How does giving a loop diuretic actually cause the body to retain CO2??? What does that have to do with fluid management?! Surprise, quite a bit actually. Tune in and find out!

We have most likely all had the phone call from the lab before, asking for a re-draw on our patient due to lab hemolysis. Have you ever thought about why that happens and how we can reduce it? It is not just the desire of a larger-bore IV catheter...you can pull fantastic non-hemolyzed labs off of a 24G IV catheter...let's talk about how!

Similar to the Aortic Stenosis and head-bobbing, Mitral stenosis can also cause a peculiar side effect, that being Dysphagia. Can you figure out how this might happen before listening? See if you were right!

Thrombocytopenia and Heparin aren't usually thought of together, at least Heparin not as being a potential cause. This episode will look at how that can be possible!

There are some things in medicine that, when you learn the mechanics behind it, are just, well,...cool! Unfortunate, but cool to see. One wouldn't initially think something like aortic regurgitation would be that, but this episode looks at how AR can actually cause head-bobbing in patients. It is rarer than you think but still something to look for!

We have heard about O2 and CO2 in patients like COPD'ers...but what happens truly when CO2 builds up to dangerous levels in the body? How does ventilation actually shut down? What do we do about it?

DKA is a wild animal. Taming it in our sick patients can be incredibly challenging. The newest criteria are out for diagnosis of DKA, and there have been a few bigger changes. Tune in to keep up!

We are all most likely pretty adept at initial fluid resuscitation and repletion rates for pediatrics. What happens after the patient is more stable-ish? In that time period where we must now maintain the patient? How do we calculate appropriate fluid infusions and electrolyte infusions?

This episode is a review on the pharmacology behind Phenylephrine, a very potent alpha vasopressor, its uses, cautions, and more!

If you interpret lab values, you have most assuredly fallen into the same trap I have in the past of taking something at face value and not reasoning against trends or in conjunction with other lab values. In medicine this can cause dangerous conditions of either inappropriately-diagnosing someone with something they don't have, or missing a diagnosis of something they do have. Both have their consequences. In this episode I look at 4 of the more common lab interpretation traps and how to avoid them. Learn from my mistakes!

If you are like me, you probably have trouble remembering the difference between heart murmur grades, whether S4 comes before S1, S3 after S2, and why it even matters. This episode breaks this down as simple as I think it can possibly be broken down, with the "why" behind it.

Who are you more concerned about, the patient with a blood pressure of 96/70 or the patient with a blood pressure of 200/35? Besides the fact that this episode is titled Isolated Diastolic Hypotension, can you figure out why option B is more concerning to me if I had to choose just based off of blood pressure? Tune in and see if you are correct in your reasoning! Your future patients may thank you!

SIRS and especially qSOFA just don't stack up. Not in adults, and definitely not in pediatrics. This has begged the question for a while of is there a better sepsis screening tool out there for children given how well they compensate and hide insult from occult shock...

Recently a pediatric age/vitals-specific sepsis screening tool has been proposed, called the qPS4 scale, and early evidence is showing it is much more sensitive and specific in the pediatric population, especially when combined with the TAMSI, or the Temperature and Age-Adjusted Shock Index. In this episode I will tell you all you need to know about how this stands to help in your pediatric shock populations.

One of the very first episodes I covered was on a concept called ALM Therapy. For those not familiar, this is a mix of Adenosine, Lidocaine, and Magnesium infusion therapy in trauma patients. Why? Great question. Tune into this episode as I outline more about what this is and what the advancements are that have been made since I last covered this.

Take a second and really think...how solid is your understanding of acute kidney injury vs chronic kidney disease? Are these conditions silos, or is there overlap? How do lab values play into diagnostics beyond face value? What does it really mean on a complexity level system-wide when someone has AKI superimposed on CKD?

Oxygen nanoparticles? What the heck am I talking about now? Hypoxia can be an incredibly complex cascade in the body, and is not just a one-size-fits-all issue or treatment. We have to identify the type of hypoxia, the process(es) involved, where we are on the curve, and more. This episode will look at the concept of oxygen nanoparticles and how they play into all of this.

2026 is the Year of Sepsis! There are big changes and pushes for identification and treatment of sepsis both in the hospital and pre-hospital. Tune into this episode for an overview of the changes to the guidelines with evidence-based recommendations!

I see quite often providers not obtaining ECG's on pediatric patients. There seems to be this idea especially in EMS that cardiac issues are reserved for anyone over the age of puberty. How about we correct that thinking today and talk about 4 of the pediatric ECG findings you really need to know about. 

The magic of Ketorolac...the power of narcotics packed neatly into an NSAID's body. But is it a wonder-drug, or are there issues to be aware of? When should it be used, and what do we need to look for? These questions and more are answered here.

What is euvolemic, or normal volume, cardiogenic shock, and how does this differ from what we typically expect??

It is incredibly important to understand the differences in pathophysiology and presentation physically and lab-wise when it comes to differentiating DKA vs HHS (previously known as HHNK). We will discuss both of these in detail, as well as the condition known as SIADH. It is more common than you may think, so it is imperative to be able to recognize it and treat it appropriately!

This episode dives into the concept of Cardiac Output. What is it, how do we calculate it, and how do we use it? What parameters does this use to be calculated, and how can we apply cardiac output to our patients to better manage them? This episode looks at all of this and more!

Why do patients respond so poorly to aortic stenosis and aortic regurgitation? What is happening in the heart and systemically when these are occurring? Why is an IABP contraindicated for one of these conditions? How can I use a better understanding of these conditions to prepare for and manage patients who have acute vs chronic stenosis or regurgitation of the aortic valve?

The head bones are indeed connected to the foot bones, albeit with a bunch of things in between. So too is the heart connected to the kidneys, and what affects one will assuredly affect the other. This episode looks at the relationship in detail between both organ systems to help understand why this may be the case and how to better care for these patients. 

We seem to discuss lactate a bit on these episodes, and for good reason. This episode takes it a step further and breaks down Type A vs Type B hyperlactatemia, and those patients who may also have both at the same time. How does this change things for us?

Do lab values constantly leave you confused? You are not alone. Many healthcare providers can have difficulty not just with memorizing lab values as a whole, but knowing how to interpret them in context with clinical picture. This episode looks specifically at TSH, T3, and T4, and how to use these to help determine various thyroid issues at hand in your patients. 

Wait a minute...what?? Why would you transduce an IO drill site for vascular access, and think that you would get a pressure reading off of it? Is it even similar to an arterial access site? How would this work, and why does it work? Join me on this episode and I will introduce this concept and the group of researchers pushing the boundaries in Texas to make it happen. 

This episode is a review of the sepsis biomarkers and lab values, as well as an in-depth discussion into the cytokine storm that drives sepsis, specifically what is happening at the cellular and tissue levels that makes this such a significant problem. 

There are some things that are taken for granted in medicine, and some that make sense. There are some things that "just made sense" and were followed but then evidence later on shows it was not appropriate. The CAST Trial is one of those instances, and is probably very much accountable for why we now perform trials the way we do, vs just going off of what makes sense physiologically. 

This episode is all about the concept of coronary perfusion pressure. It is essential that we understand these concepts so that we can predict, react, and treat our patients better than just a guess. This episode will get your comfort levels up in regard to the ideas that surround coronary perfusion pressure, diastole vs systole, and more. 

Hemo lympho what? Why are we talking about something you have never heard of before? Is this like Dr. House, with random oddball medical diagnosis'? What if I said a good chunk of the patients we believe to be septic actually are suffering from this condition? Would that change your mindset? Let's dive in and find out more!

Wouldn't it be amazing if we had the ability to obtain digital X-rays in the field prior to arriving at the hospital? How would this impact the care we can deliver? Wouldn't we have to have a bigger ambulance for this? Or what if there was a device that fit in a backpack, that sent real-time images to the receiving hospital as well? You'll just have to tune in to see if this is possible!

Diabetes insipidus is the topic of the day, but it has nothing to do with blood sugar. This is one of the reasons why you may see the name change soon, as people don't often take the time to understand it. Join me on this episode to set the record straight and help prepare you for future patients with this condition!

Feel unsure about how to treat sick OB patients? How about those in labor? What is the difference between Tocolytics and the other OB-related drugs? All of this and more in this episode. 

What is the ONSD, and why would this be something I would care about in emergency medicine, transport medicine, or critical care? What does measuring it show me, and how would I use ultrasound to measure it? All good questions! Tune in to find out!

This episode discusses the insult to the cells and compartments in relation to Compartment Syndrome, as well as Rhabdomyolysis. What are these? How do they occur? What actually happens at the cellular level, and how do these patients spiral? How do we treat them, and is there any way to actually monitor compartment pressures in transport if I don't have a transducer system? Tune in to find out!

In the world of venous access, there are many considerations to be made. There are times and situations where certain options are appropriate. IO's have also become mainstream and with that, procedures like the external jugular, or EJ, and the saphenous cut-down have become less common. This episode discusses these two methods, when and how they are performed, why, and limitations/considerations. Remember that if you are not approved to do these already, this podcast is not giving you permission to do so. 

This episode is bringing a topic out of the archives, but one that deserves a review. The theory behind IV drive lines, carrier lines/fluid, mixing, and why a patient can crash when you transfer IV infusions to other pumps/tubing is one that needs a solid understanding and some respect. This episode will hopefully be a review for some, new info for others, and a reminder to keep you and your patients out of trouble during these points in the care spectrum!

This episode is as much a light-hearted poke as it is a bit of therapy and thinly-veiled plea for those in our profession to step up their game. Over 20 years I have watched my own performance as well as that of my partners. I have taken notes, tried to do the right thing, failed and learned and overcome, and wished for more from those I worked with. For the longest time I focused solely on my own standards for myself, but I always feel the drive to try to help others improve themselves as well. Take this episode as you will, but remember this:

"Accountability hurts when you are not willing to accept that your words and actions, or lack thereof, directly affect those around you." -unknown

Recently I was asked "If you could create and work at the perfect critical care transport system, with whatever resources and support you needed, what would it look like?" 

This podcast episode stems from 20 years of experience in volunteer, paid, union, municipal, hospital-based, flight, ground, and military medicine programs. Seeing what works, what doesn't, how human performance and mentality changes dynamics, how lack of support from management hinders progress. This episode is a "day-in-the-life-of" view of my perfect ground critical care program, and the reasoning behind why I advocate for the things I do.

To those who have yet to find their true "place" in this profession, this episode is a reminder to keep fighting for what you are looking for. It exists out there...and if it doesn't yet, we just need to find the right door to open and make it happen with others who are like-minded at our side. 

