Critical Brain Resuscitation

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A patient with an intracranial hemorrhage can look surprisingly stable…until they suddenly don’t. Recognizing the subtle signs of rising intracranial pressure before herniation occurs is one of the most time-critical skills in emergency medicine. In this episode, Drs. James Nardini, Mike Prats, and Kim Bambach discuss a practical, evidence-based approach to critical brain resuscitation, from recognizing early deterioration to implementing tiered ICP management, choosing hyperosmolar therapy, optimizing sedation, and avoiding common pitfalls. Based on the Emergency Neurological Life Support (ENLS) framework, this episode provides a systematic approach you can apply on your next shift.

Guest: James Nardini, MD, MS; Host: Mike Prats, MD and Kim Bambach, MD; Editor: Kim Bambach, MD

🔑 Key Learning Points

1. Recognize deterioration early

  • Elevated ICP often begins with nonspecific symptoms (headache, vomiting, confusion, gait disturbance).
  • Serial neurologic examinations are more valuable than a single assessment.
  • Track:
    • Glasgow Coma Scale (watch for declining scores)
    • Pupillary size and reactivity
    • New focal neurologic deficits
    • Mental status changes
  • A >1 mm change in pupil size may be an early sign of herniation.

2. Understand herniation syndromes

  • Subfalcine: contralateral leg weakness (ACA compression)
  • Uncal (transtentorial):
    • ipsilateral fixed dilated pupil
    • decreased consciousness
    • contralateral hemiparesis
  • Tonsillar:
    • occipital headache
    • neck stiffness
    • progressive brainstem compression
    • eventual Cushing triad

3. Cushing triad is a late finding

  • Hypertension
  • Bradycardia
  • Irregular respirations

Waiting for the full triad means the patient is already critically decompensating.

4. Follow a tiered approach (Emergency Neurological Life Support)

Tier 0: Optimize physiology

  • ABCDE assessment
  • Protect airway, maintain oxygenation and ventilation
  • Normalize glucose
  • Treat fever
  • BP management
  • Elevate head of bed (when appropriate)
  • Provide analgesia and sedation
  • Obtain urgent non-contrast head CT
  • Minimize secondary brain injur

Tier 1: Temporize while arranging for definitive care

  • Hyperosmolar therapy
  • Brief controlled hyperventilation if actively herniating
  • Early neurosurgical consultation and if needed arrange transfer for neurosurgical consultation. You can advocate for your patient.

5. Hypertonic saline vs. mannitol

  • Both improve outcomes and are reasonable first-line agents.
  • Hypertonic saline may provide:
    • more sustained ICP reduction
    • better cerebral perfusion pressure
    • superior ICP control in several studies
  • Don’t delay treatment simply because one agent is unavailable.
  • In selected critically ill patients, both therapies may be used.

6. Monitor sodium carefully

  • Obtain a baseline sodium on patient arrival.
  • Check sodium frequently after hypertonic saline.
  • Typical therapeutic target:
    • 145–155 mEq/L

6. Propofol is the preferred sedative

Benefits:

  • Decreases cerebral metabolic demand
  • Reduces cerebral blood volume
  • Lowers ICP
  • Suppresses seizures

Watch for:

  • Hypotension
  • Reduced cerebral perfusion pressure

Maintain adequate blood pressure while sedating.

7. Common pitfalls

A common pitfall is waiting too long to initiate hyperosmolar therapy. If you’re seriously asking whether the patient needs hypertonic therapy, that may be the moment to act rather than waiting for unmistakable herniation.

8. Emergency physicians are the bridge to definitive care

The goal is to:

  • Recognize deterioration
  • Prevent secondary injury
  • Optimize physiology
  • Initiate temporizing therapies
  • Rapidly connect patients with neurosurgical intervention

9. Ultrasound pearl

Bedside ultrasound may provide additional information:

  • optic nerve sheath diameter measurement
  • optic disc elevation
  • transcranial ultrasound (experienced users)

📚 Further Resources

  1. Emergency Neurological Life Support Course
  2. Emergency Neurological Life Support Intracranial Hypertension and Herniation Protocol
  3. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients- Neuro Critical Care Society

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Day in the Life of… an EM Chair

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What does it actually take to become the chair of an academic emergency medicine department? In this episode, Dr. Edleda James, PGY3 and future simulation fellow interviews Dr. Jeffrey Caterino, Professor of Emergency and Internal Medicine and Chair of Emergency Medicine at The Ohio State University. He shares his career journey to become department chair, the realities of leading a large academic department, and the leadership skills that aren’t taught during residency. They discusses mentorship, developing financial and administrative expertise, intentionally building leadership skills, and practical advice for trainees and junior faculty interested in future leadership roles.

Guest: Jeffrey Caterino, MD, MPH; Host: Edleda James, MD; Editor: Kim Bambach, MD; Audio Editor: Nick Roesel

🔑 Key Learning Points

  • Leadership is rarely a straight path. Career interests often develop after becoming faculty and gaining insight into how departments function.
  • Mentorship remains essential at every career stage, including for department chairs. Peer mentorship can be just as valuable as traditional mentor-mentee relationships. Seek advice broadly.
  • Leadership is a learnable skillset that requires intentional development, including:
    • Running effective meetings
    • Hiring and personnel management
    • Delivering difficult feedback
    • Motivating teams
    • Financial literacy
    • Organizational leadership
  • Experiential learning is invaluabl. Serve on committees, observe leaders, and gain exposure to departmental operations before stepping into leadership roles.
  • Leadership courses offered through institutions and professional organizations can provide practical skills and invaluable insights from experienced leaders, such as leadership courses from SAEM.
  • An MBA or administrative fellowship can be helpful, particularly for hospital leadership, but they are not prerequisites for becoming a department chair. The key is acquiring the necessary business and leadership skills by any effective pathway.
  • If you’re considering a leadership role:
    • Talk with multiple people currently doing the job.
    • Learn what skills they actually use.
    • Intentionally build those competencies before you need them.
  • Final leadership advice: pursue opportunities with “magnitude and direction“. Be intentional about the experiences and skills you choose so they align with your long-term goals.

📚 Further Resources

  1. Administration Fellowship at The Ohio State University
  2. SAEM Chair Development Program
  3. SAEM Emerging Leader Development Program
  4. EM Resident- What You Need to Know About EM Administration Fellowships

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Drowning: Rescue, Resuscitation, and Prevention

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Drowning deaths have increased in recent years, making it more important than ever for emergency physicians manage effectively. In this episode, Corey Williams, MD, reviews current drowning terminology, the pathophysiology that drives treatment decisions, and practical pearls for resuscitation, observation, and disposition. We also discuss common misconceptions and key prevention strategies to share with patients and families (and your own!).

Guest: Corey Williams, MD; Host: Kim Bambach, MD; Audio editor: Nick Roesel

🔑 Key Learning Points:

  1. Use the modern drowning terminology:
    • Fatal or non-fatal drowning (with or without morbidity). Avoid outdated terms such as near drowning, dry drowning, and secondary drowning.
  2. Demographics:
    • Young children, adolescent males, and patients with alcohol use, seizure disorders, or developmental disabilities are at highest risk for drowning.
  3. Pathophysiology:
    • Drowning is primarily a hypoxic injury. In cardiac arrest, provide ventilations in addition to chest compressions. Compression-only CPR is not sufficient.
  4. Hypothermia:
    • Consider hypothermia when a patient has a drowning event, even in warmer months. Active rewarming remains a critical part of management.
  5. Trauma:
    • Consider cervical spine injury only when the mechanism or examination raises concern (e.g., diving injuries, unwitnessed events, neurologic deficits).
  6. Mythbusting:
    • Fresh water versus salt water does not change management. Clinically significant electrolyte abnormalities from aspiration are unlikely.
    • A normal initial chest X-ray does not rule out delayed pulmonary injury. Patients with non-fatal drowning who remain asymptomatic should generally be observed for at least 4 hours before discharge.
    • Routine prophylactic antibiotics and steroids are not recommended after drowning unless there is concern for heavily contaminated water exposure.
  7. Prevention matters:
    • Early swim lessons, four-sided pool fencing, close supervision, and CPR training for caregivers remain the most effective ways to reduce drowning-related morbidity and mortality.

