Spiked Out
Welcome to the Spiked Out Podcast - your go-to for real stories, real people, and real insight from the wildland fire world. Brought to you by The Journeyman, we interview seasoned pros, share education, tips on getting certified, landing jobs, and making the most of the season. Whether you're already on the line or just getting started, we've got you covered. Tune in and get Spiked Out with us.
Spiked Out
Sick vs Not Sick: Decisions That Saves Lives in the Wilderness
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Two hours from the nearest hospital, “standard ER thinking” breaks fast. We’re joined by Dr. Miguel Pineda, an emergency physician and wilderness medicine fellowship trained doc, to talk about what actually matters when you’re doing EMS in austere environments like wildland fires, remote rescues, and rural transport corridors.
We get into the decision skill that drives everything else: telling sick vs not sick early. From there we talk field priorities that hold up when you might lose an airway, run out of supplies, or wait on a helicopter. Dr. Pineda explains what he hopes to see from EMS crews in the woods, why a clean and confident call-ahead report helps the ER move faster, and how limited-resource work (including solo coverage in a border community) changes the way you lead, communicate, and improvise.
Then we go practical on common fire line hazards: rattlesnake bites, scorpion stings, and venomous spider myths. You’ll hear what helps in the field (rings off, mark swelling with a time stamp, protect the limb) and what can seriously hurt patients (tourniquets, cutting, sucking venom, and other Hollywood fixes). We also talk anaphylaxis and why we’d rather you treat early with IM epinephrine than wait for a “perfect” picture, plus poison oak or poison ivy smoke exposure and how allergy meds and steroids can fit into a solid prehospital plan.
If you work wildland fire EMS, wilderness medicine, or prehospital care, this one is built for you. Subscribe, share this with a teammate, and leave a review with your biggest take-home from the conversation.
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0:00 The Reality Of Fireline Medicine
4:21 Small Town ER And Border Work
7:42 Sick Or Not Sick In The Woods
13:51 Improvised Ultrasound Gel In Heat
16:49 Snakebites Without The Hollywood Myths
25:55 Scorpions And Venomous Spider Truths
36:07 Anaphylaxis And Early Epinephrine
39:56 Poison Oak Smoke And Steroids
You bring up some really interesting points that I think a lot of people might be getting into wildland fire that might not understand the constraints that come with what we do out there. It's a different level of thinking. And I think a lot of if somebody is new listening to this or watching this needs to understand if you're coming from a city box, it is a very different place to practice medicine. When you're I think the closest hospital I've been to on the fire is probably two hours at the closest, right? Sometimes you're out there on the mountain and you gotta wait for a helicopter to come.
SPEAKER_03And it's just a it's a different scenario. We love hearing your guys somebody from the field like, hey, I think this is what's going on because it at least gives us a heads up to what to be prepared for. Now, you may get there and we may call you an idiot and be like, yeah, no, this is totally hyper terrible. But you know, we're really gonna say that to your face.
SPEAKER_00You know, that's that's that's really gonna make you a Spiked Out Podcast with the Brennan's and I, our new uh band name. But uh Brennan Holloway, Brennan Hill. Brennan Hill, will you take us away with the awesome guest you aligned for us today?
SPEAKER_02So this is uh Dr. Panetta, MD, correct? Not D O. Yeah, you tell those DOs right. So first name is Miguel. Uh would you like to just give us like a quick background as what you've been doing the past little bit?
SPEAKER_03Sure. Um, so my name is Miguel. I'm a ER doctor here in St. George. Uh I am uh uh ER trained by Residency University Arizona, Tucson from uh 2017 to 2020, and then did a one-year wilderness medicine fellowship at UC San Diego uh from 2020 to 2021. Uh practiced for about year and a half, two years down in Tucson and actually uh Nogalis, Arizona, kind of near the border of Mexico, and then been up here practicing in St. George in the ER for just shy of four years. Cool.
SPEAKER_00Uh so I'm gonna assume you're outdoorsy growing up, like going into uh wilderness medicine.
SPEAKER_03Uh yeah. So I'm from Ohio originally, so from the Midwest. So did a fair amount of outdoors just as far as hiking, shooting. Um, did not do all the canyoneering that me and Brendan do now. So got into rock climbing and canyoneering and all that stuff afterwards. And then Southern Arizona is kind of like here, it's uh mecca for all your outdoor stuff. So basically did all your outdoor hobbies once I kind of moved out there. Cool.
