Ep. 5: EMS "Would You Rather?" (with Bonus Airway Chaos)

Nicole and Carson play an EMS-themed game of "Would You Rather?" while Jaden is away at work! They also play Carson's new favorite game: "Intubate or Nah."

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Transcript

0:55

Hey everyone, it's Carson and Nicole. Today we don't have Jayden with us because he's off doing adult things and he's at work. So our episode today is gonna be slightly different than what we've been doing. So we figured it would be kind of a fun one. We're gonna do some would you rathers. We're just gonna be throwing out random scenarios to each other. uh We had something planned, but we would prefer that all three of us be with us in this scenario or the episode. So it will be much better for you guys with all three of us. Yeah, like we talked about before, uh part of the critical care crossroads thing is that there's three of us and we all have really busy lives. We all work full time, are all involved in multiple organizations and committees. So we're just happy to even have two of us available when we can, but we don't want that to hold the show because we'd be maybe putting out one episode a month if we really waited for all three of us. So yeah, we decided we were going to do a little, would you rather game today, break away from the normal content, the educational stuff, just to kind of diversify all the things that we're doing. We'll see if you guys like it or not. um But yeah, without any further ado, Nicole, what do you got? Oh boy, I am excited for this. They're just kind of random, but you know, whatever. Okay, so first things first, would you rather lose your favorite trauma shears every single shift or constantly find mystery fluids on your pants with no idea where they came from? would absolutely rather lose my favorite shears every shift simply because the place that I work at has boxes on boxes full of the same shears. They just happen to be my favorite. uh Mystery fluids also suck, so that's fine. I've come to find in the flight environment, this is not uh probably true in the ground EMS, but I use my shears 90 % of the time to cut open mail and boxes and maybe like food. have rarely, rarely actually have used my shears on uh patient clothing. because usually by the time we get to our ground EMS crews or our sending facilities, they're fantastic and already exposed the patient for me. I don't know if that's what you found. I um just have my trauma shears on my flight suit just for looks apparently, because I don't ever use them on actual patients. Either I use them to open boxes or cut a piece of paper or open food, like you said. I don't use them on a patient, unfortunately. Yeah, I would love to be able to at some point actually use my real medic skills, but I guess that we don't get to use those. What would you rather have? Oh, go ahead. When I go to work tomorrow, I'm gonna make it a point to like use them on something other than a box or food or something but for me I would absolutely rather lose my trauma shears because where I work also has trauma shears, so um Yeah, I would rather lose the trauma shears because I don't like mystery fluids on my pants or my flight suit at all so funny is I was doing a couple conferences earlier this spring and uh at some of them I won some X-Shears and those X-Shears seemed really really cool. I'm just afraid to wear them, I'm afraid I'm gonna lose them. When we won those, I put them on my flight suit probably, I don't know, a month ago because I was so afraid to lose them. So now I baby the crap out of them. I watched them like a hawk where they don't disappear on me, but they're pretty bad ass so far. You will definitely not struggle opening a box. I'm afraid to even take him out of the packaging to just look cool. But I got one for you. Would you rather have a student that will not shut up or a student that will not ask a single question or really talk at all without being prompted? um I would rather have a student that doesn't shut up because I also don't. I also don't shut up. Yeah, I sit there and I talk and I talk and I talk and I tell them stories and I will bug them. um A student that is going to sit there and stare at me and not ask anything or do anything unless prompted. feel like would probably be more annoying, I guess. And I mean that in like the most loving way. um They probably wouldn't enjoy even being there if they're being that quiet, like not being prompted and like not wanting to talk or do anything. So I would absolutely have the student who will not shut up because they're always like the best. I've always had students that won't shut up and they're pretty enjoyable. I really think this can go multiple ways. I did not provide enough context, maybe just for the discussion, but also now that I'm thinking about it, there's different types of won't shut up and there's different types of won't talk. Like there's the like carrying on and on and on about things out of like a nervous tick or like, you know, talking, boasting about themselves. There's that kind of won't shut up. And there's also the like talking about the things I like talking about and that that's very different, but also I think it's one thing, especially if