📚 Further Reading:

  1. Davis CA, Schmidt AC, Bierens JJLM, et al. Wilderness Medical Society clinical practice guidelines for the treatment and prevention of drowning: 2024 update. Wilderness Environ Med. 2024;35(1):101-120. doi:10.1016/j.wem.2023.12.004.
  2. Dezfulian C, McCallin TE, Bierens J, Dunne CL, Idris AH, Kiragu A, Mahgoub M, Shenoi RP, Szpilman D, Terry M, Tijssen JA, Tobin JM, Topjian AA; on behalf of the American Heart Association and the American Academy of Pediatrics. 2024 American Heart Association and American Academy of Pediatrics focused update on special circumstances: resuscitation following drowning: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2024;150(23):e473-e501. doi:10.1161/CIR.0000000000001274.
  3. Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012;366(22):2102-2110. doi:10.1056/NEJMra1013317.
  4. American Academy of Pediatrics. Prevention of drowning. Pediatrics. 2021.

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Thin Air, High Stakes: Altitude Medicine

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Dr. Jonathan Thompson dives into the fascinating world of high-altitude medicine, explaining how hypoxia affects the body and lead to conditions like acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). He highlights how hypoxia is a universal concept relevant to emergency and critical care medicine, and that understanding altitude illness can improve care for patients, whether you practice on a mountain or not!

Bio: Dr. Jonathan Thompson is a former Green Beret in the U.S. Army Special Forces and former U.S. Army Special Operations Mountaineering Instructor that taught in Colorado, Alaska, and Wyoming. He completed a Masters in Physiology at the University of Michigan with a thesis on nitrate supplementation in the prevention and treatment of acute high-altitude illnesses. He is an annual, returning guest lecturer (2020-present) at the University of Michigan’s Department of Physiology instructing undergraduate and graduate students on high-altitude physiology, pathophysiology of acute altitude illnesses, and relevant treatments.

Guest: Jonathan Thompson, MD, MS; Host: Kim Bambach, MD; Audio editor: Nick Roesel

Key Learning Points:

  1. The unifying concept: hypoxia
    • Decreased oxygen delivery impairs cellular metabolism and underlies all altitude illness.
  2. Risk of altitude illnesses begins around 5,000 feet
    • Risk increases with rapid ascent and poor acclimatization. The classic setup is flying in and ascending quickly.
  3. Physiologic response to altitude
    • Hypoxia triggers the hypoxic ventilatory response → ↑ respiratory rate and tidal volume
    • ↑ sympathetic activity → ↑ heart rate and blood pressure
    • Respiratory alkalosis from hyperventilation → renal compensation → bicarbonate excretion → diuresis
    • Over weeks, erythropoietin → ↑ red blood cell mass
  4. Altitude Illness Spectrum
    • Acute Mountain Sickness (AMS): Symptoms include headache, nausea, fatigue, and insomnia. This is usually mild but a warning sign.
    • High Altitude Cerebral Edema (HACE): Characterized by neurologic dysfunction, such as ataxia and altered mental status. HACE can be life-threatening.
    • High Altitude Pulmonary Edema (HAPE): A form of non-cardiogenic pulmonary edema. Symptoms include dyspnea at rest, cough, pink frothy sputum. HAPE is the leading cause of death.
  5. Treatment
    • Descent is the definitive treatment. Give oxygen if available (but it’s usually not in austere environments).
    • Give Acetazolamide for AMS and HACE (both prevention and treatment)
    • Give Dexamethasone for HACE (remember “HACE is AMS on steroids!”).
    • Give Nifedipine for HAPE.

The Bottom Line:

The best treatment is descent, and everything else is a bridge. When you’re out adventuring, don’t forget to go slow to acclimatize!

Check out Dr. Thompson’s lecture for the World Extreme Medicine Organization here!

Other Resources:

  1. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update
  2. Auerbach PS, Cushing TA, Harris NS, eds. Auerbach’s Wilderness Medicine. 7th ed. Philadelphia, PA: Elsevier; 2016.

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In Your Patient’s Neighborhood

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Where you live is a significant social determinant of health that impacts health and emergency care. In this episode, Dr. Kim Bambach (Assistant Professor of EM) interviews Dr. Amogh Krishnagiri (PGY-3 Chief Resident) about how built spaces and the connections they create ultimately influence health. From transportation access and food availability to education, housing stability, and local resources, a patient’s built environment directly affects their ability to follow up, fill prescriptions, and heal.

Key Learning Points:

  1. A neighborhood is more than a built location
    • It reflects the social connections, infrastructure, and resources that shape health outcomes.
  2. Social determinants of health impact emergency care
    • Transportation, food access, housing stability, income, and education all directly affect whether patients can follow through on ED discharge plans.
  3. Consider what’s in your patient’s neighborhood
    • Not all neighborhoods offer equal access to pharmacies, clinics, grocery stores, or safe transit. Expecting identical follow-up success across different environments is unrealistic.
  4. Transportation is often overlooked
    • If patients cannot physically get to appointments, pharmacies, or community resources, the plan fails.
  5. Take the time to make a safe discharge
    • Safe discharge planning requires feasibility, not just medical accuracy. A brief conversation about barriers can prevent bounce backs and unnecessary admissions.
  6. Connect to your community resources
    • Emergency physicians are uniquely positioned to connect patients to community resources.
    • Get to know the resources in your community and your ED social worker.

Bottom Line:
Understanding your patient’s neighborhood — especially their access to transportation and community resources — is essential to creating discharge plans that are safe, realistic, and truly effective.

Resources:

  1. Close.City
  2. Columbus Street Card
  3. Central Ohio Area Agency on Aging
  4. Columbus Metropolitan Library
  5. Ohio Domestic Violence Network
  6. Columbus Food Pantries

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First Shifts: Intern Mini-Series Pt. 2

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In Part 2 of the Intern Mini-Series, Drs. Edleda James (PGY-3) and Nick Cummins (PGY-3) continue their deep dive into intern year, focusing on the remaining core rotations and how to truly thrive during them. They reflect on experiences in EMS, anesthesiology, ultrasound, and pediatric emergency medicine, highlighting what each rotation offers, key skills to prioritize, and resources that make the learning curve more manageable. The conversation expands beyond rotations to include practical advice on studying for Step 3 and the ITE, managing time and energy, and maintaining wellness during demanding months. Throughout the episode, they emphasize perspective, relationship-building, and self-compassion as essential tools for navigating residency and growing into a confident emergency physician.

EMS

Where you learn how emergency care begins and gain deep respect for prehospital medicine.

Pearls:

  • EMS clinicians are your coworkers and learning their workflow improves ED handoffs.
  • Ride-alongs highlight the physical, logistical, and cognitive challenges of prehospital care.
  • Dispatch centers teach you how calls are triaged, mapped, and prioritized.
  • Critical care transport offers insight into mobile ICUs and interfacility transfers.
  • Relationship-building pays dividends later when you see the same crews in the trauma bay.
  • This rotation can spark interest in EMS fellowship or prehospital leadership.

Anesthesiology (with Ultrasound)

A controlled environment to refine airway skills and a time to learn foundational ultrasound skills.

Pearls:

  • You get out what you put in- be proactive about getting your reps.
  • Don’t just intubate: learn preparation, medication setup, and backup planning.
  • Bag-valve-mask technique is a life-saving skill. Practice seal and positioning.
  • Use the OR’s controlled setting to build muscle memory and troubleshoot difficulty.
  • Show up early to walk through meds and equipment before the patient arrives.
  • Ultrasound training is robust and longitudinal. Image review and feedback matter.

Pediatric Emergency Medicine

A high-volume, high-acuity pediatrics experience that builds confidence with sick and well children.

Pearls:

  • You’ll see everything from critically ill, medically complex children to low-acuity complaints.
  • You’ll often be the primary resident communicating with consultants so document clearly.
  • Child Life Specialists are invaluable for patient comfort and family support.
  • Suture techs teach more than technique. You can observe how they calm and engage children.
  • Pediatric clinical pathways (asthma, abdominal pain, ortho injuries) are excellent learning tools.
  • Skills learned here translate directly to community ED practice.

Studying & Exams (Step 3 and ITE)

A short but eye-opening rotation that changes how you think about poisoning and drug exposures.