SPEAKER_02Well, I think you got a number of other hobbies, right? I mean, you're just got done wingsuiting this past weekend, or was that two weeks ago?
SPEAKER_03Uh just uh what was that, just last weekend? No, so I've had my skydiving license since 2013. Um, so I've got just shy of uh actually, no, just got over 300 jumps uh just last weekend. So I have about 300 uh solo jumps and then now have about 30, 35 wingsuit jumps. So I have no idea about any of that. It's basically feels like flying squirrel. Yeah, none of the none of the base jump stuff, so still get to jump out of a plane. So I'm not skimming mountainsides or any of that. So I'm not that cool. Yeah, not that cool yet, uh, you know, but at least get to uh fly in a wingsuit. So I actually get to I get like flying squirrel kind of horizontal travel um and basically actually uh get to basically fly in formation a little bit. So not as cool as kind of some of your blue angels pilots or anything, but like in my little baby version of it, so it's cool.
SPEAKER_02It's impressive. How many uh because you wingsuit with your brother? How many jumps does he have underneath his belt now?
SPEAKER_03Oh geez, he's got uh like well over 500 jumps. Um, and so I think he's got like 200 wingsuit jumps, so that's his like main jam. So got you into it. Uh we actually both started at the same time, and then he just got a lot better than me and and excelled a lot quicker.
SPEAKER_02That's awesome. Because how long have you been here in St. George? You've lived here for four or five years?
SPEAKER_03Just shy of four years. So yeah, so been up here since then. Came up here part-time while I was finishing up my Nogales contract. So I was actually coming up here like one week a month and working full time at the same time in Nogales for like six, seven months. Oh, that's pretty cool. And then finally got to move up here full time and start up here. So yeah, dig it a lot more up here. Yeah.
SPEAKER_02How is your experience uh working as a doc in the ER down here in St.
SPEAKER_03George? Uh it's awesome. So we got good EMS crew, we got good uh good nursing crew, good like trauma surgeon crew. Basically, all our specialists are awesome. It's very weird working in an area where you can call like a specialist, a trauma surgeon, uh, ENT at like 2 a.m. in the morning and they don't cuss you out over the phone and slam the phone on you. So it's uh everyone here is like friendly, everyone does a great job. It's an awesome community. Um, and then the population and people here are super nice. So when they come in, they're actually like thankful to get care. So uh a very minority of meth heads that try to bite you as you're taking care of them, which is you know not the norm for other areas of the country.
SPEAKER_04Yeah.
SPEAKER_02That's too funny because uh I we talked to quite a bit about some of your experiences in no gallus. Uh how long were you there again?
SPEAKER_03Uh I was in no gallus for just around eight or nine months. And uh yeah, that was uh that was an eye-opening experience because you're kind of at the end of the world. So it's the last basically no gallas, Arizona is last uh freeway stop before you go over the border to Mexico. Um, you're two hours from the nearest new uh other hospital, which is up in Tucson. Um, and then you're also the main stopping point for both border control uh border patrol for anybody that they uh catch coming over the border, anybody that gets injured trying to come over the border. And then also, at least at the time frame I was there, we would get Mexican nationals that would come across the border because legally you could come up seeking higher level medical care. So I think I've told several stories about, you know, Mexican ambulancia that just shows up at 2 a.m., no warning in your ambulance bay at 3 a.m. and they have like crazy sick baby or grandma with a brain bleed or what have you. Or you get family that even just takes them out of the hospital and drives them across the border and shows up with somebody that's on death's door. So and then uh yeah, once again, two hours, uh uh two hours ground travel to the nearest major hospital and pretty much a freestanding ED. So it was excellent training. The staff down there was amazing, but yeah, you took care of some crazy stuff. Yeah.
SPEAKER_02And you were a single, the the single provider down there.
SPEAKER_03Yeah, you were a single provider. Um you had an APP or basically a uh nurse practitioner or PA uh for some of the day shift working hours, but for overnight you were solo. So you would uh basically you, two nurses, a respiratory therapist, and uh medic that were trying to stabilize some pretty crazy and sick stuff. So it was uh basically small crew, so you got really tight and got to learn a bunch.
SPEAKER_02That's cool. I mean, what are some of the lessons you took away from there that you feel you still apply in your regular practice?
