Remember That Patient Podcast

Episode Notes: "Patch" episode: The Fog of Care – Sickle Cell & The Pain We Miss
Episode Overview
This is the first in our series of "The Fog of Care" - how cognitive bias can leak into our differentials and treatment. In this solo "Patch" Jeff Bilyk dives into one of the most misunderstood and frequently mismanaged emergencies in the prehospital setting: the Vaso-Occlusive Crisis (VOC). We peel back the layers of Sickle Cell Disease to reveal a high-stakes ischemic emergency that is often hidden behind a veil of provider bias and "the fog of care."
Key Takeaways
The "Micro-MI": A VOC isn't just "pain." It is the literal starvation of tissue from oxygen. If we treat a 12-lead with ST-elevation with aggressive urgency, why do we hesitate to treat the ischemic pain of a sickled-cell "traffic jam" in a patient’s femur?
Pathophysiology Refresher: * Hemoglobin S: The mutation that causes cells to "polymerize" and stiffen under stress (hypoxia, dehydration, cold).
The Vicious Cycle: Rigid, sticky cells create microvascular "roadblocks," leading to downstream ischemia, infarction, and systemic inflammation.
Beyond the Bone Pain: Recognizing the "Killers."
Acute Chest Syndrome: A leading cause of death. Watch for the triad of chest pain, fever, and hypoxia.
Splenic Sequestration: A pediatric emergency where the spleen traps the body's blood volume.
Navigating Cognitive Landmines: * The "Frequent Flyer" Trap: Why familiarity should breed better care, not cynicism.
The "Drug-Naming" Fallacy: A patient knowing their dose isn't a sign of addiction; it’s a sign of a lifetime of disease management.
Vital Sign Adaptation: Why a heart rate of 80 doesn't mean the pain isn't a 10/10.
Clinical Pearls for the Road
Aggressive Analgesia: Don't be the "opioid police." Use your directives early. Consider Ketamine as a powerful adjunct for "wind-up" pain.
Hydration is Key: IV fluids aren't just for BP—they help "grease the wheels" of the microvasculature to break up the occlusion.
The Handover Shield: You are the patient’s advocate. Frame the handoff to the hospital as a medical emergency, not a social or behavioral one.
Quotes from the Episode
"We aren't the moral arbiters of who deserves comfort. We are clinicians. Act like it."
"A vaso-occlusive crisis is an MI happening in the marrow of the bone. There's no 12-lead for it, but the ischemia is just as real."
Resources & Further Reading
ALS PCS Directives: Review your local protocols for Analgesia and Fluid Boluses
Support the Podcast:
If this episode changed the way you look at your next Sickle Cell call, share it with your partner. Stay safe out there.

Patch Episode: Bridging the STEMI Gap with Zalunfiban (The CELEBRATE Trial)
Episode Description: The prehospital management of ST-Elevation Myocardial Infarction (STEMI) has evolved immensely, but we still face a major physiological roadblock: the delayed onset of oral P2Y12 inhibitors like ticagrelor. By the time our patients reach the cath lab, we are often racing our own medications. In this "Patch" episode, we explore a potential paradigm shift. We break down the newly published CELEBRATE trial and look at zalunfiban, a rapid subcutaneous glycoprotein IIb/IIIa inhibitor that aims to initiate the reperfusion cascade right in the patient's living room.
In This Episode, We Cover:
The Pharmacological Lag: Why oral antiplatelets fall short in the acute, sympathetic-overdrive state of a STEMI.
A New Approach to GPIs: How zalunfiban bypasses the gut with a rapid subcutaneous injection, achieving near-complete platelet inhibition in just 15 minutes.
The CELEBRATE Trial Breakdown: We dive into the methodology and the impressive results, including an NNT of just 29 for major adverse cardiac events and significant improvements in pre-cath TIMI flow.
The QA Perspective: A critical look at the bleeding risks, balancing the minor increase in nuisance bleeding against the lack of major intracranial or GI hemorrhages.
Operationalizing the Data: How this drug fits into direct-to-PCI pathways, its contraindications alongside prehospital fibrinolysis (like TNK), and what it means for your next shift.
References & Further Reading:
The Primary Study: Zalunfiban at First Medical Contact for ST-Elevation Myocardial Infarction. NEJM Evid. 2026 Jan;5(1):EVIDoa2500268. doi: 10.1056/EVIDoa2500268. Epub 2025 Nov 10. PMID: 41211981.
Clinical Breakdown: CELEBRATE Trial: Efficacy of Zalunfiban via Medici Emergenza Territoriale Substack. Read it here: https://mediciemergenzaterritoriale.substack.com/p/celebrate-trial-efficacy-of-zalunfiban
Supplementary Video Context: Pharmacist-led presentation on the CELEBRATE trial
The medicine starts with you. Own the roadside, and I'll catch you on the next call.

In the first of our "half episode" series which focuses on a various of melting pot of prehospital topics, I sit down with Jay Loosley. Jay is the Superintendent of Education for the Middlesex-London Paramedic service. Jay along with some colleagues at his service and local hospitals (along with more I'm sure) put together a fantastic research project on this topic which we delve into.
Paramedic Research Poster:
Can't see the image above or want to download the high resolution PDF? CLICK HERE
Additional studies
Blog: John P. Schuman: Can Paramedics Find Out About Patient Outcomes?
Research: Academic Emergency Medicine Education & Training: Clinical Performance Feedback to Paramedics: What they receive and what they need.
Research: Canadian Medical Association Journal: Patient and paramedic engagement in prehospital emergency medicine research.

The Case:
Male in his 20's in the early morning hours unconscious. Upon arrival the patients father came home and found his son unconscious on the living room floor. House is not in disarray, no trauma is noted to the patient, and nothing around the patient. Father states he has no diagnosed medical history, no Rx meds, however years ago the patient struggled with cocaine abuse. Despite such his understanding is the patient has been cocaine free for the last 8 months. States it would be unlikely for him to consume excessive alcohol, no other Rx or recreational drug use, and the fathers Rx meds are all accounted for.
Initial vitals:GCS 3, flushed, sweatyHR 128 Reg, RR shallow 22, SPO2 88% ra, BGL 7.2, 82/54, T37.5C, Pupils sluggish at 4-5mm.
Prehospital 12-Lead ECG here:
If the 12-Lead is not showing properly you can click HERE to open it up in a browser window.
Sympathomimetic toxidromeClinical features:delusions / paranoia / tachycardia / hypertension / hypotension (severe) / hyperthermia / sweating / piloerection / mydriasis / hyperreflexia / seizures
Useful Links (will open in separate browser windows):
Internet Book of Critical Care - Sodium Channel Blocker Toxicityhttps://emcrit.org/ibcc/nacb/
Internet Book of Critical Care - Sympathomimetic intoxicationhttps://emcrit.org/ibcc/symp/
StatPearls - Cocaine Toxicityhttps://www.ncbi.nlm.nih.gov/books/NBK430976/
Medscape - Cocaine Toxicity (free registration required)https://emedicine.medscape.com/article/813959-overview
Life in the Fast Lane - Cocaine Toxicityhttps://litfl.com/cocaine-toxicity-ccc/
 

The Remember That Patient Podcast - Introduction or Episode 0
This brief trailer will highlight our ideas, and what we hope to accomplish going forward on our show.