Top Resources:

Pearls:

  • Plan early for Step 3. Intern year is often the best window.
  • EMS, OB, Tox, and Ortho may be better study months than anesthesia/ultrasound.
  • Consistency beats cramming for the ITE.
  • Pair studying with enjoyable activities (walking, climbing, downtime).
  • Didactics count and active participation is real studying.
  • EM physicians often have a natural advantage on Step 3 due to focus on acute care.
  • Be honest about your learning style and build routines around it.

Wellness & Thriving as an Intern

Your chance to get hands-on with labor and delivery.

Top Resources:

  • Employee Assistance Program
  • GME Counseling
  • GROW (Gearing Residence for Overall Wellbeing)
  • Program leadership, chiefs, and senior residents
  • RAFFT mentorship and community
  • Peer support and co-resident friendships

Pearls:

  • Perspective matters. Every rotation is short and intentional.
  • Be open to correction; you are not expected to know everything.
  • Ask for expectations and recommended resources early.
  • Build relationships with nurses, techs, CRNAs, and staff. It improves care and joy.
  • Maintain hobbies, therapy, movement, and sunlight when possible.
  • Plan trips and social events when schedules allow.
  • Lean on your people. Residency is hard, but you don’t do it alone.

Final Takeaways

  • It is okay to not be okay. Asking for help is part of becoming a good physician.
  • Intern year is challenging, humbling, and finite. It is shaping you into the emergency physician you are becoming.

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First Shifts: Intern Mini-Series Pt. 1

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In the first episode of the Intern Mini-Series, Drs. Edleda James (PGY-3) and Nick Cummins (PGY-3) share what it was like to begin residency and how they learned to balance the steep learning curve of intern year with personal growth and self-compassion. They share their paths to emergency medicine and experience transitioning from MS4 to intern. Finally, they walk through the major rotations of the first year, highlighting what each block teaches, helpful resources, and practical strategies for success.

Emergency Medicine Rotations

Where you start building your identity as an EM physician- learning to juggle patients, manage uncertainty, and lean on your team.

Top Resources:

Pearls:

  • Focus on forming solid habits: think through your differentials and double-check doses.
  • Learn from physicians and other team members including nurses, RTs, and pharmacists.
  • Keep a few go-to resources on your phone and actually get comfortable using them.
  • Check your university library before buying textbooks- you probably already have access.

Orthopedics

A hands-on month to get comfortable with procedures and take the perspective of ortho consultants.

Top Resources:

Pearls:

  • Practice reductions and splinting as much as possible- these are core EM skills.
  • Watch what ortho looks for: imaging, markers, mechanism, and documentation.
  • Ask questions about how they manage injuries after you hand off the patient.
  • Use this block to refine your comfort with musculoskeletal exams and joint taps.

Surgical ICU / MICU

Where you really start learning how to manage critical illness.

Top Resources:

  • EMCRIT
  • ICU nurses and respiratory therapists (invaluable teachers)
  • Fellows, pharmacists, and attendings during rounds

Pearls:

  • Focus on vent settings, pressors, sedation, and team communication.
  • ICU nurses and other team members can teach you workflow, priorities, and troubleshooting.
  • Trust your instincts- you know more than you realize.
  • Build relationships with surgery, anesthesia, and ICU teams; off-service months are great for networking and understanding hospital systems.

Toxicology

A short but eye-opening rotation that changes how you think about poisoning and drug exposures.

Top Resources:

Pearls:

  • Watch how poison-center staff and toxicologists reason through cases.
  • Don’t hesitate to call the poison center- they are a tremendous resource.
  • Follow cases beyond the ED; seeing outcomes helps connect the dots.

OB/GYN

Your chance to get hands-on with labor and delivery.

Top Resources:

  • Rosen’s and Tintinalli’s Emergency Medicine textbooks, OSU library digital access
  • Refreshers on labor terminology and fetal-heart-tracing basics

Pearls:

  • Work closely with midwives- they can help you with meeting your required number of deliveries and solidify your understanding of normal labor.
  • Learn the language of OB- it builds confidence when calling consults later.
  • Pay attention to positioning, hand placement, and what to do when deliveries don’t go smoothly (shoulder dystocia, breech presentations, etc.).
  • OB attendings are very approachable and eager to teach.

Cardiology

A great month for sharpening EKG skills and understanding what happens after you consult cardiology in the ED.

Top Resources:

Pearls:

  • Review EKGs and telemetry- repetition builds pattern recognition.
  • Understand how cardiology stratifies risk and decides on further workups (echo, coronary CT, cath).
  • Tie what you see in the ED to later care.

Final Takeaways

  • You don’t have to “drink from a firehose.” Learn it one manageable piece at a time.
  • Intern year is busy, humbling, and transformative — but completely doable.
  • Each rotation adds something valuable to your EM skill set.
  • Build relationships, ask for help often, and give yourself grace.

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Unlocking Your Potential: Coaching in Emergency Medicine

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How can you become your best professional self? What does it mean to have a coach in medicine?

In this episode of Crash Cart EM, Drs. Rob Rainer (Med Ed Fellow) and Kim Bambach (Core Faculty) sit down with Dr. Geremiah Emerson (Associate Program Director) to explore coaching as a reflective, goal-driven practice that helps physicians reach their potential. 

Dr. Emerson breaks down how coaching differs from mentorship, advising, and sponsorship, using a practical framework focused on internal motivation and inquiry. He also shares how The Ohio State’s EM program has embraced the R2C2 model to support structured coaching conversations. We also dive into how coaching fosters metacognitive skills, reflective practice, and a growth mindset– key tools for navigating the challenges of residency and building a meaningful career. Whether you’re a resident finding your path or a faculty member supporting others, this episode is full of insight on unlocking potential through coaching.

Hosts: Rob Rainer, MD; Kim Bambach, MD

Guest: Geremiha Emerson, MD 

Editor: Kim Bambach, MD

1. Coaching vs. Mentorship, Advising, and Sponsorship

  • Coaching = Internally driven, question-based. Coaches help you meet your professional goals by encouraging you to reflect on your motivations, strengths, and opportunities for growth. Coaches might not share your exact professional interests, but they guide your growth. 
  • Mentorship = Externally driven, question-based. A mentor builds a longitudinal relationship with aligned professional interests to their mentee.
  • Advising = Internally driven, answer-based. Advisors offer specific guidance on your career. 
  • Sponsorship = Externally driven, answer-based. Sponsors offer specific career opportunities.

2. The Role and Value of a Coach

  • Helps residents identify goals, reflect on performance, and stay connected to purpose.
  • Coaching encourages self-inquiry and a growth mindset. 
  • Supports long-term fulfillment- not just surviving residency, but thriving after it.

3. Structure Matters: R2C2 Framework

  • R2C2 = Relationship-building, Reactions, Content, Coaching for outcomes
    • Relationship building: building respect, trust, and understanding the learner’s perspective
    • Reactions: exploring the learner’s cognitive and emotional reactions to feedback, with active listening from the coach
    • Content: clarify objective facts and details related to performance, identifying patterns and areas of focus
    • Coaching: define goals together, share accountability, and make an explicit plan
  • Provides coaches with clear structure to guide reflection and promote meaningful dialogue.

4. How to Be a Good Coach and Coachee

  • Coaches: Understand coaching isn’t about getting answers but asking the right questions that stimulate reflection. 
  • Coachees: Come with a growth mindset and willingness to self-reflect.
  • Vulnerability is key to growth: bring your challenges honestly. The coach-coachee relationship should foster psychological safety. 

5. Coaching and Resident Well-Being

  • Coaching aligns with wellness efforts like OSU’s GROW program.
  • Reflective skills gained through coaching support resilience, self-compassion, and career longevity.

Resources:

  1. AMA Coaching Guide
  2. R2C2 Framework

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Lights, Sirens, Complicated Delivery: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this EMS-focused Crash Cart EM episode, we tackle three high-stakes delivery emergencies: prolapsed cord, breech delivery, and shoulder dystocia. Learn practical, field-ready tips for recognition, initial management, and when to transport—because what EMS does matters for both mom and baby.