SPEAKER_03Uh basically like your level of tolerance for somebody that's sick. Uh got really, really comfortable with taking care of insanely sick people and basically uh being able to just kind of manage uh under pressure and being able to use what limited resources you have at your disposal to uh to take care of somebody. So got really good one at being able to help organize a crew of people, and then two, got really good at comfortable at not being your uh stereotype, you know, uh a better than everybody else doctor, like, oh no, I can do things, I can I can move bed sheets, I can throw stuff off to the side, I can clean up poop, like I'm not above that kind of thing.
SPEAKER_02Might be a first I've heard anyhow. No, that's really interesting. Uh well, as background, right? So I have my own little side gig going on during the summers, um, and you've come in as our medical director, and we've we've talked in depth kind of about what capabilities we kind of want our paramedics to have. Um, from your standpoint as the medical director, what would you hope that your EMS personnel are doing out in again, this is an austere environment on a wildland fire? Uh, what would your hope be that they all understand and apply while they're performing medicine in the woods?
SPEAKER_03Uh I I think the biggest thing would be almost more concept than actual skill. And what I mean by that is like being able to understand the big thing they teach ER doctors, like day one of residency, is learn the difference between sick and not sick. Learn the difference between, hey, this is somebody with a bellyache, or hey, this is somebody that, you know, injured an ankle, but otherwise they're okay, versus, hey, this is somebody that's telling me they're fine, and they've got, you know, a couple hours before they're on death's door. And so being able to kind of differentiate and tell the difference between that. Um, so I say that's the biggest one that I'd want the medics to be able to take care of in the field is to kind of almost see the writing on the wall of like, hey, this person's gonna be fine, I got time to work versus hey, this person is either not looking good or gonna not look good here in a short window, and I gotta kind of get ahead of the ball.
SPEAKER_02Yeah.
SPEAKER_03Um, I think as far as skill-wise, biggest thing I'd be is hey, just trying to stabilize until uh for the sick ones that do need to get out, being able to stabilize somebody until I can get them to a hospital or get them to a specialist or whatever they would need. Um, and so I mean by that is hey, this you know, broke a leg, but this is not something that I need to make the prettiest splint of all time. I just need to get this bone from wiggling around until I can get them comfortable. Or hey, this is somebody that, you know, I don't necessarily need to get a bunch of blood transfused into them, but let me at least get an IV on it, at least get their fluids so that their blood pressure is not tanking. Or even hopefully don't have to run into this of, hey, this person's not breathing super good, let me get their oxygen up. And worst case scenario, let me get some kind of airway. Doesn't have to be an ET2, but you know, let me get some sort of king airway, LMA, whatever, into them in a short term. And once again, hopefully you guys never have to deal with that kind of situation uh out in the wilderness. But yeah, it would be one of those as far as like, hey, you don't have to get the prettiest looking everything perfectly lined up, just got to get them stable so that way we can uh kind of get them to, you know, to a hospital, to a uh to a surgeon, an ER doc, to a you know, ICU, whatever.
SPEAKER_01So before you were the medical director for Red Desert, what was your exposure to wildman fire or EMS? How do you kind of mess around with it through that wilderness medicine course you went to or uh so a little bit, yeah.
SPEAKER_03So I did one year of uh just wilderness medicine training, and a lot of it was just kind of training, hey, this is how to practice in different kinds of environments in the desert and the tundra out at ocean, um, and kind of what kind of injuries to expect. But I had the benefit of uh when I was out at UCSD, my uh program director, she was the medical director for San Diego uh mountain rescue team, so their SAR there. Okay. So I got to do their uh field trainings with them, got to do some of their medical education with them, and got to actually go out and work with the team and kind of see what their training level was and what they worked with. Now, nothing as advanced as what Brennan's crew is dealing with, because a lot of these people were not necessarily medically trained. They were engineers by trade, IT guys by trade, but still able to at least see, hey, this is what the rescues look like, this is what the extrications, actually be able to get hands on a litter and feel what it's like to carry somebody out and do a minimal amount comparable to what you guys do of high angle rescue stuff. So uh got some exposure to it from that standpoint, at least enough to know, okay, this is what the calls are looking like, and this is what the actual field work is looking like. Nice. Uh, because I think you see a lot of that from people in the hospital uh that are not exposed to that, that they get pissed off at, you know, the field teams. Why is this patient not packaged better? Why didn't you take care of XYZ? Why is there dirt all over my trauma bay? And it's like you guys have not seen what's going on out in the field and amount of things that you guys have to deal with. So luckily had that exposure, at least as an eye-opener, uh, for what's going on. Now, clearly very different from being out with you guys in the field and doing, you know, a 48-hour extrication on a sick dude, but uh at least enough to be like, all right, I have an inkling of what you guys have to deal with, enough to have some uh respect for it. Super cool.
