Dr T’s EMS Knowledge Exchange

10/29/2025

Honoring Those Who Answer Every Call

On National First Responder Day, we proudly salute the courage, compassion, and unwavering commitment of EMS clinicians, firefighters, law enforcement officers, and all who stand ready on the front lines.

Your dedication saves lives, strengthens communities, and inspires us all. Thank you for showing up — every shift, every call, every time. 💙

⸻

10/09/2025

The MARCH Mnemonic - A Framework for Tactical Trauma Care

When seconds count and conditions are unpredictable, the MARCH mnemonic. provides a clear, evidence-based sequence for trauma management in both tactical and civilian emergency settings.

Standing for Massive Hemorrhage, Airway, Respiration, Circulation, and Hypothermia/Head Injury, this structured approach originated in Tactical Combat Casualty Care (TCCC) and has become a cornerstone of modern prehospital and field medicine.

From the battlefield to the back roads, MARCH helps rescuers- military medics, EMS providers, law enforcement officers, and trained civilians - prioritize interventions in the order most likely to save lives.

By following this systematic progression, responders can rapidly identify and treat life-threatening conditions while preventing secondary injury and deterioration during evacuation.

Each installment in this upcoming series explores one element of MARCH, offering concise guidance, field considerations and key takeaways tailored for EMS and tactical responders:

Part One: Massive Hemorrhage - Stop the bleed, save the life

Part Two: Airway - Secure it early, maintain it always

Part Three: Respiration - Restore the breath, relieve the pressure

Part Four: Circulation - Preserve perfusion, prevent shock

Part Five: Hypothermia & Head Injury - Protect the head, protect the brain

Whether in an urban response zone, rural rescue, or austere tactical environment, MARCH isn’t just a checklist - it’s a mindset. It empowers providers to think clearly, act decisively, and deliver lifesaving care under pressure.

Further Reading:

American College of Surgeons Committee on Trauma. (2022) Advanced Trauma Life Support (10th Ed). Chicago, IL: American College of Surgeons.

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, MA: Pearson Education

Butler, F. K. (2017) Tactical Combat Casualty Care: Beginnings. Wilderness & Environmental Medicine 28 (2S): S12-S17.
Retrieved from https://pubmed.ncbi.nlm.nih.gov/28284483/ on October 8, 2025

Butler, F. K., Bennett, B., & Wedmore, C. I. (2017) Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments. Emergency Medicine Clinics of North America 35 (2): 391-407. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28411934/ on October 8, 2025

Committee on Tactical Combat Casualty Care (2023) Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel. Defense Health Agency, Joint Trauma System. Retrieved from https://jts.health.mil on October 8. 2025

National Association of Emergency Medical Technicians NAEMT (2020) TECC: Tactical Emergency Casualty Care Course Book (2nd Ed). Burlington, MA: Jones & Bartlett Learning

National Association of Emergency Medical Technicians NAEMT (2023) Tactical Emergency Casualty Care (TECC) Guidelines. NAEMT Education Division

National Association of Emergency Medical Technicians NAEMT (2025) PHTLS: Prehospital Trauma Life Support, Military Edition eBook (10th Ed). Burlington, MA: Jones & Bartlett Learning

10/07/2025

EMS Discussion - EMS Leadership During A Time Of Outrage

The Challenge

Today’s EMS leaders face more than operational demands — they must also navigate a world shaped by public outrage, political division, and social media amplification.

Every statement, policy, or silence can be scrutinized, criticized, or misinterpreted. Balancing staff expectations, public trust, and professional neutrality is harder than ever.

Why It Matters

Outrage culture can fracture teams, erode trust, and distract from the mission. In EMS, where teamwork and composure are essential, strong leadership in emotionally charged times is critical for morale, credibility, and community confidence.

Core Leadership Strategies

1. Anchor in Mission and Human Impact

- Ground decisions in your agency’s purpose: serving patients and protecting the public.
- Ask: Does this issue directly affect our people, patients, or mission?
- Avoid performative responses that distract from care delivery or operational priorities.

2. Foster Respectful Dialogue

- Create safe spaces for staff to share views without fear of retaliation.
- Set clear boundaries (no hate speech, no harassment) but allow for conversation.
- Model Civility — leaders must demonstrate what respectful disagreement looks like.