Guests: Katie Connell, RN, BSN, C-EFM, CLC; Thomas Connell Firefighter/NREMT-P
Host: Kim Bambach, MD
Editors: Amy Helder; Katie Connell, RN, BSN, C-EFM, CLC; Nicole McGarity, MHI, BSN, RN, CEN; Anneliese Sinclair; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Prolapsed Cord

  • Cord prolapse is when the umbilical cord exits the cervix before the fetus.
  • A visible cord is a true emergency due to risk of fetal hypoxia.
  • Insert a gloved hand into the vagina and elevate the presenting part off of the cord. Elevate the fetal head manually if this is the presenting part even if you are having trouble keeping the cord between your fingers. Avoid compressing the cord with your fingers.
  • Maintain your hand in place throughout transport until hospital handoff.
  • Position the patient knee-to-chest to reduce cord compression.
  • Clearly alert the receiving hospital that you are managing a prolapsed cord and en route so that they can prepare for emergency delivery/OR.

2. Breech Delivery

  • A delivery where the fetus presents with buttocks, feet, or other body parts instead of the head. Approximately 3% of all deliveries are breech.
  • Allow spontaneous delivery of the legs and trunk without pulling.
  • Support the baby’s body and head gently if delayed—never apply traction to the neck. A towel is around the infants torso to help lift and support.
  • If progress stalls or an arm presents first, transport rapidly for operative delivery.

3. Shoulder Dystocia

  • When one or both shoulders become stuck during vaginal delivery. Usually the anterior shoulder is trapped behind the pubic symphysis.
  • Complications include: fetal brachial plexus injury (due to overaggressive traction), clavicle fracture, fetal hypoxia (due to impaired respirations and/or compression of the umbilical cord), postpartum hemorrhage, and perineal lacerations.
  • Suspect shoulder dystocia if the head delivers and then retracts tightly (“turtle sign”).
  • Perform the McRoberts maneuver (knees to chest) and apply suprapubic pressure—not fundal pressure. This combination will resolve ~50% of obstructions.
  • If that fails, attempt the Gaskin maneuver (all fours) with gentle downward traction.
  • Additional maneuvers are possible, however this is very difficult in the prehospital setting so emphasis should be on rapid transport if these maneuvers are unsuccessful.

4. EMS Pearls

  • Always bring an OB kit, even for routine transports—you may need it.
  • Keep mom and baby together by transporting them to the same OB-capable facility.
  • Ask every reproductive-age patient if they are pregnant or recently postpartum.
  • Recognize complications early and transport rapidly when needed.
  • Place an IV in all pregnant patients—even for routine complaints—because they can decompensate quickly.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

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Hypertensive Disorders of Pregnancy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this episode of Crash Cart EM, we continue our podcast series dedicated to obstetric emergency care. This episode focuses on pre-eclampsia and hypertensive disorders of pregnancy, which are a leading cause of maternal morbidity and mortality.  We’ll discuss key definitions, trends, and critical management strategies including the importance of timely interventions like magnesium sulfate and antihypertensive therapies. This episode underscores the necessity of interdisciplinary collaboration and provides actionable insights for emergency and OB providers to address hypertensive emergencies effectively across care settings.

Guests: Cynthia Shellhaas, MD, MPH; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Amy Helder; Katie Connell, RN, BSN, C-EFM, CLC Nicole McGarity, MHI, BSN, RN, CEN; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Why It Matters

  • Hypertensive disorders are among the leading causes of pregnancy-related deaths
  • Hypertensive disorders increase risk to both mom (seizure, stroke, increased need for C section, etc.) and baby (growth restriction, preterm birth, stillbirth, respiratory distress, etc.)

2. Preeclampsia: The Basics

  • New-onset hypertension ≥140/90 after 20 weeks + proteinuria or other signs of end organ damage
  • Severe range: ≥160/110
  • Can occur up to 12 weeks postpartum, even in patients with a normal pregnancy
  • Postpartum preeclampsia is often overlooked

3. Recognition is Key

  • Ask every reproductive-aged woman: Are you pregnant or have you been in the past year?
  • Look for red flags: headache, RUQ pain, shortness of breath, edema, seizure (eclampsia)

4. Treatment Principles

  • Act fast—this is not benign chronic hypertension
  • Treat BP ≥160/110 promptly:
    • Labetalol IV or Nifedipine PO
  • If seizing, give magnesium sulfate (IM or IV)
  • Always assess for airway compromise and monitor closely

5. When to Transfer

  • Pregnant or postpartum patient with hypertensive emergency → transfer to OB-capable hospital
  • Use medical transport if unstable or severe-range BP
  • Don’t delay- delivery may be the only definitive treatment

6. EMS & Rural Settings

  • EMS plays a vital role in early recognition and communication
  • Frameworks such as SBAR (Situation, Background, Assessment, Recommendation) and MIST (Mechanism, Injuries, Signs, Treatments) can convey key hand-off information
  • Start IVs, gather collateral, and give strong handoffs
  • Ask about pregnancy even when not obvious
  • Rural teams may need to initiate treatment before long transfers

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

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CPR in Pregnancy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this episode of Crash Cart EM, we cover high-quality CPR in pregnancy- a rare emergency with a 7% survival rate. Learn how to adapt your resuscitation approach, avoid common pitfalls, and perform a resuscitative hysterotomy.

Guests: Jennifer Mitzman, MD; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Rashelle Ghanem; Nicole McGarity, MHI, BSN, RN, CEN; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Common Causes of Maternal Cardiac Arrest

  • Most common: Pulmonary embolism, hemorrhage (including trauma), hypertensive emergencies, infections, peripartum cardiomyopathy, and rare causes like stroke
  • Often occurs during or immediately after delivery
  • Risk factors: Advanced maternal age, African American race, high parity, and lack of prenatal care

2. What Stays the Same in CPR

  • Same compression rate (100–120/min), hand positioning and depth, defibrillation pad placement and energy levels, medication dosing (e.g., 1 mg epinephrine)

3. Key Differences in Pregnant Patients

  • Manual Lateral Uterine Displacement:
    • Displace uterus to the left to relieve IVC compression
    • Must be done manually- lateral tilt is no longer recommended
  • No LUCAS Device: LUCAS device use is not recommended for use in pregnancy due to safety concerns

4. Procedure and Airway Considerations

  • Prefer humeral IO (above diaphragm) over tibial
  • Chest tubes: Place higher (3rd–4th ICS) due to elevated diaphragm
  • Aggressive oxygenation: Avoid borderline sats—aim for 97–99%
  • High aspiration risk: Have readily suction available (two are helpful)
  • Airway edema common: Downsize ETT

5. Resuscitative Hysterotomy

  • Timing: If no ROSC by 4 minutes and >24 weeks gestation (or fundus at umbilicus), proceed
  • Purpose: Increases maternal preload and decreases afterload- improving perfusion. This is a resuscitative procedure for the pregnant patient and will also maximize chances of survival for the fetus. The procedure is still indicated in the case of fetal demise.
  • Steps:
    • Vertical midline incision
    • Dissect to the peritoneal cavity
    • Incise uterus
    • Deliver fetus, clamp/cut cord
    • Deliver placenta, pack uterus
    • Continue high-quality CPR throughout

7. Team Preparation & Simulation

  • The mental barrier is real– similar to performing a cricothyroidotomy
  • Debrief early, assign roles, and have equipment ready
  • Practice with simulation to improve readiness

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

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Peripartum Cardiomyopathy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special episode of Crash Cart EM, we explore peripartum cardiomyopathy- a rare but serious cause of heart failure in late pregnancy and the postpartum period. We’ll review key risk factors, clinical features, and strategies for recognition and early management.

Guests: Jennifer Mitzman, MD; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Katie Connell, RN, BSN, C-EFM, CLC; Pallavi Jonnalagadda, PhD; Jennifer Mitzman, MD; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Definitions and Risk Factors

  • Peripartum cardiomyopathy is a form of dilated cardiomyopathy causing heart failure.
    It occurs in the last month of pregnancy or within five months postpartum.
  • Risk factors include:
    • Hypertensive disorders (e.g., preeclampsia)
    • Advanced maternal age
    • Obesity
    • Multiparity
    • Cardiomyopathy is 4x more likely in black women and black women are 2x more likely to have persistently impaired cardiac function

2. Recognition

  • Often presents as acute heart failure: dyspnea, orthopnea, peripheral edema, or chest pain.
  • Watch for signs of volume overload, pulmonary edema, JVD, new murmurs, and wheezing (which may mimic asthma). Wheezing may be due to cardiogenic pulmonary edema, not asthma. New adult-onset “asthma” should raise suspicion for cardiac etiology. This diagnosis is often missed due to overlapping symptoms with normal pregnancy changes or obesity bias.
  • Always ask about recent pregnancy– especially in the case of the young female patient with unexplained respiratory symptoms.