SPEAKER_02Yeah. That's funny because you said, you know, they get upset about dirt. I don't think I've ever had a nurse yell at me six years of this, ever. Just kidding. No, I think it's like you bring up some really interesting points that I think a lot of people might be getting into wildland fire that might not understand the constraints that come with what we do out there. You know, you're talking about like, hey, this doesn't have to be an ET tube. Because a lot of city medics are coming from systems where they're running ALS calls constantly. And that's their go-to. It's like, hey, I'm gonna take this airway, no problem. I've I've innovated from yeah, yeah, but you're you're 10, 15 minutes out, and you don't have to move a patient in a schedule or what what happens if you lose that tube? Like, has that happened to you before? Are you prepared for if that scenario occurs? What's what's gonna be your next steps? Um, it's it's a different level of thinking. And I think a lot of if somebody is new listening to this or watching this, needs to understand if you're coming from a city box, it is a very different place to practice medicine when you're I think the closest hospital I've been to on a fire is probably two hours at the closest, right? Sometimes you're out there on the mountain and you gotta wait for a helicopter to come. And it's just a it's a different scenario. And unfortunately, a lot of the leadership on fire are structured firemen that have spent 20 years as a paramedic and they're like, you need to innovate this guy. You're like, I'd prefer not to. And then there's this power struggle between you as the provider at that point and them and as your leadership trying to get you to do a certain intervention when that might not necessarily be the answer. So we'll see. Because I know uh you were talking to me a little bit ago that you had published uh a couple of papers uh wilderness related, right? What were those again?
SPEAKER_03Uh so unfortunately pretty wimpy stuff compared to what you guys do. See, I published some papers on on ultrasound gel uh and what we can use in the austere environment. Uh because you get to some of your rural areas, like you get to Africa and you get to uh some of your areas in South America, they don't, you know, they'll have a hospital, but they don't have an X-ray machine. They don't have got but they don't have no CT scanner, they have an ultrasound, you know, just a butterfly or something like that. And one of the issues that they'll run into is like, all right, I got this device, I can use it till the batteries burn out, but I don't have anything to actually conduct this with, or they have ultrasound gel. That stuff is not going to stay good in a 120-degree environment for a week at a time. So basically, uh, what uh one of the residents that's now uh attending doctor out at UCSD and uh my program director were basically to uh came up with a state of like, all right, what's kind of like powders and thickening agents and food stuff that they have in these environments that they can mix up to be able to actually use uh for these kind of things. So was honey one of them?
SPEAKER_00Yeah, was it what was honey one of them?
SPEAKER_03Honey didn't stay very well and it sticks too darn much. No, so they ended up ended up using like uh what was it? Uh Manitin, uh guava uh powder, and basically a bunch of other actual like food powders that you get at a store or get it at out at a marketplace uh and be able to like mix that with water and found some of them did not stay well, some of them uh went a little yeasty and for got pretty smelly after a short period of time and just didn't work. Uh so it was like basically testing these out to be like, all right, if you're working for several months out at an African hospital and you're running out of ultrasound gel and you know you're having to ship in food and fluids for people, you probably don't want to have to ask them to ship in actual ultrasound gel too. Oh that's cool. I was gonna say jokes on you.
SPEAKER_02I'm actually like one of nerd out on this.
SPEAKER_01What were you looking for with those different things you were testing out? Obviously, it adhesion to the skin or the device too sticky.