they're like a brand new to healthcare EMT student and they're just so shy, they don't know what to speak. And usually they walk into an environment where like, we are all family and we've all like worked together for years and it's intimidating for them. like between those that might change my answer, but I think I'm with you on that one too. I that, I mean, I would still probably stay with the same answer, but you know, if they were brand new and they were coming in and they're scared because we're all like super close and we've obviously worked with each other for quite some time. Like I love students like that too, because I'm like, okay, we're gonna go have family dinner time and we're gonna go get coffee and we're gonna hang out. Like tell me all about yourself and try to make it welcoming and like also less awkward because if they're awkward, I'm gonna feel awkward. And so. Yeah, I would probably still stick with my original answer, It's so fun when you can get those students to be talkative by the end of the day. you find them when they show up and by 6 p.m. whenever their day's over or whatever, this, you know, a whole different person. yeah, when they come in the next time you're out with you they're like, hey! It's like, hey, you're not so awkward now! Yeah, now do all my things for me. Yeah, right. Okay. Go ahead. Neither would I. Let's just make that known. um Okay, so this one's kind of difficult. Would you rather have the monitor die mid-code or realize halfway through the call that your O2 tank is empty? monitor di-MID code every time. single time. Number one, that is like something I can very easily say is not my fault because I do my monitor checks. If my oxygen runs out, that's probably my fault and I'm probably getting fired. Number two, I think that all of us are trained at a very simple level and the way that medicine tries to do it is start small and build up. Meaning that at the level that least, you that we, you and I are, but also your most basic EMR and EMT should know how to run a code without the monitor. That's just a very, very necessary and very good adjunct, but you don't necessarily need to be able to at least find the pulse and do the very basics. Maybe I'm wrong. Maybe that's a hot take. No, mean, I would definitely prefer the monitor dying midcode because you can check to see if a patient has a pulse. Obviously, there are situations where you can't feel they have a pulse, but you can start very small and work your way up. Like panicking, I mean, like, OK, well, first of all, can I feel they have a pulse? Like, what do I need to do from this point? What can I fix in this situation? And like, plug the freaking monitor in, like, go look for another battery. Start doing something to try to fix that situation. If the monitor dies, sometimes monitors, like batteries don't just last forever, they end up dying randomly. uh But checking the oxygen is definitely my fault. So if the oxygen is empty, it's because I didn't do my job correctly in the morning. And we can still deliver care without a monitor. feel like without the oxygen, that's a lot of what we do. um Without going on to a huge tangent as well, you talk about like maybe you're being nervous and you're amped up and that's why you can't feel a pulse. But realistically, if you can't feel a pulse, are they really perfusing? You know what I mean? like, we rely too much on the monitor for that stuff anyway. I don't know. No, that's a hot take. We have plenty of hot takes today. Yeah, absolutely. oh So for this next one, just some context. It is July in the Midwest and you forgot your extra uniform. That is the context. Would you rather have a drunk person vomit tequila hot dog mixed water onto your suit or have a GI bleed patient similarly contaminate your suit? Oh god, Carson. em I would definitely go with the drunk person. GI bleeds, I will absolutely throw up everywhere. I cannot stand the smell. I don't want to be in the hospital. I don't want to be near the patients. I will start puking everywhere. So I'll just take the person who's drunk but vomits tequila, hot dog, water, whatever. uh I'll be hiding out in the laundry room washing my clothes until they're dry, but I would rather do that than the GI bleed. And maybe that is something that you would not, but that's my answer. Calling crew rest for laundry might have to be a move here. So I'm really torn on this one just because I am a sympathetic pukeer, but most people it's like the sound for me it's the smell. I can't do uh tequila for several reasons, but I feel like if I smell tequila vomit that just means it's coming. A GI bleed is like equally bad, so I really don't know. I might err on the side of vomit just because it's not bloody and I can eventually get that thing out of my suit, but that's like the only tipping point. Yeah, I'm definitely gonna go with the drunk person vomiting on me, not the GI bleed. Ugh, God, that makes me cringe. I have one very bad memory of a GI bleed patient that just is stuck in my head and it will not go away. I think if you've been in this business long enough, got, you you have to have a GI bleed memory of some sort. my God, yes. PTSD. Okay, would you rather be stuck on scene with a talkative family member