and sharing it with colleagues; it really helps us continue producing free educational content for the pre-hospital community.

Communication under pressure is one of the most critical and most fragile skills in pre-hospital care. When it fails, the consequences can be immediate and profound. In this episode, we explore why communication breaks down in high-stress environments, what that costs us clinically, and, crucially, what we can do to improve it.

Joining me is Dr Stephen Hearns, one of the most influential figures in emergency and retrieval medicine. A consultant in emergency and aeromedical retrieval medicine, he is the founding force behind Scotland’s Emergency Medical Retrieval Service (EMRS), a government-funded critical care organisation delivering advanced pre-hospital care across some of the UK’s most remote and challenging environments. With over 30 years of experience spanning HEMS, mountain rescue, expedition medicine, and medico-legal practice, Stephen is a globally recognised authority on human performance under pressure. He is an Honorary Senior Lecturer at the University of Glasgow, has published extensively on human factors in acute care, and has played a key role in developing postgraduate education in retrieval and transfer medicine.

Further reading relevant to this episode from Stephen can be found here:⁠ https://corecognition.co.uk/performance-infographics/8-tools-to-improve-communication-under-pressure

Learn more about Core Cognition:⁠https://corecognition.co.uk/⁠