Loud & Clear: EMS Guiding Principles - Advanced Continuing Education for Paramedics, EMTs & Prehospital Care Providers

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/

Can End Tidal CO2 Predict Mortality in Hemorrhagic Shock? Part 2 with Paramedic Courtney ”Coco” Wham

Coco Wham is a paramedic at the Denver Health Paramedic Division. She is also a 4th year medical student and has a masters in integrated sciences.  She is an author on a recent study in the American Journal of Surgery with our previous guest, Dr. Eric Campion.  Their latest study looked at prehospital ETCO2 values and if they were predictive of death and need for massive transfusion as compared to commonly accepted measurements, such as systolic blood pressure and shock index.  The new study is titled, "Prehospital ETCO₂ is predictive of death in intubated and non-intubated patients."  We discuss this study with her and what's next for this research.  We also touch on why prehospital providers should get involved with research.

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What Can End Tidal CO2 Tell Us About Hemorrhagic Shock? Part 1 with Trauma Surgeon Dr. Eric Campion

Dr. Eric Campion is an attending trauma surgeon at Denver Health Medical Center in Denver, Colorado. He has several studies published on the utilization of End Tidal CO2 (ETCO2) in critically injured hemorrhagic shock patients.  As a former paramedic, Dr. Campion has also been studying this data's application to the prehospital setting.  In this episode we discuss the results of two specific studies which lead to his most recent study with Paramedic Courtney "Coco" Wham.  There will be a companion episode released later this month!

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Recognizing Individual Differences: Personalized Approaches to Pain Management

Dr. Spencer Tomberg, a physician in the Department of Emergency Medicine and Orthopedics at Denver Health, discusses pain management and the complex nature of pain perception, highlighting the physical and emotional components. He describes how individuals may have different perceptions of pain due to variations in the action potential and synaptic regions. He dives into the etiology and routes of pain signals from the visceral system and how that contributes to referred pain. He also discusses the differences in treatment when approaching acute, subacute, and chronic pain. Ultimately, it's important to consider the individuality of pain experiences when treating patients and not take a one size fits all approach. Check out another great lecture from the Rocky Mountain Trauma and Emergency Medicine Conference.

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See more from the blog post on our website at:

https://emspodcast.com/pain-perception-is-complex/

Legendary Trauma Surgeon Dr. Gene Moore - how REBOA is changing trauma resuscitative care

In the high-stakes world of emergency medicine, innovations continually push the boundaries of what's possible. One such groundbreaking procedure is Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Dr. Ernest E Moore, who has literally written the book on trauma surgery, teaches us what REBOA is and how it is being used to save lives in critical situations. Another episode from the Rocky Mountain Trauma and Emergency Medicine Conference. 

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See more on this topic from the blog post on our website:

https://emspodcast.com/resuscitative-endovascular-balloon-occlusion-of-the-aorta-reboa/

 

Are you sure you're prepared for your next intubation? Dr. Stacey Trent Reviews the most up-to-date literature for intubation best practices.

Dr. Stacy Trent, an Associate Professor of Emergency Medicine at the Denver Health Emergency Department, discusses the importance of proper airway management in the emergency setting and introduces the mnemonic SOAPME (suction, oxygen, airway assessment, pharmacy and plan, monitor and equipment) for intubations. Dr. Trent brings with her the most up to date literature about optimizing success and decreasing adverse events during intubation. In this episode we delve deep into the often overlooked aspects of pre-oxygenation and airway assessment, emphasizing the need for thorough preparation and the potential consequences of neglecting these steps.

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More on our website at: https://emspodcast.com/are-you-prepared-for-your-next-intubation/

Plus check out this new trail on DL vs VL for intubation that Dr. Trent eludes to at the end of this episode: https://www.nejm.org/doi/pdf/10.1056/NEJMoa2301601