DUSTOFF Medic Podcast
About this podcast
Education and issues for military flight medics.
About this podcast
Education and issues for military flight medics.
DUSTOFF Medic Podcast
Dr. Andre Cap joins us for the first in a multi-part series covering the SMOGs En Route Damage Control Resuscitation, Blood Component/Fresh Whole Blood Use, and Blood Transfusion Related Reactions protocols. COL Cap is amongst the world's foremost experts on this topic, yet he is well aware of the capabilities and limitations of practicing pre-hospital medicine in flight. This is a detailed discussion that you'll definitely get a lot out of. Dr. Cap mentions the PAMPER trial as well as the COMBAT trial. Both are directly relevant to our work: Sperry, J. L., Guyette, F. X., Brown, J. B., Yazer, M. H., Triulzi, D. J., Early-Young, B. J., ... & Zenati, M. S. (2018). Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. New England Journal of Medicine, 379(4), 315-326. Moore, E. E., Sauaia, A., & Ghasabyan, A. (2015). COMBAT: A Prospective, Randomized Investigation of Plasma First Resuscitation for Traumatic Hemorrhage and Attenuation of Acute Coagulopathy of Trauma. University of Colorado Denver Aurora United States. Finally, Dr. Cap describes some soon-to-be published research by the Armed Forces Medical Examiner System that may challenges some conventional wisdom, and may have implications for how we practice in the future. Please give this episode a listen, and send us your questions and feedback via Instagram, Twitter, or Facebook!
Conflicts Across Role 1 Guidelines
Dr. Andy Fisher and Dr. Steve Schauer join us along with Sarah Johnson and Ryann Lauby to discuss their paper, "An Analysis of Conflicts Across Role 1 Guidelines." The paper, published last year in Military Medicine, compared a number of DOD pre-hospital care guidelines, including the SMOG. The authors concluded that "the reduction or elimination of conflicting information across the various guidelines, augmentation of guidance for pediatric care, more specific guidance for unique levels of care, and clear delineation of the Role 1 phases of care (as well as which guidelines are more appropriate to each) should be considered as urgent priorities within the military medical community." Our podcast has always tried to incorporate the perspective of rotary-wing flight medics from the different branches of service. When we discuss clinical topics, we survey guidelines and protocols across the DOD in an effort to identify conflicts and, hopefully, discern best practices. This paper is directly related to that work, and this conversation is a great way to understand the authors' intent as well as ways forward. Please give it a listen and let us know your thoughts! Johnson, S. A., Lauby, R. S., Fisher, A. D., Naylor, J. F., April, M. D., Long, B., & Schauer, S. G. (2020). An Analysis of Conflicts Across Role 1 Guidelines. Military Medicine.
In this episode, Trevor and Morgan talk to Dr. Whit Harvey, USN, about one of the foundational skills of out-of-hospital care: IV and IO access. Dr. Harvey has done important research on IO efficacy, and he shares some of his findings about the pressure required to keep IOs flowing, as well as techniques to generate that pressure (it's more than you think!). Additionally, Trevor mentions some critical points about flow rates through IV tubing and lock devices. This can be a blind spot for a lot of us; the convenience of a lock is great, but those couple inches of tubing can significantly reduce flow rates, and that is not ideal if you're infusing blood. There is some pain associated with flushing an IO, and this article has some good information about just how much Lidocaine you should be using to reduce your patient's discomfort.
Progressive Medical Direction
Drs. Will Smith, Steve Rush, and Ben Walrath join us for a great conversation about the role of the military EMS director. These three men have accumulated significant experience leading MEDEVAC/CASEVAC organizations, and their perspective is valuable for flight medics and Flight Surgeons alike. During the episode, the conversation frequently emphasizes the importance of educational resources for flight docs, especially: deployedmedicine.com The Joint Trauma System's Pre-deployment Prioritized Read Lists by Clinical Role COL Robert Mabry's seminal papers: Mabry, R. L., & De Lorenzo, R. A. (2011). Improving role I battlefield casualty care from point of injury to surgery. US Army Medical Department Journal, 87-92. Mabry, R. L., Apodaca, A., Penrod, J., Orman, J. A., Gerhardt, R. T., & Dorlac, W. C. (2012). Impact of critical care–trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. Journal of Trauma and Acute Care Surgery, 73(2), S32-S37. Medical direction courses at SOMSA Furthermore, Dr. Smith highlights the National Association of EMS Physicians Military and Federal Agency Chapter, a relatively new effort in which Dr. Walrath has a leadership role. Thanks for listening, and be sure to share your thoughts with us via dustoffmedicpodcast.com, on Facebook, or @dustoff.medic.podcast!