3. Initial Management

  • ABCs (Airway, Breathing, Circulation) come first.
  • Support breathing with oxygen or early BiPAP– this may avoid risky intubation.
  • Initial workup includes ordering an EKG, troponin, BNP, chest X-ray, echocardiogram (or performing POCUS).
  • Judicious use of diuretics and inotropes may be needed.
  • Consult Cardiology and Maternal FM when appropriate. Consider transport to advanced OB/cardiac centers for definitive care.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

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Postpartum Hemorrhage: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special episode of Crash Cart EM, we dive into postpartum hemorrhage, a leading cause of pregnancy-related deaths in Ohio and globally. We’ll discuss definitions, common causes, and clinical signs. You’ll also learn key management strategies, including assessing blood loss, fundal massage, medications, and advanced interventions like Bakri balloons and surgical options.

Guests: Katie Connell, RN, BSN, C-EFM, CLC; Nicole McGarity, MHI, BSN, RN, CEN
Host: Jennifer Mitzman, MD
Editors: Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Definition & Timing

  • PPH is defined as blood loss greater than 1000 mL after vaginal or cesarean delivery.
  • It can occur immediately or be delayed up to 12 weeks postpartum.

2. Causes: The 4 T’s

  • Tone (uterine atony, the most common cause)
  • Tissue (retained placenta or products of conception)
  • Trauma (lacerations)
  • Thrombin (coagulopathies)

3. Recognition

  • Look for signs of hypovolemia such as tachycardia, pallor, and restlessness.
  • Vital signs may remain normal until significant blood loss has already occured. Use additional tools for assessment.

4. Estimating Blood Loss

  • Visual estimation is unreliable. Use scales or graduated drapes.
  • One gram of soaked material equals one mL of blood.

5. Initial Management

  • Start with fundal massage, establish two large-bore IVs, and give uterotonics (Pitocin, Methylergonovine, Hemabate, Cytotec, TXA).
  • Know contraindications such as avoiding Methylergonovine in hypertension and Hemabate in asthma.

6. Escalation

  • Use uterine tamponade devices like the Bakri balloon or Jada device.
  • If not available, consider Foley catheters or gauze packing.
  • Prepare early for surgery or transfer if bleeding continues.

7. Special Considerations

  • Always ask about recent pregnancy or delivery in reproductive-age patients with unexplained bleeding.
  • Early recognition and prompt action are critical.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

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Maternal Morbidity and Mortality: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special edition of Crash Cart EM, Dr. Sheryl Pfeil is joined by Dr. Cynthia Shellhaas and Nicole McGarity, RN, to kick off our new podcast series on obstetric emergency care. This episode explores the landscape of maternal mortality in Ohio, unpacking key definitions, concerning trends, preventable causes, and persistent health disparities. The conversation underscores the urgency of this issue across all healthcare settings- from academic hospitals to rural EDs and prehospital care.
Tune in to learn how simulation-based training is helping providers build the skills needed to improve maternal outcomes.

Guests: Cynthia Shellhaas, MD, MPH; Nicole McGarity, MHI, BSN, RN, CEN
Host: Sheryl Pfeil, MD
Editors: Katie Connell, RN, BSN, C-EFM, CLC; Rashelle Ghanem; Anneleise Sinclair; Kim Bambach, MD

Key Learning Points

1. Definitions and Trends

  • Pregnancy-associated death = death during pregnancy or within a year postpartum, regardless of cause.
  • Pregnancy-related death = death caused or aggravated by the pregnancy or its management. 61% are preventable.
  • U.S. maternal mortality rates have risen over the past decades.
  • Most deaths occur in the postpartum period. 67% occur after delivery- often weeks to months later.
  • Black women have a 3–4× higher mortality risk.

2. Recognition

  • Recognition is key, as many deaths occur outside of labor & delivery: EMS cares for ~30% of patients with pregnancy-related deaths. This is a touch-point where we can potentially intervene and help. 
  • Always ask: “Have you been pregnant in the past year?”. This is especially important for postpartum patients, where signs may be subtle.

3. Key Causes and Contributing Factors

  • Causes in the immediate postpartum period: infection/sepsis and hypertension.
    • Hypertension in pregnancy/postpartum patients is a medical emergency if BP ≥160/110 for 15+ minutes.
    • Sepsis risks include endometritis, retained products after pregnancy loss, and even breast infections.
  • Causes in the late postpartum period: Hemorrhage, thromboembolism, cardiomyopathy.
  • Mental health conditions, substance use, and lack of care coordination are common contributors.

4. System-Level Interventions

  • Data awareness: Institutions should examine their own data to identify clinical outcome disparities.
  • Effective handoffs and continuity of care are essential- especially across EMS, ED, OB, and inpatient teams.
  • Simulation training offers a safe, impactful way to prepare for high-risk, low-frequency events like eclampsia.

Resources:

  1. Ohio Maternal Health Data and Reports
  2. Ohio Pregnancy-Associated Mortality Review
  3. Virtual Obstetric Emergency Simulation Training at The Ohio State University

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Managing Sleep and Fatigue in Emergency Medicine

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In this episode, Dr. Li-Sauerwine (Associate Professor of EM and Associate Program Director) and Dr. Bambach (Assistant Professor of EM) dive into the challenges of sleep and fatigue in Emergency Medicine. They break down the basics of how sleep works, how it is affected by shift work, and the real risks that come with being tired on your shift—both for your health and your performance. Along the way, they share practical tips, from how to use strategic napping and caffeine effectively to bigger-picture solutions like smarter scheduling and system-level changes. It’s all about helping you feel better and do your best for your patients, even on those tough night shifts.

Guest: Simiao Li-Sauerwine, MD, MSCR
Host: Kim Bambach, MD
Editor: Kim Bambach, MD

Key Learning Points

1. Understanding Sleep and Chronotypes

  • Basics of Sleep Physiology:
    • Sleep is regulated by natural circadian rhythms and influenced by individual chronotypes.
    • A typical person’s natural sleep midpoint is around 3 a.m.; 8.5 hours of sleep is optimal.
  • Chronotype Variations:
    • Early birds thrive with early wake times; night owls function best with late sleep schedules.
    • Chronotypes evolve over a lifetime, explaining why teenagers are night owls and older adults wake early.
  • Implications for Emergency Medicine:
    • Late chronotypes may align better with evening or swing shifts in emergency medicine.

2. Challenges in Emergency Medicine

  • Shift Work Impact:
    • Misaligned schedules cause “social jet lag,” when a person’s work schedule and natural sleep-wake cycle are misaligned. This leads to physical and mental fatigue.
    • Emergency medicine prides itself on 24/7 availability but requires managing inherent risks.
  • Fatigue Risks:
    • Being awake for 18+ hours is akin to having a blood alcohol level of 0.05-0.1%.
    • Fatigue affects reaction times, decision-making, and increases errors during high-stress situations like patient resuscitations at the end of shifts.

3. Types of Fatigue

  • Transient Fatigue:
    • Occurs from short-term sleep deprivation, like cramming for an exam or a single sleepless night.
  • Cumulative Fatigue:
    • Builds over days of restricted sleep, where even losing an hour nightly adds up to a full night’s loss over a week.
    • Leads to chronic exhaustion and reduced cognitive performance.
  • Circadian Fatigue:
    • Your body’s sleep-wake cycle is out of sync with your environment. This often results from working during the window of circadian low (2-6 a.m.), when melatonin peaks and alertness is at its lowest.

