Dr. Jeff Williams' Discussion forum for biotechnology, pacemakers, defibrillators, and electrophysiology studies including ablation.
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I'm Paul from PassACLS.com and I'm here to help you pass ACLS. Like an audio flash card, this podcast is intended to aid any medical professional preparing for an Advanced Cardiovascular Life Support (ACLS) class. Each one-to-nine minute episode covers one of the skills needed to recognize a stroke or cardiac emergency and work as a high performing team to deliver safe, quality patient care. Listening to a tip a day for 14-30 days prior to your ACLS class will help cement the core concepts t ...
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"Heavy lies the crown" is a common misquote of "uneasy lies the head that wears a crown" from Shakespeare's Henry IV, Part 2. It refers to the responsibility and insecurity of governing an entire kingdom. Likewise, "heavy lies the helmet" refers to the responsibility we face as critical care transport providers working in an autonomous and often unpredictable environment. Our minds are eased with education that better prepares us for any situation that we may encounter. That is exactly what ...
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The newest EM:RAP project and the first to be done by and for residents. We will cover the cardinal presentations, the canonical literature, and the coolest cases all with an eye to board-review appropriate chunky nuggets of clever goodness. Note: no funny Australian accents but we do have a French-Canadian.
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Review of Atropine & Dopamine for Unstable Bradycardia
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When we should use the bradycardia algorithm. The signs & symptoms of unstable bradycardia. Atropine's bradycardic dose and maximum. The use of atropine when a patient is in a second degree type II or third degree heart block. ECG changes that indicate subsequent doses of atropine are likely to be ineffective. The starting dose of Dopamine. The use…
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Episode 121 - Outside the Box: Cardiac Arrest Management
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Not all cardiac arrests are created equal. Whether the presenting rhythm is asystole, ventricular fibrillation, or PEA, these patients require tailored interventions beyond "blanket" protocol and ACLS/PALS algorithms. When refractory to conventional therapy, the pulseless V-Tach/V-Fib patient, in particular, requires critical thinking "outside the …
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Adenosine is the first IV medication given to stable patients with sustained supraventricular tachycardia (SVT) refractory to vagal maneuvers. Symptoms indicating a stable vs unstable patient. Common causes of tachycardia. Cardiac effects of Adenosine. Indications for use in the ACLS Tachycardia algorithm. Considerations and contraindications. Aden…
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Recognition of Second Degree Heart Blocks and Possible Interventions
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To pass the written ACLS exam and mega code, students need to be able to identify basic ECG dysrhythmias, including the two types of second-degree heart block. One method of ECG rhythm identification is to ask a series of questions such as: What's the rate (<60, 60-100, 101-149, or >150); Is the rhythm regular or irregular; What's the shape, width,…
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When treating patients with Acute Coronary Syndrome (ACS), MONA is an acronym sometimes used to help us remember the initial interventions. The O in MONA is Oxygen. When we should administer oxygen to ACS patients. When O2 administration is unnecessary based on an accurate pulse ox. Monitoring patient's oxygen saturation (SaO2) using a pulse oximet…
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Along with early defibrillation, high quality CPR with minimal interruptions is one of the two factors that has been shown to improve cardiac arrest outcomes. How do we know if high quality, effective CPR is being performed? Objective measures of good, high-quality CPR include: Compression rate; Compression depth & recoil; ETCO2; and Chest Compress…
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The tongue is the most common airway obstruction in an unconscious patient. Insertion an oropharyngeal airway helps keep the patient’s tongue from falling to the back of the pharynx, causing an airway obstruction. The oropharyngeal airway is sometimes called an OPA or simply an oral airway. Indications for using an oral airway. Contraindication for…
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Hypoxia: An H&T Reversible Cause of Cardiac Arrest
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Hypoxia is a state of low oxygen levels in the blood. Determining hypoxia using a pulse oximeter or arterial blood gasses (ABGs). A goal of ACLS is to recognize signs of hypoxia and provide timely treatment to prevent an arrest. Examples of some things that might lead us to think of hypoxia as a cause of cardiac arrest. Why we should not rely on pu…
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Sinus Tachycardia vs. Supraventricular Tachycardia (SVT)
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ECG characteristics of supraventricular tachycardia (SVT) vs. sinus tachycardia. Signs & symptoms that indicate a patient is unstable. Delivery of a synchronized shock for the treatment of unstable SVT using a biphasic vs monophasic defibrillator. Consideration for team safety while performing synchronized cardioversion. Actions to take immediately…
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When working to resuscitate a patient in sudden cardiac arrest, Epinephrine is the first IV medication we administer. When we give the first dose of epinephrine depends on whether the patient is in a shockable or non-shockable rhythm. When to give the first dose of epinephrine and its frequency for patients in asystole or PEA following the right si…
