Evolving Shock in Major Trauma: A Prehospital Case Review with Michael DeFilippo

On today’s episode, we’re diving into a case study that captures the reality of modern prehospital care at its most demanding: a high-speed road traffic collision resulting in major trauma, an evolving shock presentation, and tension between competing priorities in the field. This case comes from Dr Michael DeFilippo, an Emergency Medicine and EMS physician, and it challenges us to think beyond protocols, to physiology, pattern recognition, and decision-making under pressure.In this episode, we’re going to slow this case down and unpack it, drawing out the key learning points, clinical decision-making frameworks, and practical prehospital strategies that shaped the outcome. From early shock recognition to fluid strategy, analgesia, and transport decisions, this is a case packed with insights for anyone working in high-acuity, time-critical care. You can read Mike's Substack post here: https://emsdrmike.substack.com/p/c1-dcr-traumaThis episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

This special compilation brings together three of our most important episodes exploring the medico-legal aspects of pre-hospital care. From documentation and communication to legal responsibilities and ethical decision-making, this collection provides practical guidance to help clinicians navigate some of the most challenging situations they will encounter in practice.We begin with Mark Faulkner, who was the Assistant Medical Director at the London Ambulance Service at the time of recording. Drawing on more than a decade of experience supporting and leading the organisation's pre-hospital legal department, Mark shares invaluable insights into the legal principles that underpin safe clinical practice and how clinicians can protect both their patients and themselves.Across the series, we explore:High-quality documentation and effective clinical handoversDuty of care, negligence, and professional accountabilityMandatory reporting and safeguardingConfidentiality and working alongside law enforcementManaging legal challenges during major incidentsPatient autonomy, capacity, and refusal of treatmentAdvance decisions and end-of-life carePractical approaches to ethical and legal decision-makingThe compilation concludes with Steve Bell, Consultant Paramedic and Consultant HEMS Paramedic, who discusses the complex intersection between ethics and law in pre-hospital care, providing practical strategies for navigating difficult decisions in the field.Documentation and Communication: Medico-Legal Aspects of Care – Part 1 (Mark Faulkner)Managing Complex Legal Scenarios: Medico-Legal Aspects of Pre-Hospital Care – Part 2 (Mark Faulkner)Ethical and Legal Decision-Making: Medico-Legal Aspects of Pre-Hospital Care – Part 3 (Steve Bell)Whether you're a student, paramedic, critical care practitioner or physician working in pre-hospital care, these conversations offer practical, evidence-informed advice to strengthen your clinical decision-making, improve patient safety and reduce medico-legal risk.This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

In pre-hospital care, few environments demand more precise and timely judgment than within a HEMS system. Decisions are made rapidly, often with incomplete information, within dynamic and unforgiving conditions. It is an operational space where clinical urgency intersects with aviation risk, and where each intervention requires a careful balance between decisive action and the principle of doing no harm.Today’s guest, Adele Dobler, works at this exact interface. With thousands of flight hours spanning urban HEMS, remote medical evacuation, and high-risk environments, from central London to the deserts and high-altitude regions of Kenya, she brings exceptional depth of experience in high-stakes decision-making. Her operational background includes flying aircraft such as the H135 and H145, frequently at night, under night vision goggles (NVG), and within complex, evolving mission profiles across diverse global settings.In this episode, we examine the realities of decision-making in HEMS, including cognitive load, inherent biases, operational trade-offs, and the critical inflection points that shape outcomes. The discussion focuses on dynamic judgment, risk management, and professional accountability in an environment where decisions must be made in real time, with minimal scope for error. This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

What you do in the first few minutes after a burn injury can influence not only survival, but pain, healing, scarring, and long-term quality of life.In this special compilation episode, we've brought together both parts of our conversation with burns specialist Krissie Stiles into one comprehensive masterclass. Whether you're revisiting these episodes or listening for the first time, this is an evidence-based guide to the assessment and management of burns in the pre-hospital environment.Across the episode, we discuss:The pathophysiology of burn injury and why it matters clinicallyEvidence-based burns first aid, including optimal cooling strategiesAssessing burn depth and total body surface area (TBSA)Airway assessment and recognising inhalation injuryAnalgesia and pre-hospital pain managementFluid resuscitation—who needs it and whenDressings, packaging and transport considerationsReferral criteria and working with specialist burns servicesCommon myths and pitfalls in burns managementThe lifelong physical and psychological impact of burn injuriesKrissie combines decades of clinical expertise with practical advice that can be applied immediately by paramedics, emergency physicians, nurses, and all clinicians involved in pre-hospital emergency care.Listen to the original episodes:Part 1 – Pre-Hospital Burns with Krissie Stileshttps://podcasts.apple.com/us/podcast/part-1-pre-hospital-burns-with-krissie-stiles/id1441215901?i=1000672971414Part 2 – Pre-Hospital Burns with Krissie Stileshttps://podcasts.apple.com/us/podcast/part-2-pre-hospital-burns-with-krissie-stiles/id1441215901?i=1000673376119Whether burns are a rare part of your clinical practice or something you encounter regularly, this episode is packed with practical pearls that will improve your confidence and your care.If you enjoy this episode, please consider subscribing, leaving a review, and sharing it with colleagues; it really helps us continue producing free educational content for the pre-hospital community.