Propofol & Sedation
Dr. Steven Bradley joins us to discuss the SMOG Propofol guideline, along with sedation and analgesia pearls. Lieutenant Commander Bradley is a U.S. Navy anesthesiologist, and he is very active in mentoring aspiring physicians. During the episode, Trevor mentions the Military Enroute Care Performance Improvement Report 2019 Events, as well as Tyler Christifulli's 2018 FOAMfrat article on post-intubation strategies. Trevor also discusses using the Richmond Agitation-Sedation Scale (RASS). You can find an easy-to-use version of the RASS on page 29 of the Joint Trauma System's Pain, Anxiety and Delirium Guideline (CPG ID: 29). It's definitely a good one to print out and keep handy. If you want to use this episode as part of your Table VIII medical training, use the following tasks per TC 8-800: 081-831-0010, Measure a Patient’s Respirations 081-833-0034, Manage an Intravenous Infusion
MCI AAR Part 3
In 2019, Jamie and Jon flew a combat mission where they evacuated several patients. Later that day, they transported the same patients to a higher level of care. In this third and final episode, we hear about the interfacility transport phase of the mission, and we get some good wisdom as both men evaluate their own performance.
MCI AAR Part 2
In 2019, Jamie and Jon flew a combat mission where they evacuated several patients. Later that day, they transported the same patients to a higher level of care. In this second episode, hear about the difficult landings Jon executed to pick up patients, as well as the textbook care Jamie provided in the back.
MCI AAR Part 1
In 2019, Jamie and Jon flew a combat mission where they evacuated several patients. Later that day, they transported the same patients to a higher level of care. In this first episode, hear from both men as they describe how the mission dropped, and their initial actions at the point of injury. There are plenty of lessons to be learned from this call for pilots, medics, crew chiefs, and ECCNs.
Maryland State Police Aviation Command
In this episode, Trooper Adam Murray joins us to discuss the Maryland State Police's use of Trooper/Flight Paramedics in their Aviation Command. Trooper Murray is a critical care flight paramedic and field training officer for the Maryland State Police in southern Maryland. Adam discusses the history of the program, the criteria for flight medic selection, the types of missions they respond to, the types of continuing education they run, and some pearls of wisdom for medics looking to use their skills in the civilian sector.
In this episode, Ricky Ditzel joins us to discuss the role of calcium in trauma patients. Ricky is a former critical care flight paramedic for the 160th Special Operations Aviation Regiment (SOAR), currently a pre-medical student at Colombia University, and the lead author of a groundbreaking paper on the role of calcium in the decompensation cycle in trauma. Ricky talks with us about how calcium works in the body, how trauma induces hypocalcemia, and how the flight medic can use calcium during trauma resuscitation. Ricky's original article in the Journal of Trauma and Acute Care Surgery: Ditzel RM Jr, Anderson JL, Eisenhart WJ, Rankin CJ, DeFeo DR, Oak S, Siegler J. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020 Mar;88(3):434-439. doi: 10.1097/TA.0000000000002570. PMID: 31876689. The recent article in the American Journal of Emergency Medicine: Wray JP, Bridwell RE, Schauer SG, Shackelford SA, Bebarta VS, Wright FL, Long B. The diamond of death: Hypocalcemia in trauma and resuscitation. Am J Emer Med. 2021 Mar;41(1):104-109. doi:10.1016/j.ajem.2020.12.065 Ricky mentions a study in which 97% of transfusion patients were hypocalcemic. That study is here: Giancarelli, A., Birrer, K. L., Alban, R. F., Hobbs, B. P., & Liu-DeRyke, X. (2016). Hypocalcemia in trauma patients receiving massive transfusion. Journal of Surgical Research, 202(1), 182-187. If you want to use this episode as part of your Tables III medical training, use the following tasks per TC 8-800. 081-833-0034 Manage an Intravenous Infusion 081-835-3002 Administer Medications by IV Piggy Back
Prolonged Field Care for Flight Medics
In this episode, Dennis from the Prolonged Field Care Podcast joins us to discuss the basics of prolonged field care on medics and their patients. Dennis is a Special Forces Medical Sergeant and an instructor at the Special Warfare Medical Group. In this podcast we talk about the definition of prolonged field care, the operational considerations, and the specific considerations when picking up patients who have received care under PFC conditions. Check out the Prolonged Field Care Working Group website. If you want to use this episode as part of your Tables V medical training, use the following tasks per TC 8-800. 081-831-0011 Measure a Patient's Pulse 081-833-0145 Document Medical Care: SOAP Note Format 081-833-0156 Perform a Medical Patient Assessment 081-831-0012 Measure a Patient's Blood Pressure 081-833-0247 Perform a MACE Screening for Traumatic Brain Injury 081-833-3017 Insert a Urinary Catheter 081-833-0006 Measure a Patient's Intake and Output 081-833-0012 Perform Wound Irrigation 081-833-0165 Perform Patient Hygiene 081-833-0090 Apply Local Anesthesia