This episode is geared towards those EMS providers using the Zoll Z-Vent (formerly the EagleVent) and the ED staff/respiratory therapy staff who may assist in preparing patients for transport/receiving patients from transport crews. This discusses the difference between Additive (PEEP-Compensated) vs Absolute (Uncompensated) ventilators, and how you can use Rise Time and Cycle % as a psuedo-bias-flow in the ZVent, which does not have bias flow 2nd to it being a compressor-driven ventilator. 

This episode will hopefully prepare staff to use the ventilator and eliminate the potential of patient-ventilator desynchrony.  

We have all heard about THC inducing cyclical vomiting syndrome and a host of other issues, often attributed to the biphasic effects of THC on the sympathetic and parasympathetic systems, depending on dosages. Were you aware that THC usage is also being linked to complete AV Block/3rd degree heart block? This episode stems from a recent case and is a fascinating look at the possible links between cannabis and complete heart block in young, otherwise healthy individuals. 

For many of our medications we administer, we have to consider how they are absorbed and utilized in the body. Some various medications are what we call lipophilic, meaning they combine or dissolve in fats. When the levels of these drugs becomes toxic, it can be hard to treat overdoses. This is where an IV bolus and/or infusion of a fatty lipid solution can be helpful. If this piques your curiosity, tune in and find out more!

For the longest time I was taught that SIMV, especially SIMV in pressure mode, was a great transport alternative for patients. As more and more evidence comes out, and more ventilation modes are developed, it is time to look at whether or not SIMV is a dead mode of ventilation relegated only for weaning trials, or if it still has some utility?

A bit of a departure from the normal A&P, pathophys, and pharmacology topics but today is a look at how backwards and inconsistent the national EMS model is, and what steps *could* theoretically be taken to clean this mess up. I say theoretically because the amount of legislature and administrative rules that would need to be changed/updated in each of the 50 states is mind-blowing. But it is still worth a look. 

We have discussed transthoracic POCUS in cardiac arrest and the challenges that come with that. We have discussed an alternative view of the carotids during arrest as well. But is there feasibility in performing resuscitative transthoracic echo in the field? In this episode I will discuss what this is, the barriers to it, and the services and their related data where it is being performed in the field in the US.

Digitalis is not just a beautiful flower to look at. This drug was once widely prescribed, but has since fallen out of favor for other, newer, less-problematic options. However, patients are still seen with this in their medication list, and given how infrequently we see it now, it warrants a review of the drug, how it works, its narrow therapeutic window, and how to reverse it. Signs and symptoms of toxicity are also discussed. We also discuss the theory of the Stone Heart Syndrome surrounding digitalis.

Most people have heard of left ventricular hypertrophy, but few have heard of Armstrong Algorithm used to identify MI hiding under the massive voltages of LVH. Even fewer seem to remember how to identify right ventricular hypertrophy on the ECG. In this episode I discuss LVH and RVH, criteria for identification, as well as the Armstrong Algorithm for evaluation of MI underlying LVH.

The link to the American Journal of Cardiology page with the full Armstrong Algorithm is here:

Electrocardiographic Criteria for ST-Elevation Myocardial Infarction in Patients With Left Ventricular Hypertrophy - American Journal of Cardiology

There are many conditions to be aware of in emergency and critical care medicine, and sometimes it can feel overwhelming to remember them all. However one to be very much aware of is pericardial tamponade, not just because it is one of the causes of cardiac arrest. What is it, how do we diagnose it, what are the actual signs and symptoms, and how is it treated? All of this and more in this episode!

The traditional treatment for PSVT's, whether AVNRT or AVRT, is vagals, Adenosine, and possibly synchronized cardioversion. These require trained medical professionals, IV access, etc. What if there was a way for repeat *stable* PSVT patients to treat themselves at home and convert their rhythm without all of this? Or for EMS to be able to administer a medication to *stable* PSVT patients without IV access? This episode looks at the newer medication, Etripamil, otherwise known as Cardamyst, an intranasal medication for treatment of stable PSVT!

For those of you are nervous to deliver and care for a neonatal patient during the initial resuscitation and stabilization periods, this episode is for you. Traditional EMS initial training programs woefully fail to prepare you accurately for this at any level, and there are key steps and tips that must be observed depending on what presents in front of us. In this episode, I will give you *some* of the key parts of the AAP Neonatal Resuscitation Program and S.T.A.B.L.E. program components, but remember, this is barely scratching the surface. Be a great clinician and go learn more after this! 

Some recommendations beyond PALS and PEPP include NRP, S.T.A.B.L.E., BLSO, ALSO, NALS, and more!

We have discussed Acid-Base before, using various methods to identify the disorder, whether it is the First, Middle, Last Name method or others. Today, we take it a step further. In this episode, we move past whether this is just a respiratory/metabolic acidosis/alkalosis, and use the anion gap, the delta gap, the expected compensation (15 Rule), and serum osmolar gap to identify the strong ion difference abnormalities, compensation limits, and whether or not your issue is being caused by a strong alcohol or other causes. 

This episode is all about pacing bradycardic symptomatic patients. Transcutaneous vs transvenous pacing, pearls and pitfalls of both, how effective they are, etc. I also discuss the importance of receiving facility staff NOT TOUCHING the transport team's pacer pads/device until yours is also on the patient, and how you work both devices together to phase one out and bring yours online while maintaining capture electrically and mechanically!

The FAST-ED score is a modified stroke scale combining elements of the NIHSS and other simplified stroke scales used to evaluate for LVO in the front 2/3rd of the brain. NIHSS is a very detailed stroke assessment to identify severity. However, both have their pros and cons. In this episode I am examining both of these, their utility in various settings, and proposing a change to the FAST-ED to make it more encompassing for the rear 1/3 of the brain. If you are a "Stroke Champion" then tune in!

This simple concept is responsible for what we call "Clean Kills" in medicine, especially when providers at any level are not aware of the various methods to discern VTach from SVT with pre-existing aberrant conduction (think bundle branch blocks). In this episode I will discuss several different methods and criteria sets to use to help you in the future, and what can happen when we get it wrong. 

We all know the idea behind the GCS...but how good are you at it really? Are there times where it just doesn't work? Do you actually trend it out and obtain multiple scores? What about for intubated patients/sedated/paralyzed patients? In this episode we will examine the GCS, as well as alternatives such as the SMS and FOUR Score systems and when/where those may be of better use for us and our patients. 

Ok folks, here's another episode that I must ask you to hang your dogmatic practices on the shelf before tuning in. If you can't do that, this episode may not be the one for you!

We will look at the history behind obtaining two sets of cultures (aerobic and anaerobic) on patients, why they have to come from different sites, and why we seem to cling desperately to this idea that ALL infection patients who need cultures absolutely MUST have them obtained before administration of antibiotics. Join me and we will look at the reasoning, discuss high-performing pre-hospital and hospital systems that are doing the opposite now, and why. Think you can sit through this one? 

Ever find yourself in a seemingly endless conversation trying to identify the pros and cons of Epinephrine in cardiac arrest? Or maybe wondering why we blindly give it per the guidelines in every cardiac arrest when in reality very few may need it? In this episode I will discuss this and more, including how Epinephrine can actually *worsen* refractory V-Fib arrests, is not helpful in trauma arrests, and is used poorly in hypothermic arrests. Strap on your big-boy/girl pants, it's time to challenge your dogma!

For those hospitals and critical care transport teams who are not able to provide PAC/Swan-Ganz monitoring, but want real-time invasive monitoring that relies on something your patient probably already has, an arterial line, the FloTrac monitoring system is a possibility to look at. This device gives us real-time information about cardiac output, stroke volume, stroke volume variability, and more. How you use this information and when it is reliable vs not, well, that is up to you and the patient conditions. This is a bit more on the critical care side, but is still worth listening in on as we discuss aspects of sick patient care like systemic vascular resistance. 

Have you ever administered a drug to a patient too quickly and seen what can happen? Or are you one of those that brushes off that part of pharmacology? Rate of administration is just as important as drug choice and contraindications, and in this episode we will discuss some of the more important drugs to pay careful attention to rate of administration on. 

Remember what tidalling is? Are there supposed to be bubbles in the suction chamber? Why do we set suction to -20mmHg? This and more in this quick review of chest drain systems!

How confident are you at controlling possible junctional hemorrhage? It is not as simple as applying pressure. You can apply all the pressure you want, but if you are even an inch off the mark, it will not matter. Know your anatomy. Tune in to find out more! 

Let's talk all things TXA. From the history to where it is going in the future, and everything in between. Clean up some myths, set some facts straight, and make sure you are comfortable using it on your trauma patients when the time is right!

This episode is both a notice to providers about Andexxa's removal from the market for DOAC reversal, specifically Eliquis and Xarelto, as well as a dive into the FDA's rapid approval process for drugs that propose to be game-changers for lifesaving conditions. The evidence just didn't pan out for this specific drug, and it leaves questions about how the FDA approves drugs on the quick track process, and how they review them after approval is granted. What happens next? 

Similar to the ACLS, PALS, and BLS updates, the AHA and the ASA have released their joint 2026 Stroke Guidelines updates. This episode is a short review on what has changed, from mobile EMS stroke units, to tPA vs TNK, establishment of the first pediatric stroke guidelines, and more. 

For as long as I can remember, I have been taught that Early Repolarization was, well, Benign...a good thing, a no-nothing finding that is very common in young males and athletes. However, back in 2008, that changed. Subsets of ER were found to be very much linked to episodes of spontaneous ventricular fibrillation and sudden cardiac death syndrome. How do we know when Early Repolarization on ECG is a mundane finding vs when it is pathologic? Tune in to find out!

aVR is often taught as the "non-diagnostic" lead, or the "forgotten" lead. aVL is often not viewed as the only truly reciprocal lead (to III), but also that isolated T-wave inversion or ST-elevation in aVL can be a very ominous finding, even though traditional STEMI criteria do not recognize these findings. Join me on this episode as we establish what to look for with these two leads to help save your patients in the future!

Traditional STEMI criteria continue to fail us with sensitivity vs specificity. There are certain conditions and presentations on ECG that do not meet the traditional criteria, but absolutely should be activated for cardiac cath under the OMI mindset. This podcast episode explores Aslanger's pattern, with non-traditional identification criteria discussed. 

Cardiogenic and vasodilatory shock can be incredibly difficult conditions to recognize and treat for some providers. There are nuances that can complicate things, and certain medications and procedures may be more beneficial than others during these times. This podcast is a small dive into cardiogenic vs vasodilatory shock, as well as what to do when both are present together. 

Many patients and healthcare providers alike do not fully understand Postural Orthostatic Tachycardia Syndrome. What is it, how many forms are there, and how do we diagnose and treat it? Is it really that simple? This is a short but in-depth review on the condition. 