who won't let you work or be stuck in the ER with a doctor who's lecturing you on a skill that you already know? I would probably take the doctor with the skill on that one. No offense to our talkative family members, like, you know, sometimes I just need the ability to work. That doctor, like maybe he's repeating something that like I need the repetition on, even if I already know it or coming at it from a different angle, but at least under this context, he's letting me work. And if I need to, can filter it. um Typically, I like to use the assertion. Now, those of us with. other licensures and other certifications and degrees, we obviously have our place in our specialties, but usually that guy that went to medical school, residency, fellowship, and now is an attending physician might know a little bit more than I do with my associate's degree in nursing and a couple of advanced certs. That's just my own thought. Yeah, I would think that I would take the physician as well. em I'm always up to learning something different from a physician. mean, they probably know way better than I do, and that's OK. um So yeah, I'd probably pick that one as well. I don't think so. So we're doing great. Yeah, this is not as controversial as I really wanted it to be when I came up with it. That's okay. Would you rather have a student that thinks they know more than you or a partner that doesn't think you know anything? God. um Repeat the question. Would you rather have a student that thinks they know more than you or a partner that doesn't think you know anything? The shift is the same amount of time, so you can't just say the student's only with me for half the day. my gosh, probably a student. Really? I guess I could see how like emotionally, mentally you can just brush that off as like, they're a student, they're a student, know, Dunning Krueger. um I almost would want to have a partner that doesn't think I know anything. Cause like, well, I don't know everything by any means. I do get some personal satisfaction in proving people wrong, especially like if I get to prove myself to them in a respectful way, but then they both suck. Don't get me wrong, but maybe that one. I know, I feel like having a partner who's with you consistently, like who doesn't think you know what you're doing, would just like eat at you consistently and that would like bring you to a breaking point where you'd be like, hey, shut up. uh if this is just for a one-off, like you guys don't usually work the same shift, it's an overtime work over situation, you'll never know this person again, but you know, for both these times, the same amount of time, does that change your answer at all or? I mean, maybe I would choose the partner. Just if I have to deal with them for a short amount of time, maybe like work with them for that one shift and then not again. And that's fine if they don't know or they think that I don't know what I'm doing. That's fine. But yeah, that's a hard question. Yeah, that one, I don't know the right answer to any of these by the way. We're doing great. um Would you rather work with a partner who talks nonstop the entire flight or one who's dead silent and just stares at you? Well, I've worked with both versions of Nicole and it depends on if it's 2 p.m. or 2 a.m. No, I'm just kidding. It again probably depends on the subject matter, but I like talks nonstop just in the sense that I know that person's over there and their brain's working and that's really, really cool. Or if it's about nonsense, that's also awesome because usually when partners go silent, that's like scary in the helicopter where I would 100 % pivot on that is if they're talking during like sterile cockpit procedures and they're not talking, you know, they're not really on mission when I need them to be on mission. And sometimes I'm the kind of person whenever I'm taking care of a patient that I need to be locked in and like, you know, I don't like to caveat the conversation away from that patient. So if the conversation is on par with those sorts of things, and then we can just, you know, BS the rest of the time, I'm 100 % down for that. Yeah, I think I would take the partner who talks nonstop because I'm the partner who talks nonstop. But I'm also the partner at 2 a.m. that really doesn't say much unless I absolutely have to. Now if we're on a flight and I need to talk, I will. But like on the way back from a flight, I'm just kind of like awkwardly sitting there not saying anything unless I absolutely have to. I'm sure that we've all we can all say we've been there. But like McDonald's in the console. Yes, yes. But I would absolutely take the partner who talks nonstop just because it's more enjoyable, know, like being able to shoot the shit with your partner em and sometimes getting the pilots involved because sometimes it's fun to poke fun at them. So. Yeah, especially like hearing our pilots take. So for those of you that don't know, most helicopter EMS programs do not train their pilots medically whatsoever. like hearing our pilots take can be hilarious. We had one pilot, he's a good friend of ours still. We used to, so for our comms device or communication device with the patient, we'd have to manually turn that on and off every time