In this episode, Dr. Ben Walrath joins us to discuss the SMOG Shock/Hypotension guideline. The conversation focuses on hypovolemic shock, but also includes a discussion of other types of shock that sometimes get less attention in the tactical setting. Commander Walrath is a U.S. Navy emergency medicine physician and the EMS Director at Navy Medical Forces Pacific. He has made major contributions to military medical literature. Here's his Google Scholar citation list. Trevor mentions an episode of Heavy Lies the Helmet. This is a great episode, and you should definitely subscribe to the podcast. Max discusses Jamie Eastman's recent paper in the Air Medical Journal, Point-of-Care Laboratory Data Collection During Critical Care Transport. Jamie is a friend of our podcast, and we will be hearing more from him soon. The article is behind a paywall, but you can use your OpenAthens account from the MEDCoE/AMEDD Virtual Library (AVL) to log in and read it free. Read this piece from Next Generation Combat Medic for step-by-step instructions on how to get access to AVL. If you want to use this episode as part of your Table VIII medical training, use the following tasks per TC 8-800: 081-833-0047, Initiate Treatment for Hypovolemic Shock 081-833-0034, Manage an Intravenous Infusion 081-835-3000, Administer Blood 081-835-3054, Administer Blood Products
Dr. Will Smith joins us to discuss the SMOG Altitude Illness guideline. COL Smith, MD, brings his decades of military and wilderness medicine experience to bear in a discussion of "mountain sickness." Altitude illnesses have a significant spectrum of symptoms and severity, and this episode's conversation ranges from initial diagnosis to evacuation strategies. Keep the SMOG handy during this episode, and find more detailed information in the Wilderness Medical Society's (WMS) Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update. Additionally, our friends at Next Generation Combat Medic (NGCM) have an excellent summary of the issues in "High and Sick: Altitude Illness." We've got a link to both the WMS CPG page and NGCM at dustoffmedicpodcast.com There are a number of medications that are useful for treating altitude illness, but remember this key point from the WMS: "As with AMS and HACE, descent remains the single best treatment for HAPE." So, if you're flying on a critical patient with suspected altitude illness, load, go, and get low!
Dr. Seth Assar joins us to discuss the SMOG Respiratory Distress guideline. This is a wide-ranging discussion that covers many of the differential diagnoses for a patient who is having difficulty breathing. Listen closely for a use of Ketamine that you may be less familiar with. Dr. Assar points out the inherent risks of intubation and mentions a study identifying a real risk of mortality with the procedure: Schwartz, D. E., Matthay, M. A., & Cohen, N. H. (1995). Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. The Journal of the American Society of Anesthesiologists, 82(2), 367-376. The risk is further increased in patients in hemorrhagic shock and an article in the last JSOM makes this clear. See: Thompson, P., Hudson, A. J., Convertino, V. A., Bjerkvig, C., Eliassen, H. S., Eastridge, B. J., ... & Rappold, J. F. (2020). Risk of Harm Associated With Using Rapid Sequence Induction Intubation and Positive Pressure Ventilation in Patients With Hemorrhagic Shock. Journal of Special Operations Medicine: a Peer Reviewed Journal for SOF Medical Professionals, 20(3), 97-102. Finally, be on the lookout for Dr. Assar's forthcoming article in the JSOM on mechanical ventilation. This episode relates to TC 8-800, Table II and IV.
Los Angeles County Sheriff's Department Special Enforcement Bureau
We're stepping back from our clinical medical discussions this week to hear from Los Angeles County Sheriff's Deputy Stephen Doucette. In this episode, Dep. Doucette talks about his role as a tactical medic on the LASD Special Enforcement Bureau. SEB has a comprehensive tactical medical program that includes SWAT medicine, mountain rescue, and rotary-wing capabilities. Dep. Doucette gives a great overview of his Department's program, talks about some critical patients that he has treated in flight, then wraps up with some advice for anyone interested in career opportunities with LASD.