4. Individual Solutions

  • Sleep Hygiene Tips:
    • Create an ideal sleep environment: blackout curtains, cool temperatures, and noise reduction.
    • Practice tech-free sleep routines; avoid screen time before bed.
    • Use weighted blankets and fans for added comfort.
  • Pre-shift Preparation:
    • Schedule naps before night shifts to reduce fatigue onset.
    • Consider caffeine naps: drink coffee, then nap for 15-20 minutes to maximize alertness.
  • Coping During Shifts:
    • Take strategic breaks to step away, move, or refresh. Evidence supports breaks in reducing errors.
    • Manage caffeine intake to avoid disruptive rebounds later in the shift.
  • Post-shift Recovery:
    • Allow time for decompression and sleep, even if it’s fragmented.
    • Recognize and address “sleep inertia” (groggy feeling and temporary performance decline) when transitioning back to normal schedules.

5. System-Level Solutions

  • Policies to Support Sleep:
    • Safe ride home programs for fatigued clinicians, covering ride-share costs to and from the hospital.
    • Incentivized schedules for nocturnists, offering financial benefits and predictable shifts.
  • Shift Design Innovations:
    • Waterfall Scheduling: Progresses from day to evening to night shifts for better circadian alignment.
    • Casino Shifts: Divides shifts to allow a consistent sleep block during natural sleep hours.
  • Long-term Accommodations:
    • Policies to reduce night shifts after a certain age or years of service.
    • Protecting post-night shift hours from daytime responsibilities, like meetings or nonclinical obligations.

6. Long-term Risks and Importance of Sleep

  • Health Risks:
    • Long-term dysregulated sleep increases risks for diabetes, cardiovascular disease, cancer, and overall mortality.
  • Occupational Hazard:
    • Shift work is an occupational exposure akin to other health risks, requiring proactive management by employers and healthcare systems.
  • Mitigation Through Awareness:
    • Building systems to address these risks is essential for long-term clinician well-being.

Closing Thoughts

  • Key Takeaways:
    • Sleep is foundational for clinical and academic excellence.
    • A shared responsibility model—balancing individual and system-level solutions—mirrors the Federal Aviation Administration’s approach to managing pilot fatigue.
  • Call to Action:
    • Evaluate workplace policies during job searches to prioritize sleep-friendly systems.
    • As leaders, implement measures to support colleagues and residents managing erratic schedules.

Resources to Learn More

  1. NIH- Circadian Rhythms
  2. CDC- Shiftwork, Long Hours, and Fatigue
  3. AMA Journal of Ethics- Managing the Effects of Shift Work in Medicine
  4. SAEM Pulse- Dark Nights, Dark Moods: Recommendations for Fatigue Mitigation for Emergency Physicians
  5. Night Shifts in Emergency Medicine: The American Board of Emergency Medicine Longitudinal Study of Emergency Physicians
  6. Chronotypes in the US – Influence of Age and Sex
  7. Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors

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SDoH: Caring for the Deaf and Hearing Impaired

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Hearing impairment is a significant social determinant of health that often impacts emergency department care. In this episode, Dr. Kim Bambach (Assistant Professor of EM) interviews Dr. Sophie Bolaños (PGY-2) about practical approaches to improve care for deaf and hearing-impaired patients in the ED. From understanding barriers to effective communication to leveraging local resources, this discussion provides actionable insights for creating a more inclusive and supportive care environment.

Guests: Sophie Bolaños, MD
Host: Kim Bambach, MD
Editors: Kim Bambach, MD and Chris San Miguel, MD

Key Learning Points:

  1. Understanding Hearing Impairment:
    • Over 1.5 billion people worldwide are deaf or hard of hearing, including 33 million children.
    • By 2050, one in ten people globally will have disabling hearing loss.
    • Hearing impairment intersects with other social determinants like unemployment, homelessness, and mental health challenges.
  2. Barriers to Care in the ED:
    • Communication challenges due to the need for ASL interpreters or clear communication methods.
    • Bias and frustration among clinicians unfamiliar with deaf culture or communication techniques.
    • Practical challenges such as non-functional nurse call buttons for hearing-impaired patients.
  3. Actionable Solutions:
    • Utilize an ASL translator even if the patient can read English or lip-read.
    • Stock audio amplifiers or use stethoscopes to enhance communication with hard-of-hearing patients.
    • Use clear masks to facilitate lip-reading.
    • Learn basic ASL signs, like the sign for “doctor,” and your last name to establish rapport while waiting for interpreters.
    • Maintain visual accessibility by keeping curtains open when privacy isn’t an issue.
  4. Community Resources:
    • Deaf Services Center (Columbus, OH): Offers ASL classes, advocacy, and peer support.
    • Ohio Relay: Provides a free service to facilitate phone calls for deaf and hearing-impaired individuals, supporting communication in English and Spanish.

Bottom Line:
Caring for deaf and hearing-impaired patients requires empathy, awareness, and resourcefulness. Clinicians should strive to minimize barriers and biases while leveraging available tools and resources to provide equitable care.

Resources to Learn More:

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Unseen and Unheard: Caring for Survivors of Sexual Assault and Violence in the ED

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When patients present to the Emergency Department after experiencing sexual assault, violence, or abuse, they often feel unseen and unheard. In this episode, Kate Chesko, BSN, RN (Forensic Program Manager and Forensic Nurse at OSU), and Dr. Creagh Boulger (Medical Director of the Forensic Program at OSU) discuss the crucial roles of forensic nurses and emergency providers and provide guidance on delivering empathetic, trauma-informed care to survivors.

Guests: Kate Chesko, BSN, RN, and Creagh Boulger, MD
Host: Amanda Fawcett, MD
Editor: Kim Bambach, MD

Key Learning Points:

  • The Role of Forensic Nurses: Forensic nurses (such as Sexual Assault Nurse Examiners) provide specialized care to victims of sexual assault and violence, including forensic evidence collection and interfacing with the legal system. They work closely with social workers and law enforcement, serving as patient advocates.
  • Supporting the Patient: It is vital to listen to patients and ensure they know they are in control of their care. Patients should feel empowered to start or stop an exam at any point. Providers must be mindful of privacy concerns and avoiding re-traumatization as even touching a patient can be traumatic or interfere with evidence collection.
  • The Role of Emergency Medicine Providers: In hospitals with a robust forensic nursing program, emergency providers conduct medical screenings and support forensic nurses. Documentation should be minimal to avoid contradicting the patient, and terms like “alleged” should be avoided. There should be a unified narrative in the medical chart, provided by the forensic nurse.
  • Strangulation as a High-Risk Form of Violence: Strangulation is a felony in Ohio, and serious injuries can occur even without external signs. Screen patients by asking if anything was placed around their neck or if something was constricting their neck at any time. Workup should include a CTA or MRA of the neck.
  • Correcting Common Misconceptions About Forensic Nursing:
    • Sexual assault exams are not diagnostic; they are for forensic evidence collection.
    • There is a limited window for evidence collection: 96 hours in adults and 72 hours in pediatrics.
    • Abuse is often under-recognized and underreported. Don’t assume that “these are not my patients.” Victims of human trafficking frequent the ED and the abuse goes undetected. Sex workers also often slip through the cracks.

The Bottom Line:

Empathy should always be our top priority. If any of the information in this podcast is new to you, take this as an opportunity to educate yourself on caring for victims of abuse. Start by learning just one thing from the resources below.

Resources to learn more:

  1. The International Association of Forensic Nurses
  2. The Training Institute on Strangulation Prevention
  3. RAINN (Rape, Abuse, and Incest National Network)
  4. SARNCO (Sexual Assault Response Network of Central Ohio)
  5. National Human Trafficking Hotline

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Moving Beyond “Pump and Dump”

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When caring for breastfeeding patients in the ED, it’s essential to understand the unique challenges they face. While the phrase “pump and dump” has been commonly used, it’s time to retire it and embrace practices that protect both the health of the parent and the breastfeeding relationship. Dr. Krystin Miller shares insights based on her experiences as both an emergency physician and a mother, provides practical tips for better supporting lactating patients in the ED, and answers which medications are safe for lactating patients.

Guest: Krystin Miller, MD. Host: Kim Bambach, MD. Editors: Jennah Morgan, MD and Kim Bambach, MD.