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If a person suddenly develops symptoms such as weakness, slurred or garbled speech, loss of balance, or a massive & severe headache; it’s possible they could be having a stroke. The Cincinnati Prehospital Stroke Scale. There are several conditions that can mimic a stroke. Identification & treatment of hypoglycemia or hyperglycemia. Identification &…
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Alternative Routes for Medication Administration - IO & ETT
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Most ACLS medications are given IV push. But, what happens if we can't get an IV? Why IO is better than ETT as an alternative route. The locations we should place an IO when running a code and a location we should avoid. The ACLS medications that can be given intraosseous. Where you can find more information about intraosseous access during resusci…
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EMS and Transportation to the Most Appropriate Facility
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The chain of survival for a cardiac emergency and stroke start the same: preparedness & recognition of an emergency; activation of EMS; delivery of Advanced Life Support; and transporting to the most appropriate facility. ALS ambulances are staffed with paramedics who have training in ACLS skills. Why EMS "Destination Protocols" for suspected strok…
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Performing good CPR and delivering a shock as soon as possible to a patient in Ventricular Fibrillation or pulseless V-Tach are the two most critical interventions that have been shown to increase survival from sudden cardiac arrest. Studies have demonstrated significantly better out-of-hospital cardiac arrest survival outcomes in communities with …
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Cardiac Arrest Algorithm: Asystole & Pulseless Electrical Activity (PEA)
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For apneic patients without a carotid pulse or patients with only gasping/agonal respirations, we will follow the Adult Cardiac Arrest algorithm. For pulseless patients that the AED doesn't advise a shock, the patient's ECG shows asystole, or a non-perfusing organized rhythm (PEA), we will follow the right side of the Adult Cardiac Arrest algorithm…
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Providing good, high-quality CPR with minimal interruptions and early defibrillation are two key interventions shown to improved cardiac arrest outcomes. A training tool used in many CPR and ACLS classes is to use a song (or a song list) with a tempo of 100 to 120 beats per minute to help the person doing chest compressions maintain an adequate rat…
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A patient’s medical history will help us identify things that may be causing (or contributing) to their current condition as well as guide our decisions so we provide the safest evidence-based care possible. Examples of information obtained in a medical history that will impact the treatment we provide. There are several mnemonics and memory aids t…
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Although magnesium can be used in the treatment of other medical conditions such as eclampsia, asthma, & digitalis toxicity; for ACLS, magnesium is primarily used to treat Torsades de Pointes. Identification of Torsades on the ECG. Administration of a magnesium infusion for stable patients vs slow IV push for patients in cardiac arrest. Procainamid…
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Hypovolemia as an H&T Cause of Cardiac Arrest
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When a patient loses excessive amounts of fluids, we say that they are in a state of hypovolemia. The most obvious cause of hypovolemia is from bleeding. Bleeding can be internal or external and caused by trauma, pathology, or iatrogenic. Classic signs & symptoms of hypovolemic shock. Volume replacement with crystalloids vs blood. Connect with me: …
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MONA is the acronym sometimes used to help us remember the interventions to consider for patients with Acute Coronary Syndrome or ACS. Morphine's use in the Acute Coronary Syndrome (ACS) algorithm. Why Morphine is helpful for patients with ACS. Contraindications and considerations for the safe administration of Morphine. Morphine as an alternative …
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Maintaining a Chest Compression Fraction (CCF) Above 80%
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Even good CPR is far less efficient at circulating blood than a functioning heart. The indicators of high-quality CPR that were identified at the 2012 AHA CPR Quality Summit in order of importance include: Chest compression fraction (CCF); Chest compression rate; Chest compression depth; Allowing for full recoil; and Adequate ventilations. Using re…
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Epinephrine and Dopamine are adrenergic agonist used in several ACLS algorithms. The use of epinephrine for severe anaphylaxis and unstable bradycardia. Review epinephrine’s effects on blood vessels and bronchioles. Why epinephrine is helpful for patients with anaphylaxis. Using an epi drip for unstable bradycardia. Epinephrine administration durin…
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Providing rescue breathing to apneic patients with a palpable pulse. Normal end tidal CO2 for patients with a pulse. Identification of cardiac arrest and our immediate actions. Providing artificial ventilations during CPR without an advanced airway vs with an advanced airway in place. Using quantitative waveform capnography to confirm placement of …
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Hypothermia as an H&T Reversible Cause of Cardiac Arrest
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Hypothermic patients aren't dead until they are warm and dead. When a patient’s core body temperature drops below 96.8 F (36 C), they are hypothermic. As the body’s temperature drops below 36 C, hypothermia may further be classified as moderate or severe: Moderate if the patient’s body core temp is between 30-34 C; and Severe if it's below 30 C. Mo…