EtCO2...is it over-used? Is it just a thing of pestering QA/CQI nightmare? Or is there actually use for it? When does it work and when does it just not? Is the information you are obtaining actually useful to you for your specific patient? Or are you just checking a box you might not even fully understand? Let's see where this goes!

Ok, I'll be the first to admit it...often I overlook the RDW-SD, MCV, MCH, and the MCHC. Why do we need these anyways, I just need the WBC, RBC, H&H, and platelet count! However, these components, known as the RBC Indices, gives us a lot of information towards our differential diagnosis' when it comes to blood issues. If you have no idea what these are, or need that refresher, this episode is for you! We will also take a look at the various components of the leukogram, including the neutrophils, basophils, lymphocytes, monocytes, eosinophils, and immature bands, to help us better understand our patient's conditions.

Subxiphoid view for POCUS in cardiac arrest is more or less the standard go-to during compressions. However, what if there was another site that could be used as a surrogate, and is actually even easier to obtain? One that showed evidence of perfusion, not just wall movement? A recent study on paramedics using POCUS in the field evaluated carotid POCUS views vs subxiphoid views in cardiac arrest. While the evidence is not substantially ground-breaking, it does offer yet another easy-to-obtain view that remains out of the way during compressions...

Tired of the "doom-and-gloom" ECG reviews of late? Don't worry, there's more where they came from! But until then, join me for a look at an ECG finding that maybe isn't quite as scary, but still a good one to know about!

How well do you know your way around the Circle of Willis? Can you predict where the occlusion is in a stroke patient based on their presentation of signs or symptoms? This episode is all about linking those together to help you better understand your patient and their stroke. We also discuss the FAST-ED, how turning it into the BEFAST-ED helps increase its sensitivity from just LVO's in the front 2/3 of the brain to also help pick up on posterior occlusions, and the NIHSS as well. 

How many of our patients are told they have hypercholesterolemia? How many are on statins? How many seem to do very poorly on statins, and seem to be told to chase lower and lower cholesterol levels? What does this actually do to the body? What does the science vs. "Big Pharma" actually say? We know too much cholesterol is not good...but what about too little?

We often focus heavily on STEMI vs NSTEMI, OMI vs NOMI...what about Precordial Swirl? No, it's not an ice cream flavor! What about Northern OMI? Has nothing to do with geopolitics! Bifasicular block, new onset? Excuse me? Confused? Tune in to find out more! You may just end up saving a future patient's life when others would have not even noticed these on ECG.

No, we aren't going for a drive. Instead, we will look at what driving pressure actually is, and why it is such an important part of mechanical ventilation in general. What tends to trip people up is the strict adherence to one specific equation, when in reality, especially when dealing with Hamilton ventilators, it is just not that simple. Still confused? Tune in and hopefully we can make this a lot clearer!

We have all seen massive textbooks devoted simply to IV fluids. Colloids and crystalloids...balanced vs not...dextrose variations...so many to choose from. How do we choose? What is right for my patient? This episode is an attempt to break down these hundred-page textbooks into a summary for you. Keep it short, simple, and effective, right? Let's take a look at some of the more common options, and really iron out the idea of isotonic, hypertonic, and hypotonic while we are at it!

We are overloaded with tools, scales, and other job aids in healthcare. It can be very difficult to know which ones are helpful or not, which ones are too hard to remember or to navigate, etc. In this episode, I review 4 gaps and their equations that are actually fairly relevant to emergency department and critical care interactions. Want to know what they are? You'll just have to listen in!

Have you ever had an AV Block that didn't respond to transcutaneous pacing? Is that even a real thing? This episode details this phenomenon, the Phase 4 AV Block, and discusses what it is, how it happens, and why our traditional therapies don't work. It is a bit heavy on the A&P and pathophys, but that is necessary for the understanding of why our treatments won't work here. We will discuss the benefits of Isoproterenol and Epinephrine instead of pacing...

If you have ever put a patient on NiPPV and wondered "Ok, how do I know how long to keep them on, and when do I find out if the patient fails NiPPV and needs to be intubated?," then this episode is for you. HACOR score is useful for EMS and hospital realms as a tool for judging the effect of NiPPV and whether or not you need to intubate the patient. It is validated, easy to use, and most importantly, simple. Listen in to this episode and use this tool in the future! 

What is hypoxic pulmonary vasoconstriction? Is it entirely a bad thing, or can it actually be protective? How do we alter it, and when is altering or blunting it actually a bad thing vs a good thing? Tune in to find out!

LVSD vs LVDD...HFpEF vs HFrEF...what is all of this gibberish? This episode looks at the differences between left ventricular systolic vs diastolic dysfunction...in other terms, Heart Failure with Preserved (or Reduced) Ejection Fraction. We will talk about what this means, how to differentiate these, and the differences in treatments. 

Is sepsis really just about fluids and antibiotics? What if there was something else we could do to actually remove part of the problem and get patients on the road to recovery quicker? Something that could filter out the endothelial damage byproducts? The circulating inflammatory particles? Stay tuned on this episode for a review of some of the newest potential therapies for sepsis filtration.

The Gregg Phenomenon? The Garden Hose Principle? What are these? How do they apply to our patients? What specific patients do these apply to? This is a great episode to tune into and learn something that impacts patients almost daily.

Can Influenza cause NSTEMI? Cardiomyopathy? Elevated troponins in general? Especially with this nasty flu/respiratory season, expect to see this more and more. What is the mechanism behind this relationship? Are these true NSTEMI's and cardiomyopathies? Do they have lasting effects on the body? Tune in to find out!

It's been a while since we looked at Acid-Base, and I figured now is as good a time as any to really dive into full acid-base interpretation. Brush off your skills, sit back and enjoy a little review if this is something you are very comfortable with, but don't get too comfortable! We will also review something known as the SID, or strong ion difference, and how this also plays into acid-base and differentials. 

I've said this before...there are NO randomized control trials evaluating the safety and efficacy of parachutes...we put our faith in them when we step out of an airplane. With the evidence that already exists out there, both from military and civilian realms, it is absolutely mind-boggling when it comes to the amount of kick-back and resistance that occurs when an EMS agency states they want to initiate a whole blood program. Often hospital physicians and blood banks try to block it and say there isn't enough evidence...but we know that if you are bleeding, the evidence is there that replacement of what you lost, and quicker replacement at that, brings better outcomes than pasta water. Now with the more reliable and available third-party EMS-specific blood banks around the country that are helping services get around hospitals trying to block these advancements, I say it is game-on! This is not cowboy medicine, this is hard fact. Anyone that wishes to say otherwise can be the control group bleeding out and just getting saline. 

Our healthcare system is broken. Nurses and paramedics are leaving at rates never seen before. Is it really just the pay? The hours? Or is there something a bit more obvious, but often shunned or denied, that is part of the driving cause? Are the patients really supposed to be the Number 1 focus of the management, or should it be more along the lines of what Fortune 500 rescuer Richard Branson always says? "Your clients don't come first. Take great care of your people, and they will take amazing care of your clients." This is probably going to be a spicy podcast episode, but one that is not directed at any specific person, rather, it is instead stemming from conversations with EMS personnel, hospital personnel, in various states and services I have worked with in my past. No matter where we go, it is the same story, the same message...so how do we change it?

By now most of you have probably heard of ECMO, and if you tuned into my Intro to ECMO podcast, you should have a pretty solid understanding of what it is and how it helps oxygenate our patients when traditional methods fail. Well, what about severe ARDS refractory to standard treatments where we need super-lung-protective volumes and minute volumes with Vt's down near 3-4mL/kg? In the past we would be hesitant to approach these levels due to hypercarbia and other issues. But enter ECCO2R, which is like a mini-version of ECMO but instead of adding oxygen to the blood outside the body, we are actually able to clear pH and PaCO2 so that their baby/injured lungs can handle the super-low minute volumes. Intrigued? Tune in to learn more!

Welcome back to the Synapse! We are starting Season 3 off with a look at some of the bigger items, procedures, and changes coming down the line in the medical fields that will impact emergency, interfacility transport, critical care transport, and ICU's around the country in the next year or two. From continuing research on the islet cell therapy for Type 1 Diabetics, to changes to arterial line usage, to an off-shoot of ECMO that focuses more on CO2 elimination, there's a lot on the horizon!

Piggybacking off of episode 100, we examine AVNRT and AVRT, two types of PSVT's that can be brought on by seizure activity, or just from other causes, as well as each of their own specific sub-types. I discuss how to identify them on ECG and how each one will be affected by Adenosine, Procainamide, and other treatments. For those who are primarily treating arrhythmias in their practice, you don't want to miss this! 

Thank you for your support over the past year. Season 2 could not have happened without you all! I look forward to you tuning in for Season 3 in January!

Did you know that seizures can bring about a cardiac arrhythmia in your patient? Have you ever stopped to think about how the brain and heart are connected and how this could occur? In this episode I discuss the anatomy and physiology behind these connections and what can happen in the heart when the brain goes haywire. This is a two-part episode to cap off Season 2 of The Synapse. Keep an eye out for Episode 100a!

Ok, we talked about Winters Formula for expected PaCO2 in metabolic acidosis...but what happens if our patient has the opposite issue, and is metabolic alkalosis instead? Is there a magical (albeit empirical) equation to help with PaCO2 prediction there too? Well, ask and thee shalt receiveth! There IS an equation, but it is the lesser-known (and un-named) cousin to Winters Formula. What is it, how do we use it, and what are the pitfalls? Glad you asked! Come join me and find out!

Expected PaCO2 = 0.7 x [HCO3] + 21     (+/- 1.5)

What is a stress dose? Why do the adrenal glands need help? Who exactly needs this, what do they need, and why? All important questions, friends. Join me on this episode and all will be explained!

The world of PIFT protocols vs CCT can be a very confusing place for sending hospitals to dwell in and navigate. Some crews are able to take patients at higher levels of care needs than others. Some don't have the same training or experience, or more importantly, the confidence and comfort levels. Many PIFT paramedics have been pressured or even threatened in their career either by their own management or hospital management to take a patient that it was potentially unsafe to do so for many reasons. This episode navigates the grey areas between PIFT and CCT, including the alternative staffing and exceptions, what processes' must be followed, etc, in the hopes of making this easier for sending hospital staff. Just remember that at least in our state of NH, the PIFT paramedic has the final say in whether they take a patient based on comfort level, not the hospital, not the ambulance service managers, even if the call has already been booked. 

Wouldn't it be amazing if Type 1 Diabetics had a cure? What would we see happen to our case load in healthcare from accidental insulin overdoses or hyperglycemia from under-dosing? Would it be that easy if there was an option? VX-880 is a novel islet cell therapy that has shown amazing results so far in the small cohorts and phase 1 & 2 trials, with patients who have received the therapy being able to generate their own internal C-peptides and insulin! Want to know more? Join me on this episode!