we want to talk to them. And so we would use the term patient coming on, patient coming off. And this pilot legitimately thought we were bringing the patient back to consciousness every time we said that in order to talk to them and knocking them back out. So like hearing their little taste like that, think it's hilarious. I, uh, we had a pilot one time we were going to transport a lady who was, think, like 35 weeks pregnant or something. And she was having contractions like every, I don't know, five minutes. We got approval from medical directions, end up flying this patient. There were some other additional factors playing into this, but, um, the pilot was like, he was carrying a bottle of water on the way out. And he said that he wanted so badly to. Like tell her like hey, I'll be sitting up front with you. You know, I'll be like next to your feet basically But you know like I'm right there in case the baby comes I need to catch the baby and he's like and I wanted so badly to say that and like fumble the water bottle and drop it at the same time I'm saying that I'm like That would be terrible. They're so funny because they don't, mean like, they're, don't get me wrong, they are very smart because they pay attention to what we're doing and they are like absolutely the best with coming in and helping us. But it's so funny sometimes to hear their takes on things that are like, I have no idea. Like Carson and I were insubmitting this patient and I was getting ready to do this patient and he opened the back doors of the ambulance just to be like, hey guys, like the aircraft's pulled out or whatever. And he's like, huh, so that's what an innovation looks like. Yeah, he'd been flying for like five years, probably, you know, taking dozens, if not hundreds of innovative patients before. And he's like, that's the procedure. Like you actually put the tube in the throat. Yeah, that's, that is that. Well done, buddy. Um, so I got one more on the would you rather is before we move on to the clinical scenario at the, you know, the final round. mine is, would you rather have your ventilator break and you have to manually ventilate the entire transport or your, your is a sick critical patient. have your IV pump break and you have to manually push your pressors in your sedation every couple of minutes to keep them alive. I would do the vent one because you and I have done that the vent broke and I was bagging the patient so forgot about that call until literally right now. So thanks for bringing that up. I would choose that one. I would choose that one. Yeah. Um, I would choose that one too, mainly because like coming from the ICU background, especially it's, can be very, very challenging depending on the type of sedation and pressures are on pressers that they're on to really find that balance. And once you find that sweet spot, man, sometimes patients just log in and that's that sweet spot where now with these bumps, I'm like all over the place trying to figure it out. And then their pressure can only cycle. Cause we usually don't do invasive lions or pressure can only cycle every few minutes. you might not have good real time readings to see how you're doing with your sedation and your breasts, pushes. So I think I agree with that one too. Yeah, I would definitely choose the vent. I have one more question. Okay, McDonald's or Taco Bell at 2 a.m. while we're stuck at a hospital waiting for our night pilot to come and get us. Don't sue me McDonald's, but I'm a Taco Bell guy. um I don't eat healthy, but I feel like, and this is probably not true whatsoever for any nutrition gurus out there listening to it, but I feel like there's semi-healthy options, Taco Bell, there's more options, and I know, I can just smash a burrito at 2 a.m. so much harder than a quarter pounder with cheese. Oh, I'm gonna go with McDonald's. I've got the tummy troubles, but you know, I'll full pound down a uh cheeseburger at two in the morning or two of them. Just know if I pound any that much down, we're to be out of service for a solid hour. Well, I, you know, take care of that on the back end. I mean, we got back to base. The backstory of this is that, which we talked about it in, I think, our second episode or something maybe, but Carson and I were stuck at a hospital for several hours and we had been flying all freaking day long, didn't have anything to eat. um Our pilot ended up bringing us food, but we were so busy with the patient that he took off with the food and we Yeah. So he had to go back and get the night pilot. And so we were stuck at this hospital and we finally got picked up at like one in the morning or something. think like one or two in the morning. It was awful. And we're flying back and I realized that McDonald's is like there because he's like, Hey, the McDonald's is back there. I'm like, fantastic. So I start pounding down this cheeseburger and fries and I asked Carson, I'm like, Hey, do you want yours? was gonna say that McDonald's was back there. Carson and Nicole's McDonald's were back there. Yeah. I'm like, Carson, do you want this? He's like, no, I'm okay. And so I am just downing this McDonald's, which I knew was not a good idea because it was cold and whatever, but I was so hungry. didn't