Key Learning Points:

  • Ask about breastfeeding: It’s important to ask if patients are breastfeeding, not only for medication choices, but also to make the patient comfortable while in the ED.
  • Provide access to a breast pump: If a patient needs to pump, ensure they have access to a pump, and minimize their NPO time to support hydration and milk supply.
  • Say “pump and save” instead of “pump and dump”: Most medications are safe for breastfeeding, and when in doubt, milk can be saved for later use rather than discarded.
  • Medications that are safe: Most pain medications, sedation agents, antibiotics, and imaging contrasts are safe for breastfeeding. Avoid codeine, tramadol, and meperidine, and be cautious with medications that reduce milk supply, like steroids, pseudoephedrine, and phenylephrine.
  • Use reliable resources: For medication safety, refer to the InfantRisk app or LactMed for up-to-date guidance on drugs and breastfeeding.

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Down the Rabbit Hole: Alice in Wonderland Syndrome

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In this episode we’re going down the rabbit hole and talking about something rather bizarre. Alice in Wonderland Syndrome is a neurologic disorder causing perceptual disturbances. Dr. Zach Smith (EM/IM PGY-3) breaks down what we need to know.

Guest: Zach Smith, MD, MBA. Host: Kim Bambach, MD. Editors: Mike Prats, MD and Kim Bambach, MD.

Key Take-Aways:

  1. What is it? Alice in wonderland syndrome typically affects a pediatric population is an alteration of visual perception that may be associated with time distortion and derealization/depersonalization.
  2. Why does it happen? The underlying cause is unknown, but proposed causes include encephalitis, EBV infection, migraines.
  3. What’s the prognosis? Symptoms are typically episodic and the prognosis is usually favorable, but workup and treatment are aimed at more serious possible underlying causes (such as encephalitis).
  4. How are symptoms treated? Antipsychotics are considered ineffective. Symptoms are controlled with a migraine treatment regimen.

References:

  1. Blom JD. Alice in Wonderland syndrome. Neurology Clinical Practice. 2016;6(3):259-270. doi:10.1212/CPJ.000000000000025
  2. Shah A, Magaña SM, E. Youssef P. Do You See What I See? A Case of Alice in Wonderland Syndrome With EEG Correlate. Child Neurol Open. 2020;7:2329048X20932714. doi:10.1177/2329048X20932714

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Under Pressure: Abdominal Compartment Syndrome

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Abdominal compartment syndrome is an elusive diagnosis that can cause or worsen multi-organ failure in your sickest patients. How can we avoid missing it? It’s a classic case of “if you don’t think of it, you can’t diagnose it.” Dr. Ruben Geeraert, PGY-3 and future critical care fellow, breaks down how we can recognize and treat it.

Guest: Ruben Geeraert, MD
Host: Kim Bambach, MD
Editor: Kim Bambach, MD

Key Take-Aways:

What is it? Abdominal compartment syndrome is sustained pressures > 20 mm Hg in the abdomen with evidence of end-organ damage. End-organ damage can occur with abdominal hypertension > 16 mm Hg.

What’s the pathophysiology? Compressing structures in the abdomen ultimately leads to decreased cardiac output and multi-organ failure due to hypoperfusion.

Why is it so easy to miss? These patients can be easy to miss because they are already critically ill, and multi-organ failure might be attributed to a different cause. Consider it in patients receiving massive fluid resuscitation, massive transfusion protocols (MTP), polytrauma patients, septic patients, patients with an acute abdomen, and any mechanically ventilated patient. It is shockingly common in MICU and SICU patients.

Can’t I just tell based on abdominal exam? Unfortunately, you can’t. It’s important to recognize a tense abdomen, but the abdominal exam is unreliable—only 50% sensitive for this diagnosis!

How do you measure abdominal pressure? Assess for abdominal compartment syndrome by taking a bladder pressure, which you can do with a Foley catheter and arterial line setup.

How is it treated? Initial management is medical (treating the underlying disease process), but the patient may ultimately require decompressive laparotomy. Evidence is limited on the optimal timing of this procedure.

References:

  1. Masneri DA, O’Brien M. Acute Abdominal Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed February 07, 2024.
  2. EMCrit Project. “Abdominal Compartment Syndrome.” Accessed September 27, 2024. https://emcrit.org/ibcc/abdominal-compartment-syndrome/.
  3. Popowicz, Patrycja, Nalin Dayal, Richard K. Newman, and Elvita Dominique. “Abdominal Compartment Syndrome.” In StatPearls. Treasure Island (FL): StatPearls Publishing, 2024. http://www.ncbi.nlm.nih.gov/books/NBK430932/.
  4. Reintam Blaser, Annika, Adrian Regli, Bart De Keulenaer, Edward J. Kimball, Liis Starkopf, Wendy A. Davis, Patrick Greiffenstein, and Joel Starkopf. “Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients—A Prospective Multicenter Study (IROI Study).” Critical Care Medicine 47, no. 4 (April 2019): 535. https://doi.org/10.1097/CCM.0000000000003623.
  5. Regli, Adrian, Paolo Pelosi, and Manu L. N. G. Malbrain. “Ventilation in Patients with Intra-Abdominal Hypertension: What Every Critical Care Physician Needs to Know.” Annals of Intensive Care 9, no. 1 (April 25, 2019): 52. https://doi.org/10.1186/s13613-019-0522-y.

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Peds Airway Pearls: Status Epilepticus

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In this peds airway pearls segment, we’ll walk through a case of a nine year old in status epilepticus. She’s hypoxic and you need to optimize pre-oxygenation and ultimately intubate her in the ED. Dr. Runkle gives her peds airway pearls as we walk through the case!

Guest: Anne Runkle, MD. Host: Lizzy Hellmann, MD and Kim Bambach, MD. Editor: Kim Bambach, MD and Ben Ostro, MD.

Key Take-Aways:

  1. Optimize pre-oxygenation for this patient: look at positioning (ear to sternal notch), bagging technique, use airway adjuncts, suctioning, elevating the head of the bed. A PEEP valve on your BVM or temporary NIPPV are additional options.
  2. Choose the right blade: “Mac 3 in 3rd grade”. If the patient is 8 years old or 30 kilos, consider starting with a Mac 3 because the longer blade will help you reach the vollecula and you could also use the Mac blade as a Miller and lift the epiglottis. iI the 8-10 year old range you are at a transition point from pediatric to adult airway anatomy.
  3. Have multiple tube sizes (one size smaller) prepped and ready: remember cuffed ETT size is 3.5 + age/4. Having a smaller tube available will help if there are copious secretions (which is likely if the patient is seizing) or edema.
  4. Have an LMA available: this may help with bagging the patient if you need a second attempt. i-Gel supraglottic airways have a suction port that can be used with a suction catheter (but be mindful that the pt cannot be bagged simultaneously and active vomiting is a contraindication to LMA).
  5. RSI med choice: Ketamine is the ideal sedative choice in this case, as propofol is difficult to obtain in pediatric EDs.

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Sub Zero: Managing Hypothermia

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Hypothermia can be deadly and as the weather turns colder, we need to be ready to treat it. In this episode, Dr. Close (PGY-3 Chief Resident) and Dr. Kaide (Professor of EM) teach us how to manage the spectrum of hypothermia from mild cases to cardiac arrest.

Guest: Colin Kaide, MD. Host: Alex Close, MD. Editor: Kim Bambach, MD.

Key Take-Aways:

  1. Hypothermia= core body temp <95* F (35* C)
  2. Risk factors: environmental exposure (winter sports, lack of shelter), ethanol use, extremes of age, underlying illness with impaired thermoregulation (ex. sepsis)
  3. Hypothermia can progress to altered mental status/CNS depression and cardiac arrest due to arrhythmia 
  4. Have a high index of suspicion for trauma, concomitant injuries (ex: SDH after fall and prolonged time down, C spine injury in the submerged patient) 
  5. Loss of shivering is an ominous sign of moderate-severe hypothermia.
  6. For mild hypothermia rewarming may be passive external: warm environment, blankets. Remove any wet clothing. For moderate hypothermia: initiate active external measures like warm blankets/Bair hugger, warm IVF, heated humidified oxygen, targeted temperature management (ex. Zoll catheter). For the critically ill patient with severe hypothermia such as a post arrest patient: chest tube placement for thoracic lavage, consider ECMO. In a lower resource setting consider hemodialysis.
  7. In cardiac arrest the key to obtaining ROSC is high quality CPR and rewarming. Anti-arrhythmic medications have limited efficacy. Common arrhythmias are sinus bradycardia, atrial fibrillation with slow ventricular rate, VF, VT, systole. Look for Osbourne waves on EKG: a positive deflection at the J point in precordial and true limb leads. 
  8. While it is true that hypothermia can slow metabolism CPR should not be terminated until the patient has a core temp of 90*F (>32 *C) “warm and dead”, there are some exceptions such as hyperkalemia >10-12 mmol/L, arrest occurred prior to insult, obvious signs of irreversible death/major trauma, patient is rigid to the extent compressions are not possible.
  9. Always make sure you have a documented core temperature for a patient who is altered or bradycardic- it just might be due to hypothermia! 
  10. Editors note: It is also critical to obtain a finger stick glucose STAT- hypoglycemia and hypothermia frequently co-occur! 