3. Engage Employees in Decision-Making

- Don’t respond impulsively to every trending issue.
- Use consistent criteria to decide which issues merit an organizational response.
- Let your workforce have a voice in shaping those priorities.

4. Lead with Consistency and Integrity

- Match public words with internal actions.
- Empty statements damage credibility — authenticity builds trust.
- Ensure policies, behaviors, and culture reflect your stated values.

5. Build New Leadership Skills

- Today’s leaders need emotional intelligence, ethical clarity, and communication literacy.
- Equip your leadership teams with training in empathy, listening, and conflict navigation.
- Recognize that leadership in a polarized era requires as much heart as it does strategy.

6. Protect Leader Well-Being

- The emotional toll of constant outrage is real.
- Develop personal coping tools, peer support, and boundaries.
- 'Presilience' - preparing emotionally before the crisis - is as vital as resilience afterward.

In Summary

For EMS leaders and providers, the path forward lies in focusing on purpose, consistency, and humanity.

Not every social or political issue requires a public stance; instead, leaders should filter decisions through the organization’s mission and its direct impact on patients and personnel.

Credibility comes from alignment - when an agency’s actions match its stated values, it builds trust both internally and externally.
Leading through outrage demands emotional intelligence, humility, and courage.

It means fostering open, respectful dialogue rather than silencing dissent, and recognizing that empathy and transparency often carry more influence than public declarations.

Ultimately, in an era of polarization, EMS can stand as a model of professionalism and composure - reminding communities that compassion and service remain the foundation of effective leadership.

This discussion is based on “Leading Through Outrage” by Shannon Gollnick, JEMS (Oct 2025).

Source:

Gollnick, S. (2025). Leading Through Outrage: EMS Leadership in an Age of Polarization. Journal of Emergency Medical Services (JEMS).
https://www.jems.com/exclusives/leading-through-outrage/

EMS leaders face unprecedented challenges in navigating internal and external outrage amid political polarization and social media scrutiny, impacting trust and decision-making.

09/24/2025

Emergency Department (ED) delays are nothing new, but for EMS Providers, “wall time” is a unique challenge.

Unlike a walk-in patient who simply waits for triage, EMS crews remain fully responsible for their patient until the hospital formally accepts care.

This Ambulance Patient Offload Time (APOT) often ties up both crews and ambulances, straining already thin resources.

Studies show that in some systems, wall times regularly exceed one, two, or even three hours.

Beyond frustration, this means fewer available units, longer response times, and increased operational risk.

For EMS providers on the ground, it also raises questions about supply readiness, patient monitoring, and when exactly responsibility transfers to the hospital under EMTALA.

Some regions, like Sacramento County, CA, are experimenting with solutions, such as streamlined protocols that allow paramedics to place stable patients in waiting rooms, expanded surge plans, and telehealth pilots.

Legislation in California (AB-40) now requires standardized APOT reporting, bringing new transparency and accountability to the issue.

For providers, the takeaways are clear:

Track your own wall times to build local data.
Work collaboratively with ED staff and administrators.
Confirm local protocols for patient care responsibilities during wall delays.
Be operationally prepared for long waits by keeping supplies stocked and equipment ready.
Wall time isn’t just a hospital problem — it’s a system problem.

By understanding, measuring, and addressing it together, EMS providers can help push for solutions that keep both patients and ambulances moving.

This is a summary of an article written by Bob Elling for the Public Safety Group in August.

Further Reading:

https://www.psglearning.com/blog/psg/2025/08/15/urban-hospital-wait-time-and-wall-time?

Long hospital wait times are a problem around the country. Bob Elling discusses the need for improved efficiency and collaboration between EMS and ERs to address these challenges.

09/03/2025

EMS Discount - Jones & Bartlett Learning Promo Code

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Share the gift of savings with 25% off their academic resources and free shipping from the Public Safety Group - https://www.psglearning.com/?

Use code WISDOM25 at checkout and pass it along to your students to unlock some back-to-school savings.

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Expires 9/30/25. Other restrictions may apply.

Public Safety Group, A Jones & Bartlett Learning Brand. EMS, Fire & Public Safety educational materials & solutions.

09/02/2025

EMS Words of Wisdom - Use Your Judgment

08/26/2025

EMS Words of Wisdom - Being Compassionate Will Always Matter

08/20/2025

EMS Discussion - Live Tissue Training

Live tissue training (LTT) involves using live, anesthetized animals to practice surgical and medical skills.