Many of you that have been following along know I have put several episodes out on Sodium Bicarb, and you also know I don't typically put Sodium Bicarb high up on my Rx list. This episode looks at how NaHCO3 can actually cause or worsen pre-existing pulmonary HTN, just in case we wanted some more reasons to possibly avoid regular usage of the bicarb.

It feels like Captain Sparrow and Captain Barbosa locked in eternal battle from the first Pirates movie...except it is Etomidate and Ketamine. The study just released purports that Etomidate is better than Ketamine again...but is it? Before we swap sides yet again in this tug-of-war, should we examine this more closely, and maybe also not fail to remember it's not about the induction agent all the time, but more about how we prepare the patient, resuscitate them, and meet DASH-1a metrics?

Which team are you on? Me? I'm on Team Good Clinician who thinks things through and chooses the appropriate med option for the appropriate situation!

How can we determine where a patient with metabolic acidosis *should* be compensating in regard to expected PaCO2? Enter Winters Formula. In this episode we will talk about how it was derived, its strengths and weaknesses, how to use it, and more. You may be surprised by when and how it was derived, and how long we went without any extra evidence to support it.

Predicted PaCO2 = 1.5 x [HCO2] + 8    (+/- 2)

The search for a suitable replacement for Succinylcholine has been ongoing for decades...a non-depolarizing agent that has the same onset and duration times as Succinylcholine, but without all the nasty side effects...wouldn't that be wonderful? Especially if it was reversible??? Enter Gantacurium...well...it almost entered anyways. A bit of stage fright? Not so much. Join me on this episode as we discuss what this is and why it disappeared before it really ever appeared, and what comes next!

Nitrous? Sure...but it comes with a host of issues. Methoxyflurane? Wasn't that banned in the US by the FDA? It was...but it's making a comeback globally and stands poised to change inhaled analgesia for good. Want to know more? Join me in this episode as we take a ride on the Green Whistle!

This is never an easy topic to discuss, but we are going to tackle it today. Whether you are EMS/pre-hospital or in the hospital, you are unfortunately involved in some of the most dangerous professions in our country today. Instances of violence, both verbal and physical, are rising. And that is just what is actually reported. What can we do to strengthen ourselves, the job sites, and our training, to protect ourselves, and what recourse and legal protections do we have? Tune in to find out.

These are the voyages of the Starship AHA. And this episode is going to go where few have actually dared to go before...a path through space unencumbered by the numbingly binding dogma that is ACLS in cardiac resuscitation. 

Let me be clear. This is not an attack on the AHA. I am an instructor in every discipline the AHA offers, and am affiliate faculty for the AHA. That being said, the ACLS guidelines are recommendations that are meant to cater to the non-resuscitation personnel in the healthcare world, those who are not yet at the point where they can apply critical thinking outside of the ACLS algorithms. Every cardiac arrest is different, and a blanket approach cannot be applied to every patient. So what should those in EMS and Emergency/Critical Care Medicine who ARE resuscitation experts do? Do we also blindly follow the algorithms? Or do we apply critical thinking and maneuver our way around and between the guidelines? Join me for what is most likely going to be a spicy episode discussing Epinephrine, hypothermic arrests, trauma arrests, POCUS and PEA, and more. 

Sliding scale insulin is often used in the hospital, especially in-patient. However, there is a multitude of issues that comes with it for our hyperglycemic patients, with the primary issue being that SSI is more of a knee-jerk reaction than a proactive treatment. Doing something because we have always done it that way is not something I enjoy hearing. This episode lays out all of the compelling science-backed reasons why SSI should NOT be the weapon of choice for hyperglycemic patients especially in-patient, whether NPO or not...change my mind? Let's see after you listen in!

There once was an anticoagulant agent named tPA...hold up, this isn't a fairytale and this story doesn't cover tPA or TNK! Those are different stories for different days. 

Does every stroke patient we encounter need to be anticoagulated? Or should we not be so quick to pull that trigger? If you are going to give a stroke patient anticoagulants, which types of strokes should it be? What are the three main subsets that really need it? With that question comes another bigger question, which anticoagulant agents are most appropriate for these types of strokes? Join me on this episode as we discuss fractionated vs unfractionated Heparin, DOAC's, and Coumadin's roles in the stroke patients. 

We know beta blockers are a staple treatment in outpatient CHF/HFpEF and stable HFrEF patients. However, what is it about the nature of beta blockers that makes them potent killers in the decompensated HFrEF patient? Why do we routinely mix up the two variations of Metoprolol and why is the common Metoprolol Tartate considered the Metoprolol Mistake in HFrEF patients? Listen in to find out!

With this case review (fictional) and dive into the pharmacology behind Dobutamine, by the end of this episode you should hopefully have a firm understanding of what it is, what it does, how it can be helpful to our patients, but also how it can harm them. I will also spend some time talking about Dobutamine in transport and how squeeze should never be the sole treatment. This concept does hold credence for in-hospital as well, but is subject to provider judgement. 

How do we prevent "death-by-induction?" How do you appropriately resuscitate a patient before intubation? Have you heard of the Shock Index before? Or are you aware that there is a difference between systolic shock index and diastolic shock index? In this episode we will explore all of this and more, and put significant emphasis on the diastolic shock index as the most reliable indicator of whether this patient will decompensate during/after the intubation attempt. 

In the absence of whole blood, if I had to choose between PRBC's or plasma in the prehospital environment for the bleeding patient with coagulopathy, and didn't get to carry both, I would choose (freeze-dried) plasma as the product to carry. Why is this? What reasoning is there to support this?

In trauma, our concern is not just the oxygen carrying capacity in resuscitation. It is also to fix the trauma-induced coagulopathy, the endothelial glycocalyx damage, and more. PRBC's make these worse by diluting the concentration of clotting factors in favor of adding O2-carrying capacity. Plasma gives us back the ability to clot and more. 

Join me in this episode as I present the evidence that would support these claims.

Right axis deviation with ST elevations? Listen in and I will explain why there is only one type of MI that will present like this. The purpose of this episode is to help cut down on false activations, understand how we can use the science behind vectors of electricity and basic pathophysiology to prove that right ventricular wall MI is the ONLY type of MI that will present with ST elevations concurrently with right axis deviation (unless inferior wall involvement is also present).

Think back to the last sepsis patient you had. Maybe they had an elevated lactate to begin with and were hypotensive. Norepi was started, BP improves, but the serial lactate is even more elevated afterwards. Why is this happening? Is the patient getting worse? Maybe not. Join me in this episode as we explore why Beta-2 activation may actually transiently elevate lactate and what this means for the patient. 

Is your patient's tachycardia the primary issue or compensatory? Will you treat it or leave it? If you are going to treat it, what will you use? This episode will discuss the nuances of tachycardia, when it is dangerous to treat, and how we can evaluate the patient to see.

Let's examine this case study, and put your differential diagnosis skills to the test. Is this DKA? Withdrawals? Tox? Or something more like a combination of all three? In this episode we will dissect this case as well as the science behind it so you can make good care decisions in the future with these very challenging patients!

While this episode may be a bit Respiratory-"heavy," it is important to understand the basics of mechanical ventilation waveforms. If you are a paramedic tasked with transporting a patient on mechanical ventilation, or a paramedic or nurse in an ED or ICU monitoring a patient without RT being present, you should have a basic working knowledge of waveforms and loops to be able to trouble-shoot patients. This episode explores the Pressure Volume loop, and details how it provides important information for you to be aware of. 

In this episode, I dissect the DIFFOCCULT-3 Trial and the evidence that it continues to amass to further support getting away from STEMI and NSTEMI, and moving towards OMI/NOMI. Why does it make sense to make this change? What will actually change with that? What are we up against for logistical challenges?

Are you looking to test for CCRN, CFRN, CCP-C, FP-C, etc? One of the test items you'll need to know about is the Swan-Ganz catheter, or Pulmonary Artery Catheter. Not only should you know about it for the exams, but also in general. Most community hospitals will stop at dual or triple-lumen central catheters, and don't typically place anything beyond that. Usually seen in very sick patients in very advanced ICU's, the Pulmonary Artery Catheter can give us a load of information about the patient and are very beneficial. However, they do come with significant risk and trouble-shooting needs to be aware of. This episode will serve as an introduction to this device and the "why" behind it. 

Have you seen or heard of a patient being placed on ECMO? Not sure what the difference is between ECPR, ECMO, or ECLS? Not sure what patients are candidates or how it is performed? Join me on this episode as I explain these answers and so much more. This is not meant to make you an ECMO expert, but rather to open your eyes to the basics of this bridge procedure for your learning enjoyment. 

Quite frequently I hear providers speaking about adjusting respiratory rates (f) on the mechanical ventilator with a heavy focus on I:E times. However, for those patients in whom the risk of AutoPEEP is high, there is a better way that takes into account the patient's actual condition and ventilator readings, rather than just arbitrary I:E changes. In this episode I will discuss the notion of Time Constants on the ventilator, how to find them on the Hamilton T-1 specifically, and how we can use this information to find the max respiratory rate threshold of safety before we will start causing the patient to generate AutoPEEP.

I am sure there is not a single healthcare provider out there who has not been told at some point to be careful of how much oxygen you administer to a COPD patient, because they will suddenly stop breathing. How much truth is there to this oxygen-dependent ventilatory drive? In this episode I will dissect this and see if it actually makes sense or not, based on anatomy, physiology, and current evidence. Care to find out? Tune in! You may be surprised...

All too often, even here on this podcast, we talk about PEEP as if all it really involves is the respiratory system. Have you ever stopped to consider what other body systems are actually affected by our PEEP settings whether via BVM, CPAP/BPAP/NiPPV, or other mechanical ventilation modes? Join me on this episode and see how far-reaching this one setting can be inside the body of our patients!

Now that we are getting back into Fall and soon to be Winter, it seems appropriate to take a deep dive into the chilly waters that are our hypothermic patients. More than just dialing down the thermostat for this cool talk on temperature, we will look at each body system that is affected and discuss what exactly happens. The episode is capped off with a look at hypothermic cardiac arrest tips and tricks. 

In this episode, I will tackle the question surrounding whether or not to do CPR in a VAD (ventricular assist device) patient who is in cardiac arrest. For the longest time we were under the impression that to do CPR in these patients would cause device dislodgement and massive internal hemorrhage. Oh, but the winds of evidence are blowing again! Let's see where we stand on this now!