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Calcium is one of the ions that move across the cellular membrane during cardiac contraction and relaxation. The primary use of calcium channel blockers in ACLS is for the treatment of stable, narrow complex tachycardias refractory to Adenosine and to lower the blood pressure of ischemic stroke patients with severe hypertension. Use of calcium chan…
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Post-Arrest Care & Targeted Temperature Management (TTM)
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The goal of CPR is to keep the brain and vital organs perfused until return of spontaneous circulation (ROSC) is achieved. Post-arrest care and recovery are the final two links in the chain of survival. Identification of ROSC during CPR. Initial patient management goals after identifying ROSC. The patient’s GCS/LOC should be evaluated to determine …
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Nitroglycerine is vasodilator that affects peripheral blood vessels and coronary arteries. Because of its widespread dilation effects on blood vessels, nitro can quickly lower a patient’s blood pressure, sometimes to the point of making a patient hypotensive. Assessment of vital signs prior to administering nitro is necessary to ensure patient safe…
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In atrial fibrillation (A-Fib) and atrial flutter (A-Flutter) the electrical impulse for cardiac contraction is in the atria but isn't the normal pacemaker of the heart, the SA node. The ECG characteristics of A-Fib and A-Flutter. Recognition and treatment of unstable patients in A-Fib/Flutter with rapid ventricular response (RVR). Suggested energy…
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Tablets & Toxins as a H&T Reversible Cause of Cardiac Arrest
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As an ACLS provider you do not need to be familiar with all of the different signs of various types of poisoning. You should be able to obtain a history and know to order toxicology. The majority of toxins don’t have a specific antidote. There are a few toxins for which we have emergency interventions and ACLS providers should be familiar with. Rev…
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The ACLS algorithms are designed to make it easier to remember the key interventions we should deliver, and the order in which they should be delivered, to provide the best evidence-based care possible. Generally speaking, if there’s a change in a patient’s condition, we should ensure we’re using the correct algorithm. Three key points to remember …
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Beta blocking medications attach to Beta receptors to inhibit or “block” the effects of epinephrine (adrenaline)and norepinephrine in the body. The primary locations of Beta I, II, and III receptors. Effects of epinephrine & norepinephrine’s stimulation of beta receptors on the heart. Beta blockers effects on the heart. When we should consider the …
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Episode 120 - Sorry, We Are Closed: Interfacility Transfers w/Austin Wingate
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Interfacility transfers are not always indicated at the time and place of which they are being requested. Whether it's referring provider misinformation or a lack of advocacy by the transport agency, these transfers can result in unnecessary risk for crew members and patients. Specifically, weather conditions, time of day, crew fatigue, and other i…
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Episode 119 - Losses and Gains: Antidiuretic Hormone
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Antidiuretic hormone (ADH) plays an essential part in the body's osmotic/fluid balance, sodium homeostasis, and blood pressure regulation. This hormone is synthesized in the hypothalamus and released from the posterior pituitary gland. In conditions such as Diabetes Insipidus (DI) and Syndrome of Inappropriate ADH (SIADH), there is a lack of synthe…
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Episode 118 - Trigger Warning: Angioedema
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Angioedema is defined by upper airway swelling secondary to an immune response. The trigger and subsequent physiological response are how we categorize it. In this podcast, we discuss how to diagnose and treat both types: IgE/Histamine-mediated and Bradykinin-mediated. We also touch on how to address the difficult airway that may or may not lead to…
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Episode 117 - Dye or Die: Methylene Blue w/Will Heuser
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When discussing methylene blue, management and treatment of methaemoglobinaemia is usually the first indication mentioned. But in this podcast, we challenge you to increase the size of your lense and focus on its benefits in other states (e.g., septic shock). Of course, we could not do this alone, so we invited a Flight Paramedic, Pharmacist, Toxic…
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Episode 116 - Around the World: HEMS in México w/Daniel Peñaflor
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Though we have delved into foreign HEMS systems in the past (See Episode 61 – Down Under Dynamics w/Dr. Cliff Reid), we have not dedicated an entire series to it. Having now rubbed shoulders with many clinicians and operators around the world, it is evident that these conversations need to take place on a regular basis. Why? Because operating in a …
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Episode 115 - Me, My Self-Loading Baggage, and I w/Miles Dunagan and Brett Reeder
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"Self-loading baggage" is a derogatory term often used by pilots to describe lazy or disengaged medical crew members in the air medical industry. Whether intentional or not, this behavior sets a bad precedent for those of us that want to embrace aviation cross-training and be able to assist the pilot effectively. In this podcast episode, we are joi…
