EMS Cast: Advanced Continuing Education for Paramedics, EMTs & Prehospital Care Providers

Toxic Alcohols: Hidden Danger in Everyday Products and an Everyday Call

Toxicologist Dr. Nik Matsler teaches us the critical topic of toxic alcohol poisoning. The discussion sheds light on the dangers lurking in everyday household and industrial products that contain methanol, ethylene glycol, and isopropyl alcohol—substances not far removed from the alcohol found in beverages yet capable of causing severe, sometimes fatal, health issues.

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Blog Post- Toxic Alcohols

Art of Laryngoscopy- The SALAD technique (Suction-Assisted Laryngoscopy and Airway Decontamination)

In the high-stakes environment of prehospital medicine, the ability to perform a successful intubation on the first attempt is critical. The complexity of prehospital airway management cannot be understated, given the challenging conditions and the acuity of patients encountered. This episode delves into the strategies and techniques that can significantly improve the success rates of prehospital intubations, focusing on preparation, positioning, and the SALAD (Suction-Assisted Laryngoscopy and Airway Decontamination) method.

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Blog post- Art of Laryngoscopy- The SALAD technique

Additional Podcast Episode- Mac 3 vs 4 podcast episode

Additional Resources-

Youtube SALAD demonstration

Published Article on the SALAD Technique

YouTube video of the hypoepiglottic ligament in action

Airway Jedi blog post

Additional SALAD Resources

The Truth about Mechanical CPR Devices: What the Data Really Says

Despite the allure of consistent compressions and reduced provider fatigue, does the data actually show that mechanical CPR devices improve outcomes? Tune in for a nuanced exploration of evidence-based practice in emergency medical services.

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Blog Post- https://emspodcast.com/the-truth-about-mechanical-cpr-devices-what-the-data-really-says/

Original Article- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328162/

Neonatal Resuscitation: Conquering the Fear, Step By Step Guide For Emergency Providers

Overcoming Fear in Neonatal Resuscitation: A Step-by-Step Guide

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Blog post: Neonatal Resuscitation

Introduction:
Welcome to another episode of EMScast, where high-level education meets real-world emergency medical scenarios. Today, we have Dr. Avery MacKenzie, an ER physician from Southwest Colorado, joining us to discuss a topic that often induces stress – neonatal resuscitation. Dr. MacKenzie shares her experiences and insights into handling neonatal emergencies in rural settings.

Summary:
Dr. MacKenzie opens the episode by acknowledging the inherent fear associated with neonatal resuscitation, especially in rural emergency departments where one might be the sole provider. She emphasizes that despite the fear, the process is not hard, and providers already possess the necessary skills.

Key Takeaways:
1. **Facing the Fear:**
   - Dr. MacKenzie encourages listeners to remember that while neonatal resuscitation may seem intimidating, the skills required are well within their expertise.

2. **Algorithm Overview:**
   - The neonatal resuscitation algorithm is simplified into manageable steps, beginning with stimulating, warming, and drying the baby for the first 30 seconds.
   - The next 30 seconds involve providing positive pressure ventilation to initiate breathing.
   - Monitoring the heart rate is crucial, and if it remains below 100, providers should focus on correcting ventilation strategies.

3. **Initial Assessment:**
   - Dr. MacKenzie introduces a simple three-question assessment for determining the need for resuscitation: term gestation, good muscle tone, and respiratory effort.

4. **Positive Pressure Ventilation:**
   - The trigger for initiating positive pressure ventilation is if the heart rate is less than 100 or the baby is apneic or gasping.
   - The emphasis is on adequate ventilation, and adjustments, such as using the MR. SOPA mnemonic, can be made to improve ventilation.

5. **Advanced Airway Considerations:**
   - While advanced airways, such as intubation, are possible, Dr. MacKenzie highlights that pre-hospital protocols may favor supraglottic airways due to the challenging nature of neonatal intubation and the need to limit pauses in oxygenation and respiratory support.