Can't get a reliable SpO2 probe reading on your intubated patient regardless of trying every trick you can think of? Hot packs, fingers, nose, cheek, ear lobe, even the fancy expensive forehead probes? Have you considered back-of-tongue oropharyngeal monitoring? How would you even do this? Join me and I'll explain this little-known Burn Center trick that can make the difference for you next time. 

There are so many challenges surrounding blood administration, compatibility, cross-matching, sourcing, storage, shelf-life, etc. We have discussed the lyophilized plasma products that are making their way through FDA clearance, but what if there was a blood product alternative that was easy to create, actually carried oxygen, and had few associated reaction/side effect risks? Enter Deoxy-Hbv, a product being tested currently in other countries that does exactly that. Tune in to find out how this "purple power liquid" blood alternative is more than just a synthetic oxygen delivery system, and can possibly revolutionize trauma and medical care here!

We see acidotic patients almost daily. This comes as no surprise. However, how often have you actually thought about the effects of the acidosis on more than just what you immediately see, or connect the dots on why it affects medication absorption, vitals, and response to treatments? This case study will examine all of that and more!

Sodium...Potassium...Calcium...the "big 3." But what about their relationships with each other, as well as say, magnesium and phosphate? Why won't your patient's potassium go back up after oral and IV repletion? Join me to see the "why's" behind this and other questions that you have probably asked during your patient care!

It should be abundantly clear by now that we should never arbitrarily be chasing EtCO2 as an end-goal for our treatments, whether in sepsis, mechanical ventilation, or any other times. There are many times where permissive hypercapnia will not immediately kill our patients and should be tolerated. What may not be very clear is a product of poor teaching, and that involves the so-called "Rebreathing Waveform." We are going to discuss EtCO2 goals and concepts, and look in detail at what this waveform really is, how you will not see  this with Asthma/COPD etc, and what we need to know. 

We have talked about Hyperkalemia in detail in other episodes, and you have seen it in the textbooks as well. However, we continue to see and hear things that are treated like dogma but in reality, they don't carry as much weight in the evidence side of the house. What am I talking about when it comes to Hyperkalemia? Tune in to find out.

When you think of Sepsis, you probably default to Lactate, maybe C-RP or procalcitonin, and most likely the CBD Differential. I am willing to bet not too many of you think of the Galectin-3's role in this process, or have even heard of it. What if I told you there is significant bodies of evidence looking at the role of Galectin-3 in sepsis, but not only that, a new easy-to-use piece of IV equipment that would allow point-of-care treatment of sepsis to actually FILTER Galectin-3 out of the blood and significantly reduce the length of time of infection? Something that can be employed not only in-hospital but also in the out-of-hospital, paramedic realm? Curious? Join me on this episode to learn more!

You have heard me talk about Sgarbossa and Smith Modification Criteria, as well as dabble a bit on the newer Basel Criteria. If you missed it, here is a great little episode that specifically addresses the Basel Criteria in LBBB and more specifically, in ventricular-paced rhythms, to further help us identify OMI's underlying the superimposed ventricular paced rhythms. These are challenging enough as it is, so hopefully the evidence plays out to support the widespread use of this novel criteria. 

This episode will further expand on the notion of the Lewis Lead, and add a few more tips, tricks, and pearls to keep in mind specifically in regard to this enhanced view of the atria and P-waves, to make your diagnostic abilities that much greater!

I have said it over and over, ECG interpretation is not always straight-forward or easy. MI's come in all shapes, sizes, and "flavors," and we cannot hinder our interpretation by looking for just "traditional" criteria. In this case review, we will look at a patient who was nearly 100% occluded and did not have textbook criteria present on ECG, as well as discuss how to better identify OMI's and not just STEMI's. 

Well...NTG...to withhold in right ventricular MI or not to withhold? What does the evidence say? For the longest time we have been absolutely a no-go for administration, that your patient will suffer the consequences...Is it really that simple though?

To oxygenate? To ventilate? To give the patient a chance to rest? To correct isolated values like EtCO2, or chase after parts of the ABG blindly? What are the true goals of mechanical ventilation? 

In this episode, we will dive into the benefits of the Lewis Lead when you really need a close look at the atria/P-waves in ECG monitoring, and how this trick can be the difference in preventing mistaken diagnosis and incorrect treatment. We will also discuss the modified chest leads, or MCL-1 and MCL-6, and their uses. Finally, we address the age-old issue of limb lead (LL, RL, LA, RA) placement and why they are actually, scientifically, supposed to go ON THE LIMBS and not just on the torso. Care to challenge your beliefs and practices with hard facts? Join me!

The world of inflammation and differential diagnosis of the etiologies of inflammation goes well beyond a CBC differential and lactate. Join me and review the pros and cons of those markers as well as others such as C-Reactive Protein, Procalcitonin, and more!

Have you ever seen a patient be transferred from one ventilator to another and all of a sudden they decompensate? Only to then hear a healthcare provider state "Well, the patient didn't tolerate that too well." In this episode we will look at differences in ventilators that you MUST be aware of and why it is so important to not just "copy and paste" settings from one unit to another. Whether you call it Additive and Absolute, or Compensated (for PEEP) and Un-Compensated, these are concepts not to ignore and often account for the patient's decompensation during that transfer from vent to vent. 

Another must-listen! How many times have we seen seizure patients who continue to seize, and providers in the field and in the hospitals give 2.5mg Versed, or 1mg Ativan, then another similar dose, struggle to find IV's, put all their faith in Keppra, Valproic Acid, etc, and wonder why the patient continues to seize? In this episode, we are going to look at all of this and more, including why the national guidelines for critical care neuro push for an up-front 10mg IM dose of benzo, and to forgo messing around for IV's? We will also look at why as time goes on, benzodiazepines actually become LESS effective and cause a paradoxical worsening of seizures as time goes on, and Ketamine becomes the best option. Keppra? Valproic Acid? Don't even get me started...

It feels like we have revived a topic from last season, and I have absolutely done so for good reason. In this episode I present multiple reasons why, if you are not already a fan of Lidocaine, you may want to listen and possibly change your practice. I am willing to be there will be some things in here about the two medications you may not have even heard of before, and that goes for the physicians and mid-level providers too! Dump the benches on both sides of this ring and let's watch these two meds throw fists. Who will come out on top, based on cutting-edge evidence?

This episode is sure to ignite some fiery debate, and this is the intention. Regardless of which alphabet-soup canned trauma course you subscribe to, the National Association of EMS Physicians (civilian and military) Trauma Compendium has released a landmark review of 4,000+ studies, papers, cases, and reviews covering the use of rigid cervical collars and backboards....sorry to be that guy, but for those still in favor, including you, Level 1 Trauma Centers, I would strongly urge you to take a look. Maybe it's truly time to re-write the guidelines. Link is below to the review/analysis:

https://doi.org/10.1080/10903127.2025.2541258

Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries - A NAEMSP Comprehensive Review and Analysis of Literature. Millin et al, 07 MAY 2025. 

For those who didn't check out the LVAD episode from way back in 2024 during season 1, here is a little refresher and some newer information to help get you up to speed. For those who have never heard of an LVAD before, or a VAD in general, tune in and find out what these are all about! We will cover some treatment and evaluation tips and some trouble-shooting ideas in case you ever have to care for a patient with a VAD!

Quite frequently we hear medical staff confusing lactic acidosis and lactate. It may seem that it is the same, but these are quite different, especially on the molecular level. Where does each one come from, which one(s) are we actually testing for and when, and what do their levels mean for our patients? This episode looks at all of this and more. 

If you interpret ECG's, you have probably at least heard of Sgarbossa criteria for Left Bundle Branch Blocks (LBBBs) and ventricular-paced rhythms. Maybe you have heard of Smith Modification Criteria, or Modified Sgarbossa. But have you heard of the Barcelona criteria? Join me and discover what this is all about and how much further it pushes the specificity and sensitivity of the Sgarbossa and Modification criteria, especially in ventricular paced rhythms, which can be especially challenging to diagnose OMI's hiding under their layers. 

We will also discuss why many times, EMS tries to activate a STEMI/OMI alert and cath lab personnel may shoot it down. What gives? Let's find out!

I've said it before, and I will say it again. The world of ECG's is full of so much more than just ST-elevations and depressions related to MI's. Today's topic looks at another must-know finding that while rare, is a dead giveaway that your patient will soon be, well, just join me and find out the rest!!

Similar to the P/F Ratio, we can use the A-a gradient to help us understand more about the pathophysiology affecting our respiratory patients, how we can tweak our treatment pathways, and more. This isn't your high school algebra class, and is something you can use on your ventilated and even non mechanically-ventilated patients. 

Back by request, this is a brief overview of some of the more common, and one not-so-common, vasoactive and inotropic agents we see in our patients. Remember when treating patient's hypotension, besides figuring out the cause, don't forget positioning, pH drops, fluid status, alpha, beta, Vaso, and AGII receptors in your treatment plan if needed. 

What is the anion gap in the comprehensive metabolic panel? What does that number mean, and why do we care about "closing the gap" in many of our patients? Join me as we look at the anion gap, as well as the osmolar gap and how understanding these will help with your differential diagnosis'. 

What aspects of mechanical ventilation do we change to alter CO2 transport? Do we chase EtCO2? What if I said EtCO2 is putting on charades in the body, and shouldn't be blindly trusted unless we can correlate it to a current PaCO2? We will go over this and more in this episode!

Your patient comes in with a calcium channel blocker or beta blocker overdose, with subsequent associated cardiogenic shock. You are ordered to administer insulin to the patient at doses multiple times higher than anything you would see in a diabetic. Why might this be the case, and how will this help? Tune in to find out!

We frequently check for PT, aPTT, and/or INR levels in our patients to assess for coagulopathy or therapeutic levels. However, this only looks at the tiniest part of the puzzle. Many of the forward-thinking institutions are starting to implement the use of ROTEM and TEG in their Emergency Departments and ICU's to obtain fuller pictures of the clotting factors and other aspects that we really should know. Learning to identify results of the ROTEM is as simple as identifying different drinking glass shapes. What do I mean? Come join me and find out!

What is the cardiac power output, and how do we calculate this? What is it for, and how can it provide important information to help our sickest of patients?

This one is sure to ruffle some feathers, and rightfully so. It makes little sense for us to teach personnel to perform an emergency front-of-neck airway, or surgical cric, by finding the anatomy first, then cutting the airway open and making a bloody slippery mess with a small hole. Even Dr. Rich Levitan, the "Father of Airways," recently lectured on this at a renowned critical care medicine conference. So if we have been teaching this wrong, which method makes more sense?? Tune in to find out!

*Caveat, this new method only makes sense if you PRACTICE consistently. This is not a skill to practice once a year to check boxes!