care. I was having the worst stomach pains of my life when we got back to the base and it was not fun to all those people out there with IBS. You understand what I'm saying. So And I was smart and slept the next three hours before it was time to go home. I was miserable. Oh my god. That was awful. And the reason why I didn't doze you that work night shift know this, um or maybe the ones that work EMS and work a lot of nights as well. But that night shift nausea is so real and I was so hungry. But with that night shift nausea, I just, I couldn't do it. And that was probably for the better so I could actually like go to bed. That's true. Yeah, I definitely didn't go to that immediately. Are you ready for this final round then? Yeah. So for our final round, we decided because it can be so controversial, intubate or do not intubate. I want to, before we go into this, talk about something called scenario bias. And what that is, is for those of that are listening, as well as the person presenting and the person uh responding, we all will have a different patient in our head based on, it doesn't matter how detailed you will be, there'll be some variances in that. So give us a little grace if you think this is a slam dunk one when it should be the other. and just kind of understand that maybe we're picturing something different. without further ado, do you want to go first or what do you want to do? unless you go first. present first or receive first. Mmm, present first. All right. So you are going to a 45 year old male that fell down the stairs. GCS is 13, that is one three, not 30, not three. He is slurring and smells deeply of alcohol bystanders state that he was hammered before he fell. Pupils are equal, but you do have a relatively significant scalp lack and a bloody nose. Are you ready for some vital signs? Vital signs are heart rate 98. Blood pressure 146 over 90. Respirations 20 times a minute. SPO 2 96%. He is trying to sit up, resisting the sea collar, yelling some obscenities, seems altered. And they want him flown to the level one, which is about 30 minutes away. What do you do? sure that what I'm gonna say is like a hot take, I don't know. okay, so do know how long the fall was? We'll say it's down a flight of stairs. Don't fly the stairs. Yeah, onto a concrete floor. Does he take blood thinners? Um, he was not able to report, but he's a 45 year old male. So there who knows. potentially, maybe not. I know. Okay, so are there any other obvious injuries to head, neck, back, chest, anything like that, or just the scalp laceration? Nothing from the outside looking in that you can really tell it would be significant, just stuff like consistent with abrasions, maybe some blunt trauma here and there, but no like massive deformity, no major bleed, nothing like that. Okay. So, I mean, with him resisting and he's altered, I would probably try really, really hard to um get him to calm down or maybe consider giving him like a little bit of pain meds, um Because as he altered and has a GCS of 13 because he is absolutely hammered or is he having a GCS of 13 because he has a head injury. Pupils are equal. Do they report a loss of consciousness or anything? Um, per the scenario, the one that I found didn't report yes or no, but we will say he has been lightly in and out of consciousness kind of his AFP would go from alert to maybe like a verbal, maybe a little painful, but back to verbal. You know what I mean? Yeah, I mean, it's hard to judge. I mean, it's a GCS because he is highly intoxicated or is it because of a head injury? I would probably try to um calm him down and maybe potentially give a little bit of pain meds, like, you know, and see where that kind of gets me. um I would obviously fly him to a level one trauma center due to the fall. um I would watch his airway throughout transport. I put him on end title. I would watch what his end title is throughout the transport. And if I did need to take his airway, then I could. Just because he fell down a flight of stairs, he's got the scalp laceration, he's slightly altered, doesn't mean that I need to take his airway right then and there. If he starts having snoring respirations or em he's unable to maintain his own airway, then I would definitely consider taking his airway. However, em just because he is resisting and he's altered, And he has alcohol on board. Doesn't mean that I instantly need to jump in and take his airway. His vitals are stable-ish. mean, they're pretty stable. Blood pressure is slightly high. But I mean, if he was absolutely resisting to where he was fighting me to get in the aircraft and was thrown afit, to where it's his against the his safety and my safety, then that would be something that I would consider tubing him for. um But trying to calm him down as much as I can with starting to look like pain meds or something, seeing where that gets me, and just coaching him potentially, and then going from there. Yeah, no, I like your thought process process on that a lot. Some of the things I probably should have prefaces with just for the audience's sake and knowing is that uh we fly in pretty tight model aircrafts. I fly in tight bell models and even an EC 135 is not the most convenient thing. So. ah One thing to