6. **Continued Support:**
   - The algorithm emphasizes a continuous loop of assessment, correction, and reassessment, with the goal of maintaining the baby's heart rate above 100.

Conclusion:
Dr. MacKenzie wraps up the episode by reassuring providers that familiarity with the neonatal resuscitation algorithm and periodic mental reviews can alleviate the fear associated with these critical situations. The key is to focus on what providers already know and apply those skills with confidence.

Crush Injury and Crush Syndrome- Is What You Learned Folklore?

Dr. Nik Matsler is back to discuss the treatment of patients with crush injuries and crush syndrome. Dr. Matsler's insight as an emergency physician and a toxicologist are put to work helping us understand the pathophysiology of crush related injuries.  We also try to discuss very practical approaches to these situations which are complex.  No two crush injuries will present the same.  Many variables contribute to the presentation of these patients. Duration of crush, amount of force applied, the size of the body part crushed, all play a role.  There is much EMS folklore about treating these patients prophylactically in order to stave off deadly arrhythmia.  Does this work?  What treatments matter for these patients?  Paramedics and EMS are the first line of care for these patients.  How can you give them the best chance of survival?

This episode topic was submitted by a listener! Thank you, and please keep the ideas coming.

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Lessons From a Sage: Interview with Jim Barrick

Jim Barrick has more than 37 years of experience in Emergency Medical Services and Helicopter Emergency Medical Services (EMS and HEMS).  His humble approach makes him a wealth of wisdom for anyone in this career field.  As kickoff for 2024 we depart from our normal format of short education topics to long term reflection.  If you work in and around EMS and Critical Care Transport, learn from Jim.  Take time to listen to those in your world that have years of experience and expertise.  Take time to be humble and learn the lessons they pass forward.  Many of them have been paid for with hardship.  Take time to reflect on your goals as a provider and how you want to better yourself in 2024! 

We sat down with Jim in the kitchen of his North Carolina home to learn about his experience with Orange County, North Carolina and Carolina Air Care.  Jim was in a group of 5, that were the first Flight Paramedics in the state of North Carolina.  They helped pioneer a program that is now a staple of EMS in the State of North Carolina.  Carolina Air Care is a division of UNC Health, a part of the University of North Carolina system.  They currently provide critical care transport to the entire state of North Carolina.  They are affiliated with a level I Trauma Center, Burn Center, and a large multi-specialty educational institution.  If it can happen, Jim has seen it.

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Postpartum Hemorrhage- What To Do When the Bleeding Won't Stop

We delve into the high-stakes world of postpartum hemorrhage management with the esteemed Dr. Maria Moreira. Joins us to demystify the management of postpartum hemorrhage in the pre-hospital setting. Dr. Moreira presents a systematic approach to intervention. Learn about the four T's of postpartum hemorrhage and on-field strategies like tranexamic acid and uterotonic administration. Dr. Moreira guides us through a concise roadmap for effective pre-hospital care. Tune in for critical insights and be prepared for any obstetric emergency!

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Episode Summary:

Understanding Postpartum Hemorrhage: Postpartum hemorrhage, or excessive bleeding after childbirth, is a significant concern, occurring in approximately 1-5% of deliveries. The mortality rate associated with postpartum hemorrhage is around 2%, but this can vary globally. Some countries experience mortality rates as high as 20%. Additionally, there's a 10-15% risk of recurrence in subsequent pregnancies, emphasizing the importance of understanding and addressing this issue.

Physiological Changes and Risks: Pregnancy induces significant physiological changes, resulting in a high-volume, low-resistance state. The uterus receives ten times the normal blood flow during pregnancy, making postpartum hemorrhage a critical concern. Notably, vital signs might not immediately reflect bleeding, making early detection challenging. Pregnant patients can lose up to two liters of blood without immediate changes in vital signs.