King LT's....Combitubes....LMA's...iGels...Cobras...the list goes on. Which supraglottic airway device(s) really seem to be better for patients? What makes them rise above the rest, and what are some "cheat codes" we can use to fully unlock the potential of these devices?

Are you still stuck in the older mantra that CVP monitoring is the best tool we have for fluid status and most other things perfusion? Have no idea what CVP monitoring is? That's ok if you answered "yes" to both! Join me on this episode while I present why pulmonary artery pressure (PAP) is the most ideal of all invasive monitoring parameters to focus on. 

When performing invasive monitoring for parameters such as CVP, PAP, etc, there are certain considerations and adjustments that must be made to ensure accuracy. These modifications are essential to obtain correct measurements to direct treatment appropriately. Tune in to find out exactly what you need to consider!

Yes, you read that right...what is behind this push to consider Lidocaine in stroke patients when tPA is administered? Is there data to support this, and what is the reasoning behind it? Listen in to find out!

Is misting in the tube, and even immediate EtCO2 waveform/numeric values really enough to truly confirm placement of ET tubes? Have you ever placed an ET in the field or in-facility, and confirmed via multiple methods only to find out shortly thereafter that it was actually an esophageal intubation? Join me on this episode to discuss what is being recommended as the new standard of care for ETT confirmation.

In this short episode, we will take a look at some little pearls of wisdom in regard to atrial fibrillation. Join me to find out more, to apply to your future patients!

Is that a faulty reading on the NiBP? Do you keep hitting re-cycle hoping that it is false? Reach for the manual BP cuff and dust off your basic skills? Well what happens when that patient presents with marked hypotension, but NO tachycardia...will you fall for that trap?

You are taught in school that a QRS complex is just that, a Q-R-S. But most people do not have Q-waves, although it can be quite normal for children. When should we be worried about Q-waves? What is a normal one and what is pathological? Tag along on this episode and find out!

The question routinely comes up on how do you decide after the patient's first few breaths what you will set your respiratory rate, or really, the "f" at, on the ventilator. In this episode we will explore specifically the RCexp with the Hamilton ventilators, and how to leverage this to help us determine an appropriate rate for the patient. 

What is the real deal behind CO2 in the body? Yes, we know about PaCO2 and EtCO2, or do we really? How does the body truly like to transport and eliminate CO2? What happens when these processes' fail, and what can we do about it? 

In this brief episode we will dive into the concept of Pulse Pressure, discuss what it is and what really is helpful to know when taking care of our patients. 

If you have been paying attention to mechanical ventilation in the past few years, you know there have been significant changes and improvements to the reliability and options, proprietary modes, etc. Some have been reliable, some not so much. While AI and machine-driven ventilation poses some great advancements in healthcare, it is also something to use cautiously. Today I bring you AVAPS, or for the Hamilton users out there, VS. Join me as we explore these modes and how they potentially impact our delivered respiratory healthcare.

Is NS better? What about LR? Plasmalyte? What does "better" actually mean? Should we instead focus on which one(s) might do more harm in the hyperkalemic patient? Can you take a guess? I will give you a hint...don't focus on the potassium concentration in the fluid...

Join me to find out the answers!

If you have ever participated in potassium repletion before, you are probably aware that for every 10mEq of K+ we administer, we should expect the serum K+ lab value to increase by 0.1mEq/L. Well, what happens when we give K+, and lots of it, but the serum potassium doesn't budge? Might I recommend remembering it's partner-in-crime, the magnesium? In this episode, we will look at their relationship and talk about some strategies that might help. 

In today's world of medication shortages, particularly the seemingly near-constant eb-and-flow of sedative shortages, who would have thought that a beta-blocker like Propranolol might actually be useful in assisting with sedation and decreasing the need for sedatives?

In this episode, we will examine a recent study looking at this very topic, and the results, while just one study, may point us in some new directions. 

We have all probably encountered the hypoxic patient who did not improve with oxygen. Why might that have been? Did you stop at that moment and consider which of the four types of hypoxia they may be suffering from? Or whether this was a ventilation and oxygenation problem? A perfusion problem? Multiple of the above? Is there some way we could tell in the moment where exactly the problem was? 

What about the relationship between EtCO2 and PaCO2? When is EtCO2 unreliable? And finally, what is the relationship between SpO2 and PaO2? Find out all of this and more in this episode! 

Hang on...didn't I just spend almost an entire episode talking about how we should not delay getting OMI and "NSTEMI" patients to the cath lab??? Now what is this about delaying catheterization??? Join me and find out about this potential game-changer and the DTU-STEMI trial.

Credit for some of this presentation goes to Bruce Hoffman, RN/CCRN, Baystate Medical Center in Springfield. Thank you Bruce!

STEMI and NSTEMI have been the unchallenged terminology for too long. However, unlike the modern culture of just simply changing things to see them changed, the push across interventional cardiology to change "STEMI" and "NSTEMI" to OMI and NOMI is driven out of the understanding that:

a) Traditional STEMI criteria just flat out miss too many occlusions, and

b) Traditional NSTEMI criteria and dogma leads us to put NSTEMI patients lower on the totem pole, leading to delays in PCI and irreparable damage...

Join me and take a look at the new OMI criteria, OMI diagnostic algorithm, and really take a deep dive into how we are in need of better care of our NSTEMI patients!

Coming soon to a valley near you!

What: 2025 Mt. Washington Valley Emergency Medicine Conference

When: Saturday, June 14th and Sunday June 15th

Where: Grand Summit Hotel at Attitash (Bartlett)

Open to all area EMS and hospital emergency medicine/critical care staff. Join us on the 14th for awesome optional pre-conference workshops (extra fees may be associated) and on June 15th for the General Conference Assembly where you can earn continuing education/contact hours for EMS and nursing, learn some new and interesting topics, participate in an awards ceremony, and more! Oh, did I mention your Day 2 General Assembly ticket cost covers some pretty amazing food, with breakfast and lunch catered by the resort???

Check out the website for more information at:

https://2025MWVEMConference.com

*Please note, this conference is not sponsored by MaineHealth, and while I have done everything I can to keep costs for you as low as possible, I can't cover this all myself. Day 2 entry tickets are $100/person, which covers breakfast, lunch, the Day 2 conference, continuing education, site fees, surprises in store, and more.

Don't wait too long, the conference is capped at 200 persons for attendance, and pre-conference workshops also have max attendee caps. See you there!!!!

...Which is the better of them all? Alkalosis, or Acidosis? We know both can be incredibly challenging to treat, but what about the theory that athletes are intentionally making themselves alkalotic to see improved health benefits? How can there be benefits to it if shallow-water blackouts are related to the induced alkalosis? It all seems contradictory, but join me as we dissect these two sides of the acid-base balance, and see if there is more to this than just being a fad.

Sound like a cryptic title? So too can ECG's seem cryptic...however, if you approach them all with a standardized approach, apply rules of cardiology, the world opens up and much more is possible with them than just ST-elevations and depressions...care to join me and find out?

Taking a deeper dive after our Cardiogenic Shock episode, we will look at Dobutamine and Milrinone more in-depth, compare the two, and see which one is more beneficial at specific times. 

If you have taken any type of 12-Lead ECG training, you have probably heard of a condition known as LVH, or left ventricular hypertrophy. It is possible that you also heard there is no way to diagnose an Occlusion Myocardial Infarction (OMI/STEMI) if LVH is present. What is LVH exactly, how does it affect our patients, and what tools can we use to evaluate if LVH is hiding an MI?

Considered one of the more challenging types of shock to treat, Cardiogenic shock can present in different ways in different patients, and each patient may require a different treatment modality depending on cause, physiologic differences, etc. Do you reach for the Norepi? Epi? Milrinone? Dobutamine? Some fluids? Or maybe something mechanical in nature? Let's find out!

Ok, because we touched on Sodium Bicarb in the last episode, I felt it made sense to not only re-visit this topic, but to also look at ways to reduce the negative effects of the hypertonicity with dilution in D5W, when to consider diluting and when to just full-send the 8.4% IV bolus, and a few other situations to consider administration of IV sodium bicarb that have nothing to do with cardiac arrest or acidosis. 

First of all...no. Not quite. But I got your attention, didn't I? Recently a *Retrospective case study with meta-analysis* was released that basically purports that there is no place or evidence for Calcium Chloride/Gluconate in Hyperkalemia without ECG changes, no place or evidence for Calcium Chloride/Gluconate in Hyperkalemia WITH ECG changes, and really no place for sodium bicarb either. Let's read between the lines and see why we should not quite pump the brakes on Calcium just yet. 

Where are my tPA holdouts? And what about my TNK fans? Let's take a look at why TNK is quickly becoming the "ringleader" for STEMI, and more frequently, in off-label usage in CVA situations.

Why do we obtain a 12-lead ECG on every syncope patient? What are we looking for? What are the possible causes of syncope from the cardiac and pulmonary side of the anatomy/physiology "house?" Tune into this episode and add these to your mental bank for your next syncope patient evaluation!

Have you ever administered Droperidol before? What would we give it for, and what do we need to consider when it comes to age of the patient, medication clearance, and what can go wrong if administration is done properly? We will explore these questions and more!

When you think causes of cardiac arrest, I bet your mind doesn't typically go right to candy as the cause. Maybe when we talk about our H's & T's, we should expand our "toxicology T" to something more than just opioids/opiates...what else could there be? Join me and find out!

Pediatric resuscitations can be incredibly challenging mentally and physically. From maintaining your composure and separating yourself mentally, to ensuring you provide the best care possible, it is never easy. Now throw in massive trauma as well, and the case becomes even harder. Join me for a review of a case study of a pediatric patient who went into arrest after a trauma, and lessons that can be learned. 

Intubation of the conscious or semi-conscious patient is an incredibly invasive and painful experience. Propofol alone is not sufficient nor appropriate for a patient. Join me as I discuss not only sedation strategies, but just as important, analgesia for these patients. 

From Epinephrine administration to dual-sequential defibrillation, changes for hypothermic arrests, and much more, let's look at some considerations for your next cardiac arrest resuscitation!

Let's take a look at commonly asked questions surrounding lactate, as well as a dive into the use of and background surrounding C-Reactive Protein, or CRP. What can we really use these for, and what do their results indicate? Join me and let's find out!

This episode dissects an unfortunate case from across the country, where a significant number of medical errors in decision-making were made, and little accountability was taken, if any. The father of the patient has made it his goal for the remainder of his life to honor his late son's life by pushing this story out to all EMS, critical care transport, and hospital personnel that he possibly can so that this type of mistake never claims a life again. I am honored to be able to help spread Drew's story. 

www.doitfordrew.org

We know large fluid bolus' in massive PE are not helpful. What about early vasopressor usage while awaiting the TNK? This begs the question of which pressor and why? Perhaps Norepi is not the one we should reach for first, and maybe look for something that can provide inotropy, despite the increase in HR...?