Dr. Jeffrey Siegler joins us to discuss the SMOG Airway Confirmation guideline. The first half of this episode follows the SMOG, then we pivot to discuss "the sledgehammer." Dr. Siegler has conducted important research on the excessive tidal volumes delivered by the "adult" BVM. After you've listened to this episode, watch his presentation to the Joint Trauma System, and read Siegler, J., Kroll, M., Wojcik, S., & Moy, H. P. (2017). Can EMS providers provide appropriate tidal volumes in a simulated adult-sized patient with a pediatric-sized bag-valve-mask?. Prehospital Emergency Care, 21(1), 74-78. Trevor mentions the difficulty of effective lung auscultation. StatPearls has a good summary. We've posted a great ETCO2 waveform reference from the PFC Airway Management CPG under 'Resources' at dustoffmedicpodcast.com. Use the cheat sheet, but read the CPG too—it's an excellent document. Ultrasound may be a faster method to confirm airway placement that end-tidal capnography. Take a look a this recent article: Chowdhury, A. R., Punj, J., Pandey, R., Darlong, V., Sinha, R., & Bhoi, D. (2020). Ultrasound is a reliable and faster tool for confirmation of endotracheal intubation compared to chest auscultation and capnography when performed by novice anaesthesia residents-A prospective controlled clinical trial. Saudi Journal of Anaesthesia, 14(1), 15. Finally, ultrasound is proven to be safe and effective for use inside helicopters. The earliest reference we can find for this is below, and many studies since have bolstered this. Lichtenstein, D., & Courret, J. P. (1998). Feasibility of ultrasound in the helicopter. Intensive care medicine, 24(10), 1119.
Interfacility Transport Clinical Practice Guideline
MAJ Lani Pineda, RN, joins Max and Wayne to discuss Clinical Practice Guideline 27, Interfacility Transport of Patients Between Theater Medical Treatment Facilities. Wayne mentions several studies that preceded the most recent update to this CPG. These include: JROCM 026-12, Tactical Critical Care Transport DOTMLPF Change Recommendation (click 'Resources,' at dustoffmedicpodcast.com) Mabry, R. L., Apodaca, A., Penrod, J., Orman, J. A., Gerhardt, R. T., & Dorlac, W. C. (2012). Impact of critical care–trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. Journal of Trauma and Acute Care Surgery, 73(2), S32-S37. Dickey, N. W. (2015). Combat trauma lessons learned from military operations of 2001-2013. Defense Health Agency/Defense Health Board Falls Church United States. Dickey, N. W. (2011). Tactical Evacuation Care Improvements Within the Department of Defense. Defense Health Agency/Defense Health Board Falls Church United States. The entire Clinical Practice Guideline library is on the Joint Trauma System website. We've got a link to it under 'Links' at dustoffmedicpodcast.com.
Dr. Jennifer Gurney joins us to discuss the SMOG Multiple Trauma guideline. Dr. Gurney discusses challenges in military pre-hospital documentation. Schauer, et al discuss this at length: Schauer, S. G., April, M. D., Naylor, J. F., Oliver, J. J., Cunningham, C. W., Fisher, A. D., & Kotwal, R. S. (2017). A descriptive analysis of data from the Department of Defense Joint Trauma System Prehospital Trauma Registry. US Army Medical Department Journal. Dr. Gurney further emphasizes the need for military-civilian partnerships to ensure medical providers maintain their skills. If your unit has an effective partnership in place for pre-hospital providers, please let us know about it at dustoffmedicpodcast.com. Max mentions literature describing the effects of hypothermia on traumatic brain injury. More information: Jeremitsky, E., Omert, L., Dunham, C. M., Protetch, J., & Rodriguez, A. (2003). Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion. Journal of Trauma and Acute Care Surgery, 54(2), 312-319. This episode relates to TC 8-800, Table I, III, and VII.
Dr. Andy Fisher joins us to discuss the SMOG Hemorrhage guideline. Dr. Fisher mentions a case involving manual compression of a patient's aorta: Lewis, C., Nilan, M., Srivilasa, C., Knight, R. M., Shevchik, J., Bowen, B., ... & Kreishman, P. (2020). Fresh Whole Blood Collection and Transfusion at Point of Injury, Prolonged Permissive Hypotension, and Intermittent REBOA: Extreme Measures Led to Survival in a Severely Injured Soldier-A Case Report. Journal of special operations medicine: a peer reviewed journal for SOF medical professionals, 20(2), 123-126. This episode relates to TC 8-800, Table I