While LTT has historically played a role in medical education - particularly in military trauma training - it is also a highly controversial practice due to ethical concerns surrounding animal welfare.

Arguments For LTT

Realism & Fidelity: LTT provides a level of realism that even high-fidelity simulators struggle to replicate, including the dynamic response of living tissue, active bleeding, and physiological changes.

Psychological Fidelity: The lifelike nature of LTT can evoke a stronger emotional and psychological response in trainees, potentially preparing them more effectively for the stress and urgency of real trauma situations.

Hands-on Experience: LTT offers opportunities to practice complex procedures in a setting that delivers immediate feedback based on the animal’s responses.

Confidence Building: Some research suggests that LTT increases self-efficacy and confidence among participants, particularly those preparing for combat deployments.

Arguments Against LTT

Ethical Concerns: Using live animals in training raises significant ethical questions regarding animal rights and welfare. Critics argue that it is inhumane and causes unnecessary harm.

Availability of Alternatives: Advances in simulation technology—including high-fidelity human patient simulators, cadavers, and realistic part-task trainers—are increasingly capable of replicating many aspects of LTT, often at lower cost and without ethical concerns.

Limited Transferability: Anatomical and physiological differences between animals and humans may reduce the direct applicability of skills learned on animals to human patients.

One-time Use: Animals used in LTT are typically euthanized after training, limiting opportunities for repetitive practice and skill refinement.

Policy and Regulations: The U.S. Department of Defense has implemented policies aimed at reducing and replacing LTT with alternative methods where feasible. Additional legislation has been proposed to further restrict its use.

Current Trends

The use of LTT has declined in many civilian trauma training programs, such as the American College of Surgeons’ Advanced Trauma Life Support (ATLS) courses.

However, LTT continues to be used by the military for combat casualty care training, particularly for developing complex procedural skills and preparing personnel for the stresses of battlefield trauma.

Ongoing debate and research continue to evaluate the effectiveness of LTT compared with alternative training modalities, with some studies suggesting comparable skill acquisition and proficiency.

There is also a growing push to apply the 3Rs of humane animal use to LTT: Replacement, Reduction & Refinement, seeking to minimize reliance on animals and improve their welfare when training does occur.

In Conclusion

Live tissue training presents a complex ethical and educational dilemma. While advocates emphasize its realism and benefits for skill development in high-stakes situations, critics highlight the ethical implications and the growing availability of effective alternatives.

The overall trend suggests a reduced reliance on LTT, particularly in the civilian sector. However, it remains a component of certain specialized training programs, especially in the military, as efforts continue to balance training effectiveness with animal welfare concerns.

Further Reading

American College of Surgeons (ND). Advanced Trauma Life Support (ATLS)® Program. https://www.facs.org/quality-programs/trauma/education/atls/ Accessed August 13, 2025

Department of Defense Instruction (2019) Use of Animals in DoD Programs. www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/321601p.pdf Accessed August 13, 2025

Liang, J. N., Ciampa, M., Kobylarz, F., Anklowitz, A. J., Barzanji, N. K., Sherman, W., & Faler, B. (2024) Impact of Live Tissue Training on Provider Confidence for Operative Trauma Management. Military Medicine, 190(3–4): e784 - e789. https://doi.org/10.1093/milmed/usae403 Accessed August 13, 2025

NAEMT (ND) Tactical Combat Casualty Care www.naemt.org/education/trauma-education/naemt-tccc Accessed August 13, 2025

National Academies of Sciences, Engineering, and Medicine (2018) A Review of the Department of Defense’s Programs for the Use of Animals in Military Medical Training. Washington, DC: The National Academies Press

Physicians Committee for Responsible Medicine (2025) National Physicians Group Celebrates St. Elizabeth for Replacing Animals in Surgeon Training. https://www.pcrm.org Accessed August 12, 2025

Swain, C. S., Cohen, H. M. L., Helgesson, G., Rickard, R. F., & Karlgren, K. (2023) A systematic review of live animal use as a simulation modality (LTT) in the emergency management of trauma. Journal of Surgical Education, 80(9): 1320–1339 https://doi.org/10.1016/j.jsurg.2023.06.018 Accessed Aug 12, 2025

08/19/2025

EMS Peculiar Patient Presentations - Water On The Brain

A recent medical case has puzzled scientists: a 44-year-old man has been living a seemingly normal life despite having only 10% of his brain tissue remaining.