think about if you were to go down the predicted clinical course route being one of the criteria we use to make the intubation decision is the fact that I really don't want to bite that off in an aircraft if I can in a pseudo stable back of an ambulance or even small sending rural facility. I feel like those are better areas to do it. oh not saying that wouldn't do the exact same thing you're doing, but I do want to add one more curve ball that I thought of while you were explaining here. Say that patient fell down the flight of stairs, became was unconscious reportedly. gained consciousness to smack and now is slowly dipping into that verbal state. Can you repeat that? Yeah, say that patient, um took the fall down the flight of stairs, was immediately unconscious after the fall, regained consciousness and was slowly losing consciousness. Again, like he was kind of becoming more more lethargic. I think that I would highly consider tubing him. I mean, assessing his mental status and determining if it's just going to continue getting worse or if he's going to be able to maintain his own airway. Sometimes patients can be altered, but they're maintaining their own airway and it's fine to leave it that way if they're able to maintain their own airway. he lost consciousness, he was alert and then now he's well on his way to becoming unconscious. Like, he's not answering my questions. He's just kind of out of it on the cot. Maybe has like, we've heard kind of like the snoring respirations with drunk people and whatever. If he had that, then I would maybe consider tubing him right there. I mean, it's still kind of the same. Yeah. No, and realistically, that paints a picture more towards brain bleed than it does alcohol, but that doesn't necessarily mean. I mean, yeah, for sure. It just doesn't mean that I need to cube him. That doesn't necessarily mean even if you're going down the brainwave pathway, that the brain bleed pathway that that patient will need innovated right off the get saying is that because a lot of times I like to do this whole head bleed versus drunk situation. um There are plenty of drunks that are only drunk on college campuses that present just like a brainbleed would. They're still protecting their airway. So patient positioning is huge on that. um The only caveat being and once you transition to that flight and that critical care environment or have a prolonged transport, The fact that looking down the pipe, if we're going to be in this aircraft for 30 minutes, 45 minutes, an hour, that might change my decision process, but I'm not saying it 100 % would either. So I could really go either way on that one. If I do have the context saying that it's likely a brain bleed, I'd probably be more apt to pull the trigger, but I simply don't hear it. And that's why it's tough. Yeah. mean, you know, it's been like kind of a topic of conversation for like multiple different times that I can think of of like, just because a patient has alcohol on board and they're altered, you know, do we tube the patient because they're altered, but we maybe need to consider is he altered because of the alcohol or are there other things going on? You know, there's plenty of things to play into picture for that. And, you know, seeing your patient and actually getting hands on them and like taking that assessment. in itself versus being read a scenario is completely different. My decision can be completely different laying eyes on a patient versus reading the scenario and telling you what I would or wouldn't do. The last thing I want to point out and the last little discussion point I want on this before I move on to yours is the other thing that would really clue me in to what this is one over the other would be Cushing's triad. If the breathing becomes more more irregular, if that blood pressure, especially the systolic blood pressure starts to skyrocket and the patient becomes bradycardic, and then bonus points if this pupillary changes. Those things, because what's happening is your skull is a fixed structure and you have a hole at the bottom of your skull where your spine comes. Right. And if there's pressure on it, that's where, that's where the brain is going to try to leak out. There's a blood pressuring the skull and pressuring the brain. apologize. And right there is your medulla albengata and that's what controls those functions. So it tells me that there is something pushing against the brain and doing that. And that's going to be when I'm more aggressive to realize this is probably going to be a brain issue and not a alcohol issue. But again, it's hard to tell because things, things are wish things are washy things, uh, get masked out in the field. never really know for sure without proper imaging. Yeah, for sure. mean, there's, there's always a thousand ways to treat a patient. And em like we said at the very beginning of this, like I may say that and somebody else could be like, no, she's wrong. I'm going to tube that patient without any doubt. So I don't mind my voice scratching because like, apparently it's just going to continue scratching throughout this. So I didn't notice that you said something. Okay, so are you ready for yours? Full Sends Only. Okay. So you are dispatched to a 