Communication under pressure is one of the most critical and most fragile skills in pre-hospital care. When it fails, the consequences can be immediate and profound. In this episode, we explore why communication breaks down in high-stress environments, what that costs us clinically, and, crucially, what we can do to improve it. Joining me is Dr Stephen Hearns, one of the most influential figures in emergency and retrieval medicine. A consultant in emergency and aeromedical retrieval medicine, he is the founding force behind Scotland’s Emergency Medical Retrieval Service (EMRS), a government-funded critical care organisation delivering advanced pre-hospital care across some of the UK’s most remote and challenging environments. With over 30 years of experience spanning HEMS, mountain rescue, expedition medicine, and medico-legal practice, Stephen is a globally recognised authority on human performance under pressure. He is an Honorary Senior Lecturer at the University of Glasgow, has published extensively on human factors in acute care, and has played a key role in developing postgraduate education in retrieval and transfer medicine.Further reading relevant to this episode from Stephen can be found here:⁠ https://corecognition.co.uk/performance-infographics/8-tools-to-improve-communication-under-pressureLearn more about Core Cognition:⁠https://corecognition.co.uk/⁠

Point-of-care ultrasound (POCUS) has become one of the most exciting developments in modern pre-hospital care. From enhancing clinical assessment and supporting critical interventions to influencing transport and treatment decisions, ultrasound is increasingly finding its place in the hands of pre-hospital clinicians.In this special compilation episode of the Pre-Hospital Care Podcast, we bring together three previous episodes that explore the role of ultrasound from different perspectives. Together, they provide a comprehensive overview of the opportunities, limitations, and governance considerations surrounding pre-hospital ultrasound practice.In this episode, we discuss:The evolving role of ultrasound in pre-hospital decision-makingHow POCUS can augment clinical assessment in critically ill and injured patientsThe use of ultrasound in trauma care and time-critical interventionsCurrent evidence supporting pre-hospital ultrasoundTraining, competency and governance requirementsChallenges of implementation and avoiding over-reliance on imagingThe future of ultrasound in pre-hospital and critical care practiceFeatured EpisodesSound Decisions: The Evolving Role of Pre-Hospital Ultrasoundhttps://podcasts.apple.com/gb/podcast/sound-decisions-the-evolving-role-of-pre/id1441215901?i=1000723373532Point-of-Care Ultrasound in Critical Care with Dan Nevinhttps://podcasts.apple.com/ca/podcast/point-of-care-ultrasound-in-critical-care-with-dan-nevin/id1441215901?i=1000625086379Pre-Hospital Ultrasound in Trauma: Practice & Governancehttps://podcasts.apple.com/gb/podcast/pre-hospital-ultrasound-in-trauma-practice-governance/id1441215901?i=1000724321110ResourcesFor more episodes and educational resources, visit the Pre-Hospital Care Podcast and follow us on social media for updates on future episodes and series.If you enjoyed this compilation, please consider subscribing, leaving a review, and sharing the episode with colleagues who have an interest in pre-hospital critical care.

Paediatric mental health presentations are becoming an increasingly common part of pre-hospital and emergency care. Yet, many paramedics report feeling under-prepared when it comes to recognising and responding to psychological distress in children and adolescents. Unlike physical illness or injury, mental health concerns often present subtly, evolve dynamically, and sit within complex family, social, and developmental contexts.Today’s guest, Kristina Maximous, is a dual-registered Paramedic with extensive clinical and academic experience in both Australia and the United Kingdom. She currently serves as a Lecturer in Paramedicine and Academic Resourcing Lead and is completing a PhD focused on paediatric mental health screening and assessment within paramedic-led emergency care. Her research has explored how paramedics make decisions about children and adolescents in psychological distress, and the limitations of current screening tools in dynamic, time-pressured environments. Kristina’s work aims to inform more developmentally appropriate, biopsychosocial approaches that support safer, more equitable care for young people. In this episode, we explore the distinction between screening and assessment, unpack the challenges paramedics face on the frontline, and discuss what a more holistic, biopsychosocial model might look like in practice. You can find Kristina's scoping review here: https://science-health.csu.edu.au/schools/nursing-paramedicine-health/research/projects/reframing-paediatric-mental-health-screening-and-assessment