SPEAKER_03A lot of them was just how well it actually like conducted it. So because you'll get some stuff where it's like just too liquidy, and you like go to put the ultrasound probe to the skin, like just benefits you not whatsoever. Um, and some of them was how well they stayed, like, hey, how how quickly did this get smelly? How quickly did this break down into water? Um, and then some of it was, you know, uh we test in different environments too. So we actually had like some cold, uh cold testing environments, some hot environments, some humid environments, just for since it was austere medicine, yeah, to see what could hold up in different areas of the world. So did you find like an actual like really good substitute for uh all all of it smelled, all of it went pretty bad, but we did find a lot of them where it's like it's it works mostly, you know. So enough that if like, hey, you're out here for months, like this will do. Oh, that's cool, man. Did you do one with snake bites too? I feel like we might have talked about that. Uh haven't published any um uh any major papers. The snake bite data that we uh that we did. So this was actually when I was in uh residency down in Tucson, Arizona. So they have a crazy cool toxicology center and uh poison control center there in uh Tucson. And uh it's like run by the University of Arizona people and all their toxicology people, and basically they take all the calls for rattlesnake bites for the entire state other than Phoenix County. Phoenix does their own jam, they cover the uh all the calls for all the rattlesnake bites for the rest of the entire state, and the amount of bites that you see down in that state compared to up here in Utah is insane because we'll get two to three bites a week over the summer over main time. Wow. Um, and a lot of it is like, hey, this is what to expect. Um, do you have anti venom like at your actual hospital site? What um, you know, how many vials do we need to get into this person, and also seeing, hey, how long, how many days this person needs to stay in the ICU for it. And then part of what we actually did with the paper was try to see what were like the heat windows for when snake bites were the worst. Is it like right after rains, is it when it's hot, is it when it's cold? Time of day. Yeah. And what we ended up finding is that basically winter and the heat of the summer, no bites because or at least minimal bites because snakes aren't out. Don't don't like those temperatures. Late spring into uh and and into the um or early fall is when you get like the major takeoffs. It's like the prime time temperatures. One, that the snakes are out, and two, that people are out hiking. Because the old adage they always used to tell you is was it uh teeth tattoos and uh t-shirts was like where you get the bites. So basically, you're toothless guys with lots of tattoos all over their face and and going out in like sleeveless t-shirt and trying to grab snakes. And that always used to be the joke what they taught was actually people believed. Ended up being not it's all people that are hiking, gardening, all these kind of things that are like minding their own business, and then just hey, get in the wrong place, wrong time, and get bit.
SPEAKER_02So I mean we see them all the time on fire.
SPEAKER_00Like, I mean, I've I was gonna start in water on fire. Yeah.
SPEAKER_01Oh, no, I know they happen, obviously. Like you look at the environment now. Yeah, I've seen like four of them killed. Really? Well, I thought you mentioned the actuals like patient. Oh, no, no, no. Make sure you see all the time. And I'm sure most people are like aware and cognizant of that danger out there. But yeah, it's an interesting thought to think it's if someone, you know, digging, dig in line and they just reach down to you know, clear a branch or brush and get tagged. Oh, yeah. What you do out there.
SPEAKER_03And it's one of those things like because that's wasn't covered so much in like the paper that we did, but as far as like the actual like lectures that I give about it, is like it's a don't panic kind of situation. You know, you get your you get over into Africa and Southeast Asia, you get your mambas and your cobras. Yeah, those things like that's a panic paralyze you. Yeah, you got a countdown window before you stop breathing that you got to get to a hospital. Big things with the rattlesnakes is it's just basically just thins your blood. It causes lots of swelling, lots of bruising, thins your blood, and you got a big time window to get somebody into the hospital. So it's still something where it's like, yeah, you want to get to the hospital in 24 hours and get some anti-venom started, but it's not like where you get like, oh my god, I'm gonna stop breathing or anything like that. It's like call the helicopter, get them in, don't freak out. And then you always get the people that are trying all the crazy techniques. You know, they put the tourniquet up, they're trying to cut the bite wound and suck out the venom like an old western. There's even unfortunately a lot of people like to suck out, right? There's a couple case reports of like people that tried to hook up car batteries to themselves because they thought that the electricity would break down the snake venom, and then they just end up in the hospital because now they're an electrocution victim.
SPEAKER_04Sound logic.
SPEAKER_03I love it, but yeah. That's always the big thing that I used to go over with the SAR guys when I worked with them is like, hey, you get bit, still call, still get them out of the field, don't freak out. Like, yeah, it's not something that we need to put a tourniquet and start trying to, you know, carry them overhead kind of thing. It's like, yeah, you probably need the helicopter if it's gonna be, you know, a ridiculously long extrication, but don't lose your cool.
SPEAKER_02Yeah. Because I mean, I've been through some woofer classes, and you know, they teach us like, I mean, we even got into like Australian tourniquets where you're wrapping the entire limb. Um, but I guess for like our guys on a fire, do you just want to give like a couple of tidbits in terms of interventions that you would be like stoked to see as an ER provider with a guy coming in with a bite?