The patient was diagnosed with hydrocephalus, a condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) in the brain.

In his case, the excess CSF has gradually displaced nearly all of the brain parenchyma, leaving only a thin peripheral rim of functional neural tissue. Imaging studies revealed that the majority of his cranial cavity is occupied by fluid.

Remarkably, despite this profound anatomical abnormality, the man leads a fully functional life.

He is employed as a civil servant, has a family, and possesses a measured IQ of 84 — slightly below the statistical average, but well within the range of independent functioning.

This case calls into question long-standing assumptions about neuroanatomy, brain plasticity, and the localization of consciousness and cognitive functions.

It suggests a remarkable degree of adaptability in the central nervous system, and may prompt a re-evaluation of how essential various brain structures are to everyday functioning.

Further Reading:

Feuillet, L., Dufour, H., & Pelletier, J. (2007) Brain of a White-Collar Worker. The Lancet 370(9583): 262. https://doi.org/10.1016/S0140-6736(07)61127-1 Accessed April 10, 2025

08/18/2025

EMS Words of Wisdom - Walk Tall, Speak Calmly, Be Professional

08/15/2025

EMS Neurological Emergencies - Intracranial Pressure & The Monroe-Kellie Doctrine

The Monroe-Kellie Doctrine is a fundamental concept in neuroanatomy and physiology that is crucial for understanding intracranial pressure (ICP) dynamics, particularly in the context of traumatic brain injuries (TBIs).

This doctrine posits that the cranial cavity is a fixed volume comprised of three essential components: brain tissue, cerebrospinal fluid (CSF), and blood.

According to this doctrine, any increase in the volume of one component must be compensated by a reduction in the volume of one or both of the other components to maintain stable intracranial pressure.

In the case of a TBI, several pathological processes may trigger increases in intracranial volume, including cerebral edema, hematomas, or increased blood flow due to vascular changes.

When a TBI occurs, such as from a fall, assault with a solid object (e.g., a cricket bat), or an automotive accident, the brain may swell due to injury, leading to an increase in volume that can surpass the compensatory capabilities outlined by the Monroe-Kellie Doctrine.

When the compensatory mechanisms are exceeded, ICP rises, leading to potential herniation and further neurological damage.

For EMS providers, understanding the Monroe-Kellie Doctrine is vital in assessing and managing patients with TBIs.

Recognizing the signs of increased intracranial pressure, such as altered mental status, abnormal vital signs, and pupil changes, is essential for timely intervention.

Additionally, prehospital management strategies must focus on minimizing any further increases in ICP, such as maintaining adequate oxygenation, controlling blood pressure, and ensuring proper airway management.

In summary, the Monroe-Kellie Doctrine serves as a crucial framework for EMS providers to comprehend the underlying mechanisms of intracranial pressure dynamics in patients with traumatic brain injuries.

A solid understanding of this doctrine aids in the recognition, assessment, and management of these patients, ultimately impacting their outcomes.

Further Reading:

Beecher, H. K., & Teter, H. (2019) "Traumatic Brain Injury in the EMS Setting: Challenges and Approaches." Journal of Trauma and Acute Care Surgery , 87(3): 600-605

Curtis, K., & O’Brien, K. (2016) "The Role of EMS in the Management of Traumatic Brain Injury." Emergency Medicine Journal , 33(4): 267-271. doi:10.1136/emermed-2015-205049

Hutchinson, P. J., et al. (2020) "Management of Severe Traumatic Brain Injury: An EMS Perspective." Journal of Trauma Nursing , 27(6): 309-315. doi:10.1097/JTN.0000000000000506

Kelly, W. A., & Monroe, H. (1824) "A Treatise on the Diseases of the Brain." In The Transactions of the American Neurological Association, 52: 167-168

Vogt, J. L., & Frazier, A. (2018). "Prehospital Recognition and Care of Traumatic Brain Injury: A Review for the EMS Provider." Prehospital Emergency Care , 22(2), 245-253. doi:10.1080/10903127.2017.1391648

08/12/2025

EMS Conference Opportunity - Wyoming Trauma Conference

August 21 - 23, 2025, Cheyenne, WY