The question came up of what do you look for on all your vent transports? This episode covers the initial steps in a systematic approach for each and every time you take over a vented patient. 

Leave the dogma behind! Is Ketamine to be overlooked in TBI? I would suggest for those who say yes still, and believe it increases ICP, maybe this episode is for you.

Recently, information was released about a retrospective review study looking at over 1.5 million patient records and reporting that Etomidate showed bad voodoo when it came to use as an induction agent for intubation. But is everything as they really portrayed it? In this short episode, we will take a brief look...

In this episode designed specifically for the hospital personnel and ambulance transport teams, we will discuss the Medical Necessity form, or PCS/N-PCS form, why it is so important that it be filled out accurately, completely, and truthfully, and what can happen if these are not. While this is not the most exciting topic in the world, anyone (MD, DO, RN, EMT-P, case manager, etc) who might be either filling one of these out or accepting one for transport, NEEDS to hear this talk. 

How many units of blood can we really give a patient? How about 100? Seems like a lot, but often at major trauma centers, this number is not out of the realm. In our smaller facilities, even ten units might overwhelm the capabilities of the blood bank, but even at these lower numbers it is important to understand the concepts of MTP and DCR. We will discuss these concepts and re-hash the trauma triangle and diamond concepts, ratios in resuscitation, and more.

A patient arrives at your facility with severe hypertension but is bradycardic...and paralyzed below T6...before we reach for the beta-blockers or nitrates, what else should we be thinking? What is this patient's body trying to tell us, and how does it do what it is doing? We will explore these questions and the pathophysiology behind this condition to help us shape our medical decision-making for future patients!

Is it anaphylaxis? Is it Lupus? Dr. House might think so, but perhaps we consider another differential in this episode. Let's take a look at a rare but challenging condition, the pathophysiology behind it, and how we can treat these special subsets of patients.

Is sepsis just the infection? The antibiotics and fluids? Let's discover another aspect of the condition that also should be considered! We don't typically think about the thyroid in sepsis, but this is an episode you shouldn't miss!

In this episode we will discuss needle, finger, and tube thoracostomies, with the emphasis on the finger method, to include supplies, procedure, reasoning, cautions, and more. The importance of BVM ventilation during the interim before either a chest seal with drain or a tube with wet-vac drain system can be placed is also discussed with emphasis on deviation from normal A&P to the introduction of a larger hole and loss of negative pressure. Trouble-shooting of the wet-vac drain system will also be discussed!

Cerebral vasospasm in the setting of SAH is a concerning finding and one that can cause significant issues for us to manage, and obviously these issues can hamper patient outcomes and recovery. Triple-H therapy has become widely adopted around the country, but is another one of those treatment modalities that has little supporting evidence, only good theory behind it. We will unwrap this concept and see how it plays into SAH, what it can potentially do for our patients, but also what it can potentially do as side effects or adverse effects as well...

What else can be done for the internally-hemorrhaging trauma patient? How can we buy them more time to get to definitive surgery? In this episode I will discuss REBOA, how it works, why it can help our patients, and even an external alternative to REBOA, albeit a single-use expensive alternative!

Today's episode is a really interesting case to review and discuss. This is not a case from our system, but has some really interesting learning points, and is a great example of when to treat vs not to treat, and how to not just chase numbers, as well as an example of playing the "Which of these came first and which is the effect of the other" game. Put on your detective hats, because here we go!

Today is a shorter episode but an important one, looking at some important parts of Acid Base issues, driving factors, considerations, and a bit of a introductory dive into Winter's Formula for expected CO2 compensation. 

The Cath Lab and PCI is not just for "STEMI" and "NSTEMI" patients! There are at least 6 conditions that also warrant urgent or emergent PCI, and today's topic is one of the more rare ones to encounter, but also one of the more dangerous given the nature of the condition. I will walk you through a scenario, criteria to use on ECG, and talk about false-positives as well!

Adenosine is for ACLS...Lidocaine is for ACLS...Magnesium is for ACLS...so why the heck are we talking about a trauma patient here? Let's look at the combination of Adenosine, Lidocaine, and Magnesium together as a bolus and infusion for various trauma patients and see how this solution can be a solution for trauma!

If you remember back to your New England Organ Donor Services (NEDS) training, T3 and T4 protocols may be used to preserve organ function for donation. What if we applied the same knowledge of anatomy, physiology, and the idea behind the T3 and T4 protocols to perhaps treat a condition like Sepsis? In this episode I will discuss why this came to mind, why it makes sense, and explore the idea a bit more. 

Think back to your last pediatric or young adult trauma patient...especially those who were tachycardic but normotensive. Did you brush off their tachycardia as anxiety, pain, etc? Maybe we need to reconsider this group of patients. We will use some basic math to show just how unstable they actually are, well-before the BP drops!

Let's discuss IV and IO access, flow rates, what size catheters you ACTUALLY need, and more. Do all trauma patients really need bilateral 14 gauge IV's? We will explore this and more!

Are you really aware of how Fentanyl works outside of the vial? How you actually can or can't be exposed to powder forms of the medication? Let's debunk some of the myths circulating in the media about Fentanyl and other opioids similar to Fentanyl to set the records straight!

Join me as we take a dive into some incredibly important tips for medical legal documentation in today's litigious society. We will talk about the differences in EMS vs hospital documentation (Summary vs contemporaneous), what to know about statute of limitations, what you need to have in your documentation to survive in court, etc. I also explain the process for being requested to testify or be examined in court and what role your documentation plays.

You've probably heard of Keturonium, or Rocketamine...but have you heard of Ketofol? If not, have no fear, as this episode will present the basics of procedural sedation, a little refresher on Ketamine and Propofol, and discuss why it make make sense to combine the two into one super-charged tool for procedural sedation. Is it right for every time? No. And the evidence presented will outline this. But it is a good idea to know how to prepare it and why in case a physician asks for it. 

Following a brief dive into acidosis, we will explore the basics behind sodium bicarbonate (NaHCO3), Calcium, and THAM, or Tromethamine, as treatments for the severely acidotic patient. This episode will look at when each option is suitable, the downsides for each, and why THAM is actually a decent option to reach for. 

This episode is a very brief add-on/refresher to the in-person training provided in the ED last month, to help fill any gaps in understanding surrounding the medication, its uses, mechanism, contraindications, set-up, and tips/tricks. 

Similar to the right-ventricular shock patient's death spiral, were you aware that poor mechanical ventilator treatment/setting choices can send our patients into similar death spirals? This episode aims to help identify an example of a common mistake in scenario form, then break it down to help understand why these problems add up into sometimes unrecoverable obstructive shock pathways. That hypotension and other symptoms that is not fixed by vasopressor/inopressor and other medication support may be from your ventilator settings and not the patient themselves...

The world of ECG's can be very intimidating and complex. Not everyone is walking around examining them with calipers and computer-aided vector programs. For those of us non-Cardiologists, this episode will give a brief overview of the various wide-complex tachycardias, how to keep from making the ACLS-driven assumption that all wide complex tachycardias are V-Tach, how to identify various imitators like PSVT with aberrancy, A-Fib with RVR, sinus tachycardia with hyperkalemia, etc. 

We will also discuss why Amiodarone and Lidocaine may not always be the best option, why Adenosine may be better than you think, and more. 

Whether working in EMS/pre-hospital and obtaining an informed refusal of treatment/transport, or obtaining an AMA documentation in the hospital, this procedure is one of the most common causes of healthcare workers findings themselves deposed in court to testify. After having served as an Expert Witness in court testifying for and against EMS personnel in regard to documentation and standards of care, I wanted to take some time to discuss what goes into a properly executed informed refusal/AMA process, how to ensure you stay out of trouble, and what to include to build your documentation so it is a solid defense. 

We will examine:
-High-risk patient interactions/refusals;
-The Mini-Cog Assessment for validation of executive recall and cognitive function;
-How to keep from coercing a patient into refusing and how to re-phrase your statements and questions to avoid this;
-Much more!

Sepsis, despite the bundles and attention it has recently gotten, still seems to take a back seat in the medical world to heart attacks, strokes, and trauma. We will spend some time this episode discussing SIRS, Sepsis, Severe Sepsis, and Septic Shock, look at how the standard Medicare SEPSIS "bundle" and fluid resuscitation can cause more problems than not when generically spread to all patients, and how we can better improve the Sepsis care between field providers and hospital providers. 

Piggybacking off of the Cocaine "Party Powder" episode from earlier, we take a deeper dive into sodium channel toxicity, how to recognize it, the pathology, and treatment rationale. These can be incredibly challenging patients to treat, mostly because we often find ourselves going down a different diagnosis route than where we need to be. 

A brief departure from the actual world of medicine itself, I wanted to take some time to promote respect not only between the medical disciplines of EMS, nursing, mid-level, and physicians, but also self-respect. We are all part of the same healthcare family, we all face the same overall hurdles...let's work together to build a better future and more cohesive present for us now! 

(*Note, this episode is not spurred by any recent event, just the thoughts bouncing around in my head after reflecting on 19 years of public safety and military career so far.)

Have you found yourself wondering what the doctors and paramedics are looking at and obsessing over on the ECG's? In this episode, we examine T-waves, from the cardiac memory-induced changes to pathologic changes, and the various non-STEMI (but still potentially OMI!) conditions that need to be seen by cardiology and how to identify them on ECG. 

In this episode:
-Those STEMI changes on your ROSC patient's ECG might not be there in 5 minutes!
-The sole inverted T-waves in aVL are more important than you think!
-DeWinter's what?
-And more!

This episode is a case study and discussion on the challenges of poly-substance ingestion and ECG interpretation, especially on the challenges of Cocaine when mixed with alcohol and other party substances. The effects are not what you would typically expect! 

Join me as I discuss RSI vs DSI, the choices of medications for induction and paralysis, tips and tricks, and cautions to be aware of. RSI is not rapid. It is not done in disregard for the patient. It IS different from a Crash Airway and that will be discussed as well. I am joined for this episode by a star-studded cast including Etomidate, Ketamine, Succinylcholine, Rocuronium, the HOp Killers, and more! 

Today's episode looks specifically at:

-OMI/NOMI vs STEMI/NSTEMI
-Newer ACC/AHA criteria for identification of OMI
-LBBB/Ventricular-Paced Rhythms and Sgarbossa/Modification Criteria
-LVH and proposed OMI criteria
-Hypertrophic Obstructive Cardiomyopathy (HOCM)
-Really Really Wide Complex Tachycardias (RRWCT)

The goal is to help familiarize you with some of these difficult concepts to master, and encourage future practice using these to better serve our patients. 