68 year old male with a chief complaint of difficulty breathing. That is your initial dispatch and you weren't really given much else information. arrive on scene. Yeah. Right. You arrive on scene, you walk in the living room, the patient is sitting upright in his dining room chair. He's in the tripod position and he is working extremely hard to breathe. He is breathing at 24 times a minute. He's at 89 % on a non-rebreather mask, 15 liters, due to your first responders putting him on that. When you attempt to talk to him, he is speaking in one to two word sentences and using accessory muscles to breathe. um Despite being on the non-irritator, the patient's SVO2 remains low and they are still struggling to breathe effectively. How low is low? Oh, 89%. You said that. Continue. Yeah. Blood pressure is 172 over 88. Got a pulse of 146. And the SPO2 is 89%. All right. Is that all we got so far? Perfect. um And he has a history of COPD. There we go, that's what I'm looking for. So what's hard to see OPD patients is understanding what the goal is and understanding the concept of acute on chronic. Obviously this guy's in the middle of an emergency, I'm not gonna deny that, but has this been going on for several days or is there a trigger to this as well? What I really wanna do with this patient and in the pre-hospital environment, logistically this isn't always possible, but I think this might be worth a shot. And first of all, am I going by air or by ground? whatever you want. um If I'm going by ground, I'll go down this pathway. If I'm going by air, it might change this, but I want to do a BiPAP trial. Because what I'm really concerned for, and I've had this happen, is if a patient has been like this for days and days, and this is kind of the tipping point where they just now called 911, right? This patient's going to crash and burn unless I really pre-resuscitate hard. So what I'm going to do is put this patient on BiPAP, and I'm going to start the whole resuscitate free, innovate thing while they're on BiPAP, right? And if they get better, I don't have to innovate them. they don't, well, my hands forced, right? So I'll do this BiPAP trial while I'm at that. We'll go ahead and get a steroid on board. um One of my big things in EMS is just give the damn steroid because we might not get that quick satisfying fix. And a lot of medics are like, well, it's not going to fix him in front of me, but he's not going to get that steroid in the hospital for several minutes to hours anyway. So we might as well get that on board. um Then your smooth muscle relaxing pathway. We all know that. um And with this blood pressure, this is a really interesting situation because why do we think the blood pressure is up? It's really hard for him to breathe, number one, right? Number two, um he's probably freaking out and dumping these catecholamines. If that wasn't happening, what would his blood pressure actually be is my question, right? Because if I go to innovate this patient, uh number one, we have that switch from negative pressure to positive pressure, like we talked about in the Airways episode. But number two, eventually I'm going to make him comfortable and I'm going to take away his need to have a drive to breathe, right? And that blood pressure change, even though we're super hypertensive now, is going to be significant. So despite the fact that we're super hypertensive, I still want to have my push dose pressors ready and maybe a little bit of fluid just to kind of buy myself some time on that. And maybe even if I'm really being aggressive, have a pressor, like a LevoFed drip set up on a pump ready to go and hooked up to the patient, just not quite turned on yet, right? I'm doing all of these while his BiPAP is on. And then in the meantime, uh seeing how his presentation changes. And I'll make the decision to innovate while I'm working with all that. I think that some patients like this, wait until the last second to call us and then you're chasing your ass. Or some patients, it's like, OK, is the 89 % your normal, like even with being on an honor either? How many liters of oxygen are you on typically? Are you hypertensive because you're scared and you're freaking out and you're breathing super hard because you're worried? Is your pulse high because you're worried? Like what's going to happen once I give you certain medications? Is it going to dump your blood pressure? Um, you know, or assigning a patient like this, what is it going to do more harm than good? Um, do I need to try to coach them, put them on BiPAP, you know, maybe consider doing a duo NED or the sodium edger all. Um, my biggest pet peeve is when paramedics are like, I'm not going to give sodium edger all because it's not going to work with me. it's like, it's going to work, um, just a little bit down the road and it's okay to still give it. So, um, I think that giving this all you might draw would be smart. The other thing that gets me, these COPD patients are asthma patients. A lot of times they're like, well, I tried my inhaler and then I tried it again and I tried a Neb and then the speed ground EMS responding team is, I also gave a Neb. At what point do we realize like, this guy's got four Nebs, let's move on and do something