Major incidents challenge clinicians to balance speed, simplicity, and clinical effectiveness in highly dynamic environments. In this episode, Advanced Paramedics in Critical Care Keir Rutherford and Alec Wilding reflect on lessons learned from real-world major incidents and the findings of inquiries such as the Manchester Arena bombing. The discussion explores the early recognition of terrorist attacks and how responders can distinguish these events from more routine presentations in the initial stages of a call.A central theme is triage. Keir and Alec examine the implementation of the new NHS major incident triage framework, including the Ten Second Triage (TST) tool and the Major Incident Triage Tool (MITT). They discuss how these approaches are designed to rapidly identify patients who will benefit most from immediate life-saving interventions, while supporting efficient resource allocation in mass casualty events. The conversation also explores the relationship between triage, enhanced clinical care on scene, and the role of casualty clearing stations.Joining the discussion is Dr. Philip Cowburn, Consultant in Emergency Medicine and co-author of the Ten Second Triage Tool. Phil shares insights into the evidence underpinning these developments, the influence of recommendations from the Manchester Arena Inquiry, and how national practice has evolved to improve patient outcomes during major incidents.Beyond clinical processes, the episode highlights the importance of interoperability between ambulance, police, and fire services, alongside the emotional and psychological challenges faced by senior clinicians during and after major incidents. Together, the guests provide a practical and reflective overview of modern major incident management and the evolving systems designed to deliver the greatest benefit to the greatest number of patients.This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

Today on the Pre-Hospital Care Podcast, the discussion opens with a critical question: why do even highly trained clinicians struggle to perform under pressure, and what can be done about it? To explore this, we are joined by Dr Stephen Hearns, a globally respected clinician, educator, and author whose work bridges emergency medicine, human performance science, and high-stakes decision-making.Stephen is a consultant in emergency and aeromedical retrieval medicine and played a central role in developing Scotland’s Emergency Medical Retrieval Service (EMRS), a government-funded critical care retrieval organisation delivering advanced pre-hospital care to major trauma patients and those with complex critical illness in remote environments.Drawing on his book Peak Performance Under Pressure, Stephen examines the cognitive and behavioural factors that influence performance in extreme conditions. This episode focuses on practical strategies, including mental rehearsal, shared mental models, and cognitive aids, and how these translate into sharper decision-making and improved outcomes in real-world pre-hospital care.Further reading relevant to this episode from Stephen can be found here:https://corecognition.co.uk/blog/the-arc-of-performanceLearn more about Core Cognition:https://corecognition.co.uk/This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠

Grief is an inevitable part of pre-hospital care, yet it remains one of the most complex and challenging aspects of our work. In this compilation episode, we bring together three powerful conversations exploring grief, bereavement, loss, and the role healthcare professionals play in supporting patients, families, and themselves during some of life's most difficult moments.We begin with renowned psychotherapist and author Julia Samuel, who shares insights from more than three decades of working with bereaved families. Alongside Caroline Phillips, Julia explores the process of grief and bereavement, the skills required for breaking bad news, the impact of repeated exposure to loss on healthcare professionals, and practical approaches to building resilience in emotionally demanding roles.The episode then turns to a two-part conversation with grief specialist Liz Gleeson. In Part 1, we explore key theories and frameworks for understanding grief, including Attachment Theory, Continuing Bonds, the Dual Process Model, and Kübler-Ross's Five Stages of Grief. Liz discusses the importance of presence, listening, cultural awareness, and compassionate care, while also examining the emotional toll that supporting grieving individuals can have on clinicians.In Part 2, we take a deeper look at the many forms grief can take beyond bereavement. Together, we explore anticipatory grief, perinatal loss, suicide bereavement, parental and sibling grief, losses associated with ageing, and the often-overlooked impact of divorce, separation, and family estrangement. We also discuss disenfranchised grief and how recognising these experiences can help pre-hospital professionals provide more sensitive, informed, and person-centred care.Whether you are supporting families through sudden loss, caring for patients facing life-limiting illness, or reflecting on your own experiences of grief and exposure to trauma, this compilation offers practical insights, evidence-informed perspectives, and compassionate guidance for navigating one of the most universal aspects of human experience.Guests:Julia Samuel MBE – Psychotherapist, Founder Patron of Child Bereavement UK, and author of Grief Works and This Too Shall Pass.Liz Gleeson – Creator of the Shapes of Grief podcast and internationally recognised grief educator and therapist.This episode is essential listening for anyone working in pre-hospital, emergency, critical care, or healthcare environments where grief and loss are encountered as part of everyday practice.This episode is sponsored by PAX: The gold standard in emergency response bags.When you’re working under pressure, your kit needs to be dependable, tough, and intuitive. That’s exactly what you get with PAX. Every bag is handcrafted by expert tailors who understand the demands of pre-hospital care. From the high-tech, skin-friendly, and environmentally responsible materials to the cutting-edge welding process that reduces seams and makes cleaning easier, PAX puts performance first. They’ve partnered with 3M to perfect reflective surfaces for better visibility, and the bright grey interior makes finding gear fast and effortless, even in low light. With over 200 designs, PAX bags are made to suit your role, needs, and environment. And thanks to their modular system, many bags work seamlessly together, no matter the setup.PAX doesn’t chase trends. Their designs stay consistent, so once you know one, you know them all. And if your bag ever takes a beating? Their in-house repair team will bring it back to life.PAX – built to perform, made to last.Learn more at ⁠https://www.pax-bags.com/en/⁠