Join me for a quick "coffee talk" chat regarding commonly-asked questions about the helicopter teams that are often seen at the hospital, including:

1) Why aren't they flying today, the weather is great here?
2) Why did they turn down the mission request? How do they determine if they will fly or not?
3) How come they keep asking for our meds and supplies?
4) How can I give a better report and what information are they looking for specifically?

The goal of this chat is to answer your questions and better prepare you to interact with the flight crews when handing over patients to make it as seamless of a process as possible. 

Let's take a dive into the world of Vasopressin, or ADH. This drug choice is often overlooked or seen as a "back-up date" to Norepinephrine and the other "front-line" meds, but Vasopressin has its uses, and should not be overlooked. We will also discuss off-label uses for Vasopressin emerging in the world of pediatric autism treatment and to aid in differential diagnosis of the types of Diabetes Insipidus we may be facing. 

Join me for a brief overview of the typical treatments for hyperkalemia as well as discuss the downsides to Kayexalate vs other newer options such as Lokelma to consider. This discussion centers around a case of a teenager with critical potassium levels with baseline kidney failure. 

Some quick tips in the form of a rhyme to help cut through the stories and see if the story fits the presentation of the infant. These tips could help make the difference between identifying potential cases of infant abuse vs allowing a cycle to continue. 

Let's navigate the intricacies of pediatric epinephrine administration and easy ways to cognitively offload when we are trying to administer Code Dose (1:10) Epinephrine. These tips are specific to the Code Dose (1:10 or 1:10,000) Epi concentration. 

A quick dive into the various components of blood products, antigens and antibodies, differences between Cross & Match vs Type and Screen, blood transfusion issues, and administration logistics. 

Tips to simplify pediatric medication dosing.

This short episode details a quick and simple test used worldwide to help identify possible critical congenital heart defects prior to an infant leaving the hospital, or within the first few weeks of life. 

Let's review the scenario for the pedestrian hit from Episode 34 and see how you did in the Team Leader's shoes! Consider imaging, labs, treatments, assessments, and ultimate goals for this patient. 

Want to see how you stack up in the trauma world? Curious how you would manage a trauma patient as a team lead? Take a stab at this trauma nightmare scenario and put yourself in the Provider/Team Leader shoes. Listen in to the scenario, and think about how you would manage this patient, what tests and imaging you would order, how you would assess and treat, and your reasons why. Then listen in to episode 35 to see if you were close!

Just keep in mind there are many ways to do things, so keep an open mind!

Join me as we take a deep dive into the role of nitric oxide in the human body, how it affects us when we enter a shock state, and how agents like Methylene Blue and Hydroxocobalamin can make a significant difference when we have a patient who remains in shock despite fluid resuscitation, multiple vasopressor and inopressor infusions, optimization of pH, and other typical treatments failing to work. 

Join me as we review normal right-ventricular physiology, right-ventricular overload pathophysiology, and how our normal treatments for shock can end up killing these patients in the RV death spiral. 

A Hail-Mary play in cardiac arrests when all fails? Medication toxidromes unresponsive to traditional antidotes? We will explore the idea behind fatty lipid emulsion therapy and what it could do for certain populations of our patients.

Join me as we make an attempt at unpacking the complexities of LVAD patients in a simple case-based approach to simplify care of future LVAD patients and de-mystify this low-frequency patient population. 

Tips to help you improve your ABG interpretation practice.

Neonatal Resuscitation Principles? STABLE? PALS? PEARS? PEPP? What do I NEED to know about pediatric and neonatal resuscitation?

A quick dive into various possible medication-induced toxidromes and other potential chemical/exogenous toxidromes you may encounter in your care.

Have you ever wondered how to better interpret a chest x-ray before, or how to maximize your chances at not missing a key finding? Is this your first time looking at a chest x-ray and you feel lost, unsure what you are looking at? Join me as I take you on a journey through a standardized approach to interpretation of chest x-rays for the non-Provider provider (RN's, Medics, RRT's, and more). Learn the ABCDEFGL&T approach so you minimize the possibility of missing a key findings on future interpretations!

Let's talk about Propofol! Grab a glass of "milk of amnesia" and we will discuss the when, how, and why behind this medication. Tips for transport in and out of the hospital, side effects of short-term vs long-term usage, the need for loading dose, and more. 

Taking care of sick children is scary enough. Taking care of sick children with severe sepsis and septic shock can turn the stomachs of most providers. In this episode, we will discuss basic assessment and treatment considerations for septic children, and what ways we can optimize conditions for them. We will also discuss how commonly children are throwing red flags our way that we may mistake as false flags for anxiety, stress, or just "kids being kids." 

In this episode we will explore the true purpose of nitroglycerin, high vs low-dose therapy and its effects, when SL vs infusion should be used, and dispel some misconceptions surrounding the medication.

Diabetic Ketoacidosis can be a very challenging condition to treat, and if treated incorrectly, can add to the mortality rates of these patients. Join us and our special guest, Robin Abeles (PA-C), as we explore DKA, review the true purpose of Insulin, discuss the role of Bicarb (if any!), mechanical ventilation strategies, and more. This episode will focus primarily on the adult population and will review the MaineHealth Phase 1 and Phase 2 order sets for DKA as well. While this is one of our longer episodes, it is packed full of great conversation, good medicine, and tips to keep in mind for your future patients.

Have you ever had a patient who failed all attempts at oxygenation? Were you aware that there are actually four different types of hypoxia, and that they don't all respond to simply increasing oxygenation? Let's explore 5 steps to take to improve oxygenation in your patients, whether breathing on their own or mechanically ventilated. 

Have you ever truly thought about how to set up your fluids and pressors on drip sets and pumps, and why sometimes the patients go down-hill shortly after setting up or changing over your drip sets? In this short episode, we will discuss tips for initiation of pressors, flushing extension sets and considerations to prevent decompensation of your patients. 

Cervical spinal injuries are often missed in the prehospital setting, and even with advanced imaging and assessments, can still be missed in the ED. We examine the various risk factors, the anatomical zones of the cervical spine, treatment considerations, evidence-based immobilization practices, and more. 

Join me for a continuation of the DKA series, this time covering the pediatric-specific considerations. While DKA shares many similarities between pediatrics and adults, the  treatments and aggressiveness of treatments change a bit. We will cover not only the DKA, treatment considerations for the age group, and the importance of the benefit of pediatric telehealth capabilities. 

Similarly to IV placement in the sick neonate, general assessments on these populations can be challenging and nerve-wracking for all involved and those watching from the sidelines. Join me as we navigate the assessments and findings for this age group and simplify this so we can perform more efficiently under pressure. 

Taking care of sick infants is stressful enough. Attempting to obtain IV access in a sick infant adds more stress that can be mitigated with tips and tricks presented in this podcast episode. 

We often think of iGels and LMA's, or supraglottic airways, as a "rescue airway," but what if we changed our thinking with some of our difficult airways and used them as our primary option? 

Let's explore this idea, what needs to be done, and how to best use these especially in the "DSA/Delayed Sequence Airway" mentality. 

Let's explore the uses and limitations of Precedex in and out of hospital.

No, this is not a harkening back to the days of your schooling with the Krebs Cycle, stand down. This episode looks at a simplified explanation of the Oxyhemoglobin Dissociation Curve, its importance in our medicine practice, and how we can apply it in real time to our patients to troubleshoot what we are seeing. 

What is the difference between serum calcium and ionized calcium? 
When do we want to request that iCal be added to the labs?
What do we do with that information when we have it, and how does this apply back to our trauma and other patients?

The world of interfacility transports is not as simple as throwing a patient in the back of an ambulance and heading off into the sunset, hoping everything stays ok, and matching numbers from the ED/ICU etc. There are significant challenges, considerations, stressors, and other factors to be aware of. Transport medicine at the ALS and Critical Care levels is all about pre-planning, communication, organization, and more. 

This podcast will help serve as a bit of a checklist and mental map for the hospital RN and "EMS" personnel to improve care on interfacility transfers if you find yourself accompanying a crew on one, improve understanding of the pre-hospital clinicians on the ground and in the air, and better facilitate cooperation between the entities. 

A review of Albumin through a case study, applying the basics of the pharmacology so you can break it down, simplify your understanding, and apply this agent to future cases!

Explore a case study with me that would send most of us packing in the other direction out of anxiety. Dust off the cobwebs of neonatal care from your mind, and learn about the basics of the BMAG resuscitation momentum principle to keep you on track when we need to be on the same page and organized with sick infants and children. 

Disclaimer, I do NOT take credit for the BMAG principle. Others with more letters behind their names and brain cells in their heads created this concept! 

Let's explore a different way to administer Adenosine effectively, the counter-points for this newer method, and ways to safely administer Adenosine in our patients. 

In this episode we will explore a case review and delve into the world of toxicology. While this medication is not as widely prescribed as it used to be, there is still the chance that we can run into it. This medication, when at toxic levels, can lead us to the road where treating with the right agents for the right reasons can be the wrong thing.

What should we keep in mind when preparing for emergent intubations? What process keeps us in line to minimize the possibility of mistakes? How do we identify potential risks and mitigate them? In this podcast we examine the various steps we can take to cognitively offload during preparations for emergent intubations, tips and tricks, and PEARLS. 

Trauma deaths continue to be a problem within the United States, particularly deaths from torso trauma that is non-compressible externally. What advances have been made, and what can we do to change outcomes? Does the "Golden Hour" really have any merit?

Tips for reviewing medical studies, how to read between the lines, and the paradox of practicing medicine when there is little evidence from studies to back up decisions. We will explore this concept and apply it to the world of parachutists. Weird? Maybe. But let's dive in and see how this ties in to our practice of medicine!

A dive into the world of push-dose pressors, vasopressor infusions, and thoughts surroundings these treatment options with special guest Robin Abeles, PA-C. 

Brief overview of some of the "danger signs/danger times" for transport, ED, ICU, and Med Surg providers to be aware of when patients are on mechanical ventilators and Respiratory Therapy staff is not present. 

Conditions covered include:
-Acute unexplained hypoxic desaturation;
-Acute Hypotension in the Vented Pt;
-High Airway Pressure Alarm;
-Low Airway Pressure Alarm;
-Rising (Unexplained) EtCO2.

This will cover not only these conditions but also the D.O.P.E.S. mnemonic and trouble-shooting tips for each condition. 

This podcast episode covers the "When/When Not To," Why, How, and troubleshooting tips and tricks for arterial line placement and monitoring. We explore the tough topics like Allen's Test, Phlebostatic Axis (PSA), and square wave tests, and more.

This episode is intended to coincide with competency reviews and check-off's for arterial line monitoring set-up and waveform review.