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Episode 114 - You Train Ukraine w/Kevin Collopy and Brock Jenkins
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The Russo-Ukrainian War is an ongoing international conflict between Russia and Ukraine. At times such as these, medical training is essential and sometimes required of laypersons. International Medical Corps partnered with the Harvard Humanitarian Initiative (HHI) to provide comprehensive emergency and trauma care training to healthcare workers, p…
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Episode 113 - Being B.R.A.S.H. When Treating Bradycardia w/Dr. Kate Connelly and Jake Miller
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B.R.A.S.H. Syndrome is a phenomenon with a constellation of Bradycardia, Renal failure, AV nodal blockade, Shock, and Hyperkalemia requiring identification and management in the prehospital and transport setting. In this podcast episode, live from AMTC23, we discuss the pathophysiology of BRASH Syndrome, highlighting the synergy between its compone…
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Episode 112 – Acid Base Trifecta (Presentation)
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Dan presented the talk “Metabolic Acidosis: The Eye Can Only See What the Mind Can Comprehend” at AMTC23. In this recording, he teaches you how to identify the prevalence of acid-base disorders including triple disturbances, how to calculate anion gap and determine the etiology of the gap, and how to identify adequacy of compensation for a primary …
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Episode 111 - Critical Comfort Care w/Brianna Fields
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As a critical care clinician, do you consider yourself well-versed in comfort care? Do you consider yourself well-rehearsed in having the discussions leading up to the patient's or family's decision to implement it? This concept may be outside your comfort zone, especially if you work in emergency medicine. But the fact of the matter is, from the p…
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Atrial fibrillation, particularly A-Fib with RVR (Rapid Ventricular Response), is often an emergency requiring emergent intervention beyond ACLS and its associated algorithms. Identification of A-Fib can be challenging in itself, much less trying to determine what intervention(s) are indicated. This includes chemical and/or electrical cardioversion…
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Episode 109 - 10 Things Your Gastroenterologist Wants You to Know w/Dr. Josh Peck
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Continuing our "10 Things" series, we focus our attention on gastroenterology. GE/GI goes well beyond colorectal. From bleeding esophageal varices to pancreatitis to liver failure, these patients require specific diagnostics and interventions to improve their mortality and morbidity. Join us for a "pearl packed" episode where we discuss practical s…
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Episode 108 - 10 Things Your PEM Physician Wants You to Know w/Dr. Dominique Diggs
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Pediatric Emergency Medicine (PEM) is a sub-speciality that many clinicians find intimidating. Are pediatric patients truly unique or are they simply "little adults"? In this podcast episode, we are joined by Dr. Dominique Diggs, board certified PEM physician, to demystify pediatric emergency care with 10 tips that will help you the next time you c…
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Vascular emergencies refer to any time-sensitive condition where perfusion is prevented secondary to bleeding or occlusion of a vessel. These can include, but is not limited to, the superior mesenteric artery (SMA) and aorta. And depending on the severity of the aneurysm or embolism/thrombus, downstream ischemia can significantly impact a patient's…
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Reviewing case studies with trusted colleagues can be extremely beneficial. Not only does it provide a moment of reflection on actions taken, but it also provides different approaches that may be applicable to future scenarios. Occasionally we like to challenge each other, and this episode is no exception. Tune in as Amanda, Dan, and Mike present t…
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Episode 105 - 10 Things Your Emergency Physician Wants You to Know
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Have you ever handed off to an ER doctor, and you felt they were displeased with your care? Have you ever received an order from an ER doctor, and you didn't quite understand why? In this podcast episode, we continue our "10 Things" series with a focus on the emergency department. Our very own Dr. Amanda Humphries, Emergency Physician and Assistant…
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Myocardial infarctions can present in a variety of ways depending on vessel involvement, timing of pathology, and interpretation of diagnostics (e.g., 12-lead EKG). Unfortunately, not every patient with a myocardial infarction will fit STEMI criteria's paradigm, which has lead to the adoption of a new term: OMI (Occlusion Myocardial Infarction). In…
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No matter what level of scope, management of medical and traumatic cardiac arrests is the focus of many clinicians. But what happens after return of spontaneous circulation (ROSC) is achieved? Many do not appreciate the fact that the likeliness of re-arrest is high. How can we avoid return of spontaneous arrest by appropriately treating the patient…
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Episode 102 - Long and Short of Learning w/Will Wingfield
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The medical industry puts great emphasis on formal education via university and other training programs. Due to financial incentive, these institutions often discourage independent learning despite it usually having a greater impact on patient care quality. For example, paramedics are often non-degree holders, yet they effectively practice medicine…
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