Recognizing Post-Delivery Physiological Changes: Understanding the physiological changes in vital signs during and after pregnancy is crucial for pre-hospital providers. Pregnancy induces peripheral vasodilation, causing a slight drop in blood pressure. The heart rate increases by 10-15 points, and the respiratory system undergoes changes, requiring increased oxygen. Although the heart rate goes up in a pregnancy and the blood pressure goes down normaly, it is important that any abnormal vital signs such as a heart rate above 100 and a blood pressure below 100 systolic be treated as abnormal until proven otherwise.

Four T's: Causes of Postpartum Hemorrhage:

1. Tone: Involving inadequate uterine contraction, the most common cause.
2. Trauma: Typically lacerations that result during delivery and can lead to significant bleeding.
3. Tissue: Relates to retained placental tissue.
4. Thrombin: Referring to coagulopathy or difficulty in clotting.

Approach to Postpartum Hemorrhage in the Field: In a pre-hospital setting, managing postpartum hemorrhage involves a systematic approach. Key steps include:

• Administration of TXA: Tranexamic acid, if available, can help reduce bleeding.
• Uterotonic Administration: Oxytocin induces uterine contractions. If not available, can have baby latch which will stimulate the production of moms natural occurring oxytocin.
• Fundal Massage: Applying firm pressure to the uterus to encourage contraction.
• Addressing Lacerations: Check for lacerations and apply direct pressure to bleeding points if lacerations are visible.
• Transport to Hospital: Prioritize getting the patient to the hospital immediately for further evaluation and intervention.

Secondary Postpartum Hemorrhage: In some cases, bleeding may occur after the initial 24 hours post-delivery, indicating secondary postpartum hemorrhage. Possible causes include retained products, subinvolution of the placental bed, or infection. In such cases, prompt resuscitation aimed at supportive care of abnormal vitals and transport to the hospital are critical.

Summary and Takeaways: Dr. Moreira emphasizes the importance of considering postpartum hemorrhage in every pregnant patient. Pre-hospital providers should be prepared to manage complications by following a systematic algorithm. Early recognition, administration of appropriate medications, fundal message, direct pressure and prompt transportation to the hospital are key components of effective intervention.

In conclusion, being proactive and vigilant in managing postpartum hemorrhage in the field is crucial for ensuring the well-being of both mother and child. Regular training, awareness, and a systematic approach are vital for pre-hospital providers to navigate these critical situations successfully.

Delivering Nuchal Cords, Breech Presentations, Shoulder Dystocias- Field Obstetrics, What To Do When Things Go Sideways

In this episode Dr. Maria Moreira joins us to talk us through prehospital pregnancy difficult deliveries. We'll discuss how to handle nuchal cords, cord prolapse, breech presentations, and shoulder dystocias.

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Videos of each technique- https://emspodcast.com/difficult-deliveries/

Which is Better, Midazolam IV, IM or IN?

In this episode we look at a recent observational study out of the journal of neurology looking at the effectiveness of midazolam when comparing the IV vs IM vs IN routes. We'll discuss the study as well as other studies involving status epilepticus to tease out best practices for your next shift. 

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This Episodes Journal article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9930617/

RAMPART trial: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211107/

American Epilepsy Society Algorithm: https://www.aesnet.org/clinical-care/clinical-guidance/guideline-prolonged-seizures?_gl=1*1lmlmse*_ga*MTIzMDc0MjA2NC4xNzAwMDM0ODUx*_ga_GV192D9FPY*MTcwMDAzNDg1MS4xLjAuMTcwMDAzNDg1MS42MC4wLjA.

Blog post: 

Non-Invasive Ventilation - Do You Understand the Physiology?

There are few treatments in our tool box that can have more of a positive impact than non-invasive ventilation. This episode is designed to help you better understand the physiology of how it works and how to use it more effectively. Dr. Bo Burns, the Chair of Emergency Medicine at the University of Oklahoma School of Community Medicine, joins us again for another great discussion. 

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Blog post- https://emspodcast.com/non-invasive-ventilation-understanding-the-physiology/

Intubation checklist mentioned at the end of the episode- https://emspodcast.com/ou-em-intubation-checklist/