SPEAKER_03With a bite, yeah, absolutely. Uh a couple of the biggest things. One, if it's on a hand, get the rings off. They got their wedding ring, they got anything else, that hand's gonna swell. And now you're gonna have an issue where that ring is gonna start turning into a tourniquet on the finger. So get the ring off, get the watch off. Second thing that we like to see is if they've got any swelling that's developing, get out the skin marker, mark out kind of line of where the swelling is, and put a time next to it. Like put a time and date next to it instead of just like marking, because then we have no time when uh idea when it started. Those are a couple of the biggest things. Uh, other things is in general, just try to keep the limb from getting beat up. Basically, all that snake venom does is it causes that tissue to start bruising and bleeding really easy. So it's super tender. So basically, hey, if it's a foot, try to get them off the foot. Have them limp, have them hop. You know, you can get a uh uh you can get a little splint on it if they're super uncomfortable or if it's a hand, just like get a little sling on it just so it has a little bit of pressure off of it, just so they're not repetitively using it and beating the thing up. Beyond that, not too much that you really want to do for them. Definitely no tourniquets on the arm. Definitely don't try to be cutting up the arm. Uh, and uh uh yeah, don't don't do any of the crazy techniques on it. Pretty much treat it, treat it like almost like a broken limb where it's like this thing is beat up and bruised. Let's mark out, see where everything started, get anything that could be constricting off of it, and then start calling to get them out of the field.
SPEAKER_00Are they generally pretty painful people that get bit?
SPEAKER_03It depends. Yeah, uh it depends on your pain tolerance. Yeah. I I had uh uh I had one of my uh attending bosses when I was in residency that was just got bit on the foot, and I think it wasn't until like hour 10 that he was like, yeah, I I'll take an oxycodone now, as opposed to just like I'll take a Tylenol. Um but you'll get people that'll come in wailing in pain that are more so freaked out than anything else. Yeah. Um, but it's not necessarily like you'll get your scorpion stings, and those uh those can hurt like hell. Uh but your yeah, your your rattlesnake bites are uh most of the time it's like, yeah, it feels maybe like you bruised something, like you strained something, or like you broke a bone more so.
SPEAKER_01Is there any maybe later signs and symptoms that you could look out for? Because uh there there are members that are a part of a crew where they get injured or hurt and they don't want to say anything because then the rest of their buddies got to go home or something like that. And so if it's not as painful, I could see some of these guys getting tagged and maybe not saying anything.
SPEAKER_03Or not saying anything, yes. There it there are sometimes you do have dry bites. Um I mean by that, a snake bites, but no actual venom goes in. It's not something you really want to call because you don't always have the swelling that shows up at the site. And when we get them in the hospital, we actually in the ER, even if we think it's a dry bite and there's no swelling, we watch them for at least six hours because we're checking their basically blood clotting factors. Okay. So basically it damages all your platelets, so your stuff that actually makes clots and your stuff that actually makes scabs. And so we'll watch them and get repeat labs over a period of like six hours to see if any of that goes on. Now, the issue with the guys that try to do that in the field is you may not know that that's going on, and now you may start developing some bleeding on one of your organs, you know, your kidneys, your lung, or anything like that. Uh, you run the big risk for anybody that's on you know, baby aspirin or on a actual blood thinner on a regular basis, which you're not gonna get too many guys like that in the field, but it is something just to be aware of.
SPEAKER_01Some people take um, you know, blood thinners just, you know, they get a headache and they see um uh, you know, a little packet of whatever laying around and they'll take it because they think it's gonna make it feel better, you know.
SPEAKER_03Yeah, it's it's one of those the aspirin isn't, you know, aspirin will make it a little bit worse, but you've got your people that are on your like your actual blood thinners for like blood clots, you get your eloquence, your cuminin, things like that. Those are the people you can actually get like spontaneous, just like blanket bleeds and things. So it is definitely something where it's like even if you think it's a dry bite, like you kind of don't wanna don't want to risk it. If you want to watch it for like an hour and see if you get any like swelling in the air and you're like, damn, I don't really think it was uh don't really think it was a rattlesnake, like I didn't see a rattler, it looked like a little tiny guy and probably okay. Uh I mean you can run that up to yourself, True, if you want to run that risk, but yeah, you're gonna do that. Yeah, it's one of those where it's like usually the unless you're like, hey, dead steady for sure. This was the little gardener snake, the thing was green, had no rattle, and was like a foot long. Unless you're running kind of that situation, you usually want to err on the side of caution, at least get them to the hospital, get them checked out.
