January 5, 2026

A 48-year-old male fell from scaffolding at work, is currently seizing and otherwise unresponsive. He has suffered trauma to the head, but no other bruising or trauma, with snoring respirations and significant saliva from the mouth. He is also vomiting. 

You appropriately manage the airway with full C-Spine precautions.  

You evaluate the Glasgow Coma Scale (GCS): 

• Eyes: Not opening even with noxious stimuli=1 

• Verbal: Making only incomprehensible sounds=2 

• Motor: He withdraws from noxious stimuli=4 

• Total=7 

How will you manage his airway? It is clear that he needs an airway. He is seizing, and this must be controlled immediately. 

185/105, p=45, Pulse Ox=93%, Glucose 133 

You chose Versed 2.5 mg IV with control of seizures. He is now exhibiting decerebrate posturing. GCS is now 6. 

You are 30 minutes from the trauma center; air support is grounded due to weather, and the patient’s trajectory is getting worse. There is a gag reflex. 

You are trained in rapid sequence intubation (RSI) and so is your partner; you also have an EMT to assist. The three of you go through the 7 Ps: 

1. Prepare (all equipment, suction, tubes, recue airways, meds, tubes, tube holder, capnography, and video equipment) 

2. Preoxygenate 

3. Premedicate (Ketamine 1-2 mg/kg) 

4. Paralytic medications (Rocuronium 1-2 mg/kg) 

5. Positioning (C-Spine precautions with this patient) 

6. Place tube (and confirm with visual partner confirmation capnography waveform, breath sounds and Pulse Ox as well as colorimetric CO2) 

7. Post-intubation care (watch the waveform, pox, and patient condition until arrival) 

Excellent job by the crew. The patient is found to have an expanding SDH and is taken rapidly to surgery. Decompression is complete, and after a long recovery, the patient is left with memory issues but is physically at baseline. 

Summary 

• RSI is for trained medics, and they must be with another trained RSI medic as well as a third assistant.  

• Video equipment, as well as backup airway care, is required. 

• Complete the 7 Ps for intubation under RSI. 

• Constant patient monitoring is required. When you sedate and paralyze a patient, their total care is in your hands. 

We are all in this together. Always call medical control for support. 

Sincerely, 

Don Spaner, MD

January 12, 2026

This week, we review a 70-year-old female:  

• 180/110, p=90, r=32, pox=88% co2=26 

• Can’t lie flat. 

• JVD to jaw line, +HJR, 4+ pitting edema. 

• PMH: IDDM, CHF, CRF on dialysis 3x/week. 

• Patient SOB speaking in two-word sentences. 

Treatment?  

You have correctly identified an acute exacerbation of heart failure. 

The patient is identified as having a moderate to severe CHF exacerbation. 

Treatment? 

• Be aggressive with CPAP. 

• Confirm that she is alert and the airway is intact. 

• Confirm that she is not vomiting. 

• Confirm that she is not hypotensive. 

• Confirm that there is no trauma to the chest. 

• Confirm that she tolerates the mask. 

• Confirm that there are no contraindications for CPAP. 

Pressures between 5-10 are in the green zone and barotrauma is low risk. Here, we will open the alveoli, recruit more surface area for gas exchange, allowing for better O2.

Be aggressive with nitro, continue S/L nitro until systolic is less than 120. This will dilate the vasculature and rest the heart whose pump is failing. 

If you find severely worsening heart failure and the B/P is now low, they have moved from CHF to cardiogenic shock. As much as the ED would love to vasodilate them and provide CPAP, they won’t tolerate this, and we sadly ask you to use push dose epi to provide a systolic of 90 and or a MAP of 65. Pressors are taxing on a failing pump and simply make the heart work harder. We have moved to early intervention with Impella, aortic balloon pumps, and evaluation for LVADs. In the field, we can’t let the patient suffer cellular death from lack of perfusion. We ask you to maintain these numbers and use the push dose as needed. 

Thank you for your time this Monday morning, 

Don Spaner, MD

January 19, 2026

You immediately provide suction, and the patient can even hold the Yankauer suction and handle his secretions. 

Do you try and intervene? Do you simply transport to the ED? 

These are critical questions. 

The adage that you don’t disturb an open airway is hard to argue with. However, it really is worth a look. 

If you simply have the patient open their mouth and you see partials lodged in the posterior pharynx, evaluate this quickly. If no metal hooks seem caught in the tissue, get the Magill forceps, hold the visible end, and remove the dentures. Avoid any further trauma to the posterior pharynx. 

If the airway is obstructed by the foreign body, it must be removed. If this isn’t possible, surgical options must be considered according to your level of training. There is a surgical cric procedure in the protocol, but this requires your medical director to have approved your skills in this procedure. Remember your landmarks. Even if this is a rare event for EMS, it correlates with the policy of low frequency but very high risk. These are the skills we must always practice with. 

There are different products, but all are built for providers who seldom do this procedure and need a simplified procedure kit. It is critical to know your device and review this every quarter. 

In review: 

• Quickly review foreign body airway obstructions. 

• Don’t intervene with an open airway. 

• Be prepared to immediately intervene when complete obstruction occurs. 

Thanks for spending another Monday morning with us, 

Don Spaner, MD

January 26, 2026

We have had numerous calls from trauma centers complaining about high-risk neck injury patients who have had no cervical motion restriction. Certainly, the days of backboards for everyone are over. This has somehow been diluted to the point that many providers have downplayed the importance of proper spinal motion restriction. Downplaying an unstable spine fracture can have devastating effects. Recognizing that fractures of the spine are divided equally among the various areas, we see 1/3 cervical spine injuries in trauma, 1/3 spine fractures of the thoracic spine, and 1/3 fractures of the lumbar spine. However, the higher the fracture, the higher the risk. Complete cord injuries above C3, 4, and 5 that keep the diaphragm alive can leave a patient not only in the condition of quadriplegia, but also ventilator dependent. Taking these high-risk patients seriously and ensuring no further harm comes to them is critical. 

Critical points depend on the clinical findings. 

1. The patient with an injury that concerns the providers for at-risk spine injuries, but the patient has no complaints, is not tender, is alert and oriented, and has no neurologic deficits, can be transported with neutral positioning. No collar or vacuum mattress is needed. 

2. The patient with an injury that concerns the provider and is complaining of pain, or is tender on exam, but is alert and oriented and has no neurologic deficits, may be collared, moved safely, and kept in a neutral position to the appropriate emergency department. 

3. The patient who has any of the following: altered mental state, neurologic deficits, or an extremely high-risk traumatic event, should be fully immobilized with a vacuum mattress and collar, as well as very careful movement. 

You can still use a backboard or KED board to extricate, but these should be moved to vacuum mattresses as soon as possible. 

Thanks for spending another Monday morning with us, 

Don Spaner, MD