References:

  1. Brown DA. Hypothermia. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed September 12, 2024. https://accessemergencymedicine-mhmedical-com.proxy.lib.ohio-state.edu/content.aspx?bookid=2353&sectionid=220746470
  2. Kuhl E, Yamane D. . Accidental Hypothermia and Cardiac Arrest: Physiology, Protocol Deviations, and ECMO. ALiEM. December 12, 2018. Accessed September 12, 2024. https://www.aliem.com/accidental-hypothermia-cardiac-arrest-physiology-protocol-deviations-ecmo/
  3. Furgurson M. EM@3AM: Hypothermia. emDOCs.net – Emergency Medicine Education. December 19, 2020. Accessed September 12, 2024. https://www.emdocs.net/em3am-hypothermia-2/
  4. Hypothermia. Core EM. Accessed September 12, 2024. https://coreem.net/core/hypothermia/
  5. Hypothermia. EMCrit Project. Accessed September 12, 2024. https://emcrit.org/ibcc/hypothermia/

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Diversity, Equity, and Inclusion

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Diversity, Equity, and Inclusion. Those words are found on many university websites throughout the country. What does DEI mean and why is it important within medicine and specifically here within our residency? In this episode, Dr. James and Dr. Young discuss DEI at OSU- what it means, how the DEI committee is engaging with the community, and how you can get involved!

Guest: Henry Young, MD. Host: Edleda James, MD. Editor: Kim Bambach, MD.

Key Take-Aways:

  1. The why behind DEI: The US is constantly becoming more diverse and it’s important that we have a diverse work force. It improves patient outcomes and health disparities disproportionally affect communities of color and underserved communities. Enhancing our own cultural competency also helps care for diverse patients. Inclusion of colleagues makes the ED somewhere we all want to work and inclusion of patients make the ED a place people will feel comfortable seeking care.
  2. So many ways to get involved: There are many community outreach events, DEI committee activities, health fairs, recruitment fairs, book club, summer immersion opportunities, visiting student electives, and much more to get involved! Reach out to Dr. Young directly or to the EM education admin team to find out how you can get connected.

References:

  1. Why Choose Ohio State for EM Residency | Ohio State College of Medicine. Accessed September 5, 2024. https://medicine.osu.edu/departments/emergency-medicine/education/residencies/em-residency/why-choose-ohio-state

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Should You Risk It?

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What does risk mean to you and how do you approach risky clinical scenarios? As EM docs, we encounter risk every day. In this episode, Dr. Scott Stuckey gives us a new perspective by breaking down several frameworks and vocabulary we can use to think about and mitigate risk.

Residents: Dr. Stuckey completed this podcast as part of his Kiehl Professional Development Grant. You can submit a Kiehl grant to support your professional passion too!

Guest: Scott Stuckey, MD. Host: Kim Bambach, MD. Editors: Kim Bambach, MD and Creagh Boulger, MD.

Key Take-Aways:

  1. Volken’s Hazard Evaluator: Developed by Martin Volken, a professional mountain climber. Assign likelihood and the consequences. Risk = likelihood x consequence.
  2. What is your lateral emotional driver? Emotion plays a role in how we make decisions and it’s important to be aware of this. In medicine, we try to make objective assessments. Lateral emotional drivers are not necessarily negative- they can be critically important in goals of care discussions, for example.
  3. Graham’s Risk-Frequency Matrix: when you find yourself in a stressful situation, ask yourself which quadrant you’re in. That can help you understand where to put your attention to mitigate risk. High risk or low risk? High frequency or low frequency? For example, tooth splinting is low frequency low risk. Lac repairs are high frequency low risk. Intubation is high frequency high risk. Cricothyrotomy is low frequency high risk.
  4. The GAR (Green-Amber-Red) Risk Assessment: components of the situation are assigned a color related to the level of risk (green=least risk, amber= moderate risk, red=high risk). If you’re in red, how can you move into amber? If you’re in amber, how can you move into green? This often comes down to good communication with your team.
  5. The risky choice may still be the right choice for the patient.

References:

  1. Martin Volken’s Hazard Evaluator – Pro Guiding Service. December 22, 2013. Accessed August 28, 2024. https://proguiding.com/blog/martin-volkens-hazard-evaluator/
  2. Operational Risk Using the GAR Model. U.S. Fish and Wildlife Service. Accessed August 28, 2024. https://www.fws.gov/sites/default/files/documents/GARModelWorksheet_v20230103.pdf
  3. High Risk, Low-Frequency Events in Public Safety – Today’s Tip from Lexipol.; 2021. Accessed August 28, 2024. https://www.youtube.com/watch?v=pIpRVLkv0rg

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The New Certifying Exam

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Are you ready for the new certifying exam? The exam goes live in January of 2026, so if your graduation date is in 2025 or later, this episode is for you! Dr. Matt Wilson (PGY-5, EM/IM Chief Resident) and Dr. Diane Gorgas (Professor of Emergency Medicine and President of the American Board of Emergency Medicine) discuss what you need to know to ace the test. They also talk about why it’s important and the value of becoming a board certified EM physician.

Key take-home points:

  1. The certifying exam is replacing the virtual oral exam. You need to take the qualifying (written exam) and then the in-person certifying exam to become board certified in Emergency Medicine.
  2. The new certifying exam is designed to be less like playing a game than the oral boards and to reflect the realities of an EM shift. For example, you will be assessed on key competencies such as difficult conversations, team management, task switching, and clinical decision making.
  3. There is tremendous value to becoming certified in EM. It signifies that you have reached the highest standard and are competent in the variety of skills that it takes to be an outstanding Emergency Physician. It also increases your bottom line, too.
  4. After you become a diplomat, you’ll stay certified by completing My EM Cert modules.

Host: Matt Wilson, MD. Guest: Diane Gorgas, MD. Editors: Kim Bambach, MD and Mike Prats, MD.

References:

  1. “Certifying Exam | Emergency Medicine Certification.” Accessed August 21, 2024. https://www.abem.org/public/become-certified/certifying-exam.
  2. “Value of ABEM-Certified Physicians.” Accessed August 21, 2024. https://www.abem.org/public/about-abem/value-of-abem-certified-physicians.

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Welcome to Crash Cart EM!

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In our first episode, Kim and Mike are excited to introduce you to Crash Cart EM. Crash Cart EM is the podcast for Emergency Medicine at The Ohio State University. We love to teach here, so our goal is to bring you a variety of episodes to fill your mental “Crash Cart”. You’ll learn a little bit about the history of the familiar set of red drawers too- the quintessential symbol of Emergency Medicine. A huge thank you to all of the residents and faculty who have made this project possible!

Hosts: Kim Bambach, MD and Mike Prats, MD. Editor: Kim Bambach, MD.

References:

  1. “Emergency Crash Cart.” Accessed August 21, 2024. https://americanhistory.si.edu/collections/nmah_1409567.
  2. “Emergency Nurses Association Collection | College of Nursing | University of Illinois Chicago.” Accessed August 21, 2024. https://nursing.uic.edu/nursing-research/centers-labs-interest-groups/midwest-nursing-history-research-center/collections/organizations/emergency-nurses-association-collection/.
  3. Jacquet, Gabrielle A., Bachar Hamade, Karim A. Diab, Rasha Sawaya, Gilbert Abou Dagher, Eveline Hitti, and Jamil D. Bayram. “The Emergency Department Crash Cart: A Systematic Review and Suggested Contents.” World Journal of Emergency Medicine 9, no. 2 (2018): 93–98. https://doi.org/10.5847/wjem.j.1920-8642.2018.02.002.

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