different, you know? right? Yeah, mean, respiratory patients can be kind of scary too, you know, especially if like, they look like they're gonna die on you. And so you're like, breaking out trying to give them a ton of medications. And so you're like, safety caution is like, let me get this breathing treatment. Let me give another one. And I'm gonna give another one. Like just because you know, you're like, what else do you do? But yeah, there's plenty of different treatments for this patient. And I think that we kind of like laid them all out on what we would do. And then like the pros and cons too. Yeah, and separate from just the ventilator settings, which we can go all day with like obstructive pathologies and you know what you want to do with patients like this with COPD and how to optimize your ventilator, but already getting those meds on board. Hopefully we can kind of take some of that away. What I'm more almost more worried about these both these things have to work in concert, but I feel like we neglect the hemodynamics behind the situation. So really understanding what is blood pressure is doing, what is distal circulation is doing all that after we get him comfortable. So frequently stay on top of that blood pressure. one thing that I think is kind of controversial, kind of controversial, but anecdotally I've made work for myself in a way that I really wish I could teach more people is how to use SPO2 to your advantage. I don't mean the percentage number necessarily. If you have a good distal pleth with a good perfusion index, that little number at the bottom, no one's really like, I can't find an article or anything that really says what a normal perfusion index should be, but we all, but you know, anything above 0.5. one somewhere in there with a good pleth, tells me I have distal perfusion all the way to the finger. And it makes me more confident that I have perfusion all the way up to the brain. Now, whether or not that will stick much long-term is to be decided, but I almost use that as my poor man's invasive monitoring. So keep an eye on that as well, um not just for the percentage value, but just for an overall perfusion state. I think it's incredible. The other thing I do with that as well, check up blood sugar in the ear and then check distally in the finger. right, and see what the difference is. Your patient might be in a profound shock state just by catching that, because perfusion is not just oxygen, it's also glucose and some other things, right, too. So if you can get a full picture of that, you can see, is my patient, what type of hypoxia does my patient have? Are we actually oxygenating? Is it getting to the tissues? Yeah, anyway, um that's all I've got for the prompts and the, you know, the would you rather this bit and the innovations bit. If you guys kind of like more of this informal style less so outline bit, please let us know. um I enjoy doing this kind of thing. I think it leads to more discussion and less rigid talk. But another thing I'd like to do down the line is really start coming prepared with more studies to reference and whatnot too, and dive deep into the education or deeper than we've been doing. um Nicole, what do you got before we sign this off? I have been really, really wanting to do like a couple episodes series on things related to OB emergencies. I think that those are super beneficial because they're not something that we run all the time, but I really enjoy learning more about those because there's nothing scarier than getting an OB call or like, you know, you're going to deliver a premature baby or even a full term baby. But em there's a thousand different things that can go wrong with OB emergencies. So em I would like to do like a several part series on that. And then we've obviously had many conversations about doing different types of shock. So we really enjoy doing this. This is fun. This is kind of an obviously an informal one. We're kind of just like being annoying and talking to each other, but Jayden's not here. So we figured we would just jump on and give you something. So if you guys have something in mind, feel free to send us a message or We see lots of comments on Spotify and things like that. So we see those. And if you guys have any ideas, comment there as well. um But yeah, we hope you guys enjoy what we're putting out. And we appreciate all of the follows and likes and comments and shares on Instagram. Makes us feel pretty great. So thank you for the support again. Nicole, I'm hoping you can change my mind, but I would much rather have a semi messy crike than just fine life worth having not done either knock on wood, but maybe we can change that after this little bit. I'm going to let you take the lead on a lot of that stuff. I would probably prefer a live birth over a crike. There we go, finally one that we really didn't agree on. I'm telling you, if I'm cracking a patient, I am shitting a brick. I mean that like in the most confident way possible. Like I will be shitting a brick. I guess I'll do it, but don't judge my shaky hands before or afterwards. that is a perfect sound bite to end on. So with that, you all have a great week, month, whatever it is, and uh stay safe out there. We'll catch you next time.