SPEAKER_02Definitely.
SPEAKER_03Because it could be something where it's like, hey, you get all their blood labs back, never get any swelling, it's a dry bite, and you get them back to the field like the same day or next day.
SPEAKER_00So with scorpions being really painful, is there a good pain management approach? Like no. No.
SPEAKER_03Like on the t-shirt. Oh, yeah. When we get them, uh when we get the adults in the hospital, a lot of times we're just given like regular, regular pain medicines. Occasionally we're bumping up the anita like oxycodone, or occasionally they'll start getting the real bad muscle spasms, and we'll actually give them uh basically like pill form, like stronger form of Xanax, like a Valium or something along those lines to help out with it. Uh, pretty rarely on the adults do we ever have to do any of the scorpion any venom that's pretty much safe for little kids because on adults it's gonna hurt, it's gonna wear off in a day or so, or it's gonna get like numb on the limb, but it's gonna wear off on a day. Uh only issues we run into with the scorpion stings, which is like that you guys shouldn't be having too much in the field, is the little kid stings. And with those, you get the crazy basic, like foaming at the mouth, starts blocking off their airway, can kind of cause almost like seizure activity, so it can get pretty scary with kids. Those are the ones that's like, yeah, you get them to the hospital ASAP and get the anti-venom into them. Uh but with the adults, I think we've had like two cases over the years that we've given anti-venom, and it's one of those where it's like, uh, I should write a paper about that.
SPEAKER_02That's weird. Well, we've got a lot of Arizona bark scorpions down here.
SPEAKER_03Oh, yeah.
SPEAKER_02Um in fact, funny story, Standhall, or not Sandhall of uh Snow Canyon. Tyler was out here, what, like, I mean, four years ago. Me and Tyler run around barefoot on the dunes, just having the time of our lives, jumping in the sand. And then I took my kids out scorpion hunting like a year later, and I was out there and I was like, oh, they're everywhere. I'm like so stoked. We didn't get there with the black black black big light or whatever. Yeah, the black lights like a little bit dark, right? But uh, I mean, yeah, how many cases are you guys actually treating on the day-to-day down here for scorpion stings?
SPEAKER_03We'll get maybe one every two, three days. Um, and most of the time that's adults. Like an actual kid sting, that's usually like one every month or so. Wow. Um now we did now during like the high frequency periods over the summer, we can get like one or two uh a week. Um sometimes the kids don't get that bad of a sting. They just don't get a big enough dose of venom, we don't have to give the anti-venom to them. Um, but we do have, I think it was like two cases last summer, um, and one case already uh this year that were like pretty bad stings that we had to give the anti-venom wasn't working quick enough and did have to like put in temporary breathing tubes. So it is something that can happen.
SPEAKER_02Yeah. So I mean, is that something that an EMS provider can kind of activate beforehand?
SPEAKER_03No, for sure. Yeah, if it's something where it's like you've got either saw that it was a sting or you've just got high suspicion that it was a sting, definitely it's awesome for us to hear. So it's like so just to just to like give a summary, like we love hearing your guys' summary from the fields, like, hey, I think this is what's going on, because it at least gives up us a heads up for what to be prepared for. Um, because in that kind of case, like, hey, we can have the anti-venom like up and kind of ready to go, or if we get there and see, like, yeah, this looks like now we can be ready to mix it and have it go, you know, in a minute or two, as opposed to like a big 20-minute window for you know the nurse and doc to evaluate them, draw our own conclusions, and then another 20 minute, 30 minutes to get the med ready, as opposed to like a two-minute window. So like we actually like hearing your guys' uh like summaries or or suspicions from the field. Now, you may get there and we may call you an idiot and be like, yeah, I know this is totally 100% wrong. But yeah, we're rarely going to say that to your face. You know, that's that's a beat behind closed doors kind of thing.
SPEAKER_02But uh because my question is, is like, do are you guys keeping the anti-venom there in the ER or do they have to get it from somewhere else?
