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A patient in labor suddenly becomes hypoxic and hypotensive. Minutes later, she arrests and then begins bleeding uncontrollably. Amniotic fluid embolism (AFE) is rare, unpredictable, and potentially catastrophic. AFE requiring rapid recognition and a coordinated resuscitation before the diagnosis is ever certain. In this episode, Drs. Caroline Bank and Kim Bambach discuss a practical approach to recognizing and managing AFE, including the clinical clues that distinguish it from other causes of maternal collapse, pregnancy-modified resuscitation, management of right ventricular failure and coagulopathy, and the importance of early multidisciplinary activation. They also discuss what happens after survival, from team debriefing to communicating with patients after a traumatic birth. This episode is part of the Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) series at The Ohio State University, supported by a grant from the Ohio Department of Children and Youth. Guest: Caroline Bank, MD; Host: Kim Bambach, MD; Editor: Nick Roesel Key Learning Points 1. Think of the “3 Bs”: Breathing, Blood Pressure, and Bleeding AFE is a clinical diagnosis. Consider it when a laboring or recently postpartum patient develops sudden: Hypoxia Hypotension Altered mental status Cardiovascular collapse or cardiac arrest Coagulopathy or unexpected bleeding The Amniotic Fluid Embolism Foundation describes the classic presentation using the 3 Bs: Breathing, Blood Pressure, and Bleeding. Symptoms like anxiety, restlessness, chills, or dyspnea, may precede cardiovascular collapse. 2. Timing and early coagulopathy are important clues The differential for maternal cardiovascular collapse is broad and includes pulmonary embolism, hemorrhage, eclampsia, and other causes of cardiac arrest. Two clues should particularly raise suspicion for AFE: Timing: AFE typically occurs during labor or shortly after delivery. Early coagulopathy: Sudden cardiopulmonary collapse accompanied by early DIC is particularly concerning. In hemorrhagic shock, coagulopathy generally develops as bleeding progresses and clotting factors are depleted. In AFE, coagulopathy may precede the major hemorrhage. 3. Resuscitate first, even if there is diagnostic uncertainty. When AFE is suspected: Secure the airway and optimize oxygenation. Establish adequate IV access. Support circulation with vasopressors, blood products, and appropriately selected fluids. Activate OB, anesthesia, the resuscitation/code team, and blood bank early. Anticipate rapidly evolving coagulopathy and hemorrhage. 4. If cardiac arrest occurs, use pregnancy-modified resuscitation Prioritize: High-quality CPR Airway and oxygenation Manual left uterine displacement Rapid preparation for resuscitative hysterotomy when indicated Maternal resuscitation remains the priority. The interventions that improve maternal circulation also improve fetal perfusion. 5. Think about the right ventricle Bedside echo can help identify right ventricular strain or dysfunction. Consider: Vasopressors Inotropic support Pulmonary vasodilators when available and appropriate Avoiding excessive fluid administration that may worsen RV overload 6. Activate ECMO early when available In refractory cardiovascular collapse, involve the ECMO team early rather than waiting until other options have been exhausted. Concern for hemorrhage or DIC does not necessarily preclude ECMO. Extracorporeal support can initially be initiated without anticoagulation while a patient is profoundly coagulopathic. 7. AFE resuscitation is multidisciplinary A critically ill postpartum patient may simultaneously require maternal resuscitation, hemorrhage control, massive transfusion, neonatal resuscitation, and advanced cardiovascular support. Clearly divide responsibilities according to team expertise: ED: code leadership, airway, vascular access, resuscitation OB: uterine and hemorrhage management NICU/neonatal team: neonatal resuscitation ECMO team: advanced mechanical circulatory support when indicated Early role assignment allows multiple critical interventions to occur simultaneously rather than sequentially. 8. The resuscitation does not end with ROSC Survivors of AFE may face substantial physical and psychological consequences. Coordinated post-arrest care, rehabilitation, and support for both patients and clinicians following a traumatic delivery. Further Resources Amniotic Fluid Embolism Foundation

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

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

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: 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. Demographics: Young children, adolescent males, and patients with alcohol use, seizure disorders, or developmental disabilities are at highest risk for drowning. Pathophysiology: Drowning is primarily a hypoxic injury. In cardiac arrest, provide ventilations in addition to chest compressions. Compression-only CPR is not sufficient. Hypothermia: Consider hypothermia when a patient has a drowning event, even in warmer months. Active rewarming remains a critical part of management. Trauma: Consider cervical spine injury only when the mechanism or examination raises concern (e.g., diving injuries, unwitnessed events, neurologic deficits). 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. 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: 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. 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. Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012;366(22):2102-2110. doi:10.1056/NEJMra1013317. American Academy of Pediatrics. Prevention of drowning. Pediatrics. 2021.

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: The unifying concept: hypoxia Decreased oxygen delivery impairs cellular metabolism and underlies all altitude illness. 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. 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 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. 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: Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update Auerbach PS, Cushing TA, Harris NS, eds. Auerbach’s Wilderness Medicine. 7th ed. Philadelphia, PA: Elsevier; 2016.

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: A neighborhood is more than a built location It reflects the social connections, infrastructure, and resources that shape health outcomes. 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. 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. Transportation is often overlooked If patients cannot physically get to appointments, pharmacies, or community resources, the plan fails. 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. 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: Close.City Columbus Street Card Central Ohio Area Agency on Aging Columbus Metropolitan Library Ohio Domestic Violence Network Columbus Food Pantries

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: Rosh Review Tintinalli’s Emergency Medicine (goal: ~3 chapters/week), OSU library digital access UWorld Step 3 QBank 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.

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: UpToDate Medscape, MDCalc (for scores like PERC, Wells, HEART) WikEM EMRA Antibiotic Guide Full Code Pro, Safe Local, PediSTAT apps Suture and Fracture apps Corependium Rosen's and Tintinalli’s Emergency Medicine textbooks, OSU library digital access 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: Tintinalli’s musculoskeletal and ortho chapters Radiopaedia (for imaging examples) OSU orthopedic guidebook (linked on the phone list) Online case blogs 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: Goldfrank’s Toxicologic Emergencies Central Ohio Poison Center 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: ECG Weekly (Amal Mattu) ECG stampede Mentorship from cardiology and EM faculty (including ECG elective) 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.

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 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: AMA Coaching Guide R2C2 Framework

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: Virtual Obstetric Emergency Simulation Training at The Ohio State University

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: Virtual Obstetric Emergency Simulation Training at The Ohio State University

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 and aortic 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% Be ready for aspiration risk: Suction and smaller ETT 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: Improves maternal preload/afterload and 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: Virtual Obstetric Emergency Simulation Training at The Ohio State University

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: Virtual Obstetric Emergency Simulation Training at The Ohio State University

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: Virtual Obstetric Emergency Simulation Training at The Ohio State University

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; 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 vital, especially across EMS, ED, OB, and inpatient settings. Training & simulation: Simulation training is a powerful tool to train for high-risk low-occurrence scenarios such as eclampsia in a safe space. Resources: Ohio Maternal Health Data and Reports Ohio Pregnancy-Associated Mortality Review Virtual Obstetric Emergency Simulation Training at The Ohio State University