SPEAKER_03So we have it in our central pharmacy. And we actually had our recent case where talking with our ER pharmacist, we may start carrying it in the ER to kind of decrease that window of trying to get it up from the central pharmacy, but we do have it in the hospital available. Same with the uh snake anti-venom, like we have those there in the hospital available. You'll get to some of your more rural hospitals and they won't always have it. So it is something that if you guys suspect it and say for whatever reason you're in a more you're in a different area in St. George or isn't your closest hospital or whatever isn't your close hospital, it's awesome that you guys call ahead because either one, they may redirect transport to take you to a different hospital and be like, hey, this one doesn't have the anti-venom, but this other one does. So we're gonna divert you to this one. Or two, they may say, hey, it's gonna be a long extrication, say it's a you know, snake bite in the field for one of your guys, be like, hey, we'll still take them to this hospital, but we're actually gonna start transporting the anti-venom to that hospital to have it ready. Love it. Yeah. So the fact that when you guys have those suspicions and you guys call ahead is great because it starts mobilizing us and gets us ready. It's similar to when you guys call ahead for trauma, is that we're like, all right, we got the team ready to go, we've got blood product ready to go. Um, as opposed to you get there and now we're scrambling to try to get things together. Definitely. Yeah, when you guys call ahead makes a big difference. Now, with the uh with the scorpion anti-venom, yeah, with you guys calling ahead and getting them in from the field, especially if you have suspicion, like, hey, this is a little kid, they're starting to look not right. Um, we can kind of help direct you, like, hey, these are the meds to get ready in the field, and this is what to start treating them with.
SPEAKER_02Yeah. I like it. You know, that's like one of the most common things we treat out on the line, actually, is like insect bites, insect stings. I mean, we had one guy, he was following, it was an organ uh following a dozer, just acting as a ground guide. Dozer ran over like a ground nest of some flying stinging insect. I don't know what it was. This guy got tagged like 12 times, like just welts everywhere. I was like, oh my gosh. So I'm pulling out of my kit, you know, those sting prep pads, like making like the sting go away. I'm like, I'm sorry, dude. But I was like pretty concerned in the sense of like, I don't know, like, are you allergic? Like, are you not? Obviously, he's like, no, I'm not, but I'm like, I still want to keep an eye on you, man, because I don't know how you're gonna react to like this dose of whatever bug just stung you.
SPEAKER_03I was gonna say, I think it's over 20 on anybody. You start any 20 stings on any person, you start running the risk, you can start get uh anaphylactic reaction. So it's one of those at least keep an eye on it. For sure. Even if it's not like happening right away. Yeah, that's great to know.
SPEAKER_02Well, well, tell me what you know about spiders. We get guys on the ground sleeping. Yeah.
SPEAKER_03Yeah. Yeah. So the the only two main like genuinely venomous spiders that we have in the United States that we get concerned about are your black widows and your brown recluses. Benefit to both of them, neither of them are deadly. Um, so neither one's actually gonna kill you. So nothing you need to freak out from either standpoint. Uh your brown recluses, those ones that you like get the internet videos with your giant black hole, like the chronic to the tissue. Yeah. Uh that's gonna take like a week to develop. And at the end of the day, and this sucks to say there's no specific treatment for it. There's no anti-venom, there's no anything. Basically, we treat it just like any other wound. Now, the benefit we have to be in here, the brown recluses that are two benefits. One, the brown recluses that we have here don't have that kind of venom. You find only like that crazy tissue eating venom is like in Arkansas, Tennessee. For whatever reason, spiders just have a different diet here, so their venom is different. You'll get definitely some wounds, you can get some red and swelling, but it's not gonna like the scary Google videos or Google photos that you pull up, like that's almost all those photos are coming out of the Midwest of the country. Dang. So don't really have to worry about that. Second thing, they're called brown recluse for a reason. They're usually pretty timid things. Like you gotta piss them off before they bite you. Uh now, the issue is they look super duper similar to hobo spiders. Um, and hobo spiders are uh aggressive little bastards. So they're they're the ones that are actually coming out like actively pursuing you and trying to bite you. Now, the good thing is their venom hurts, doesn't really do any damage. So don't have to be worried about it from that standpoint. Second class of spiders is your black widows. Now, those are the ones that are going to make you feel like you want to die, uh, because their venom actually makes all your muscles start locking ups, like severe muscle cramping and pain to the point where you almost look like you got tetanus, like everything's locked up, hurts like absolute heck.
SPEAKER_01Black and brown recluse?
SPEAKER_03Uh no, so this is the black widows, sorry. Or not not recluse. Uh yeah. Don't get it quite so much with the brown, uh, with the brown widows, more so with the black widows. Um, those ones you won't have to worry whether it's the spider, you know, or not, you're gonna feel it, you know. So if it didn't actually give you a uh a decent load of venom, like you won't have to worry that I need to get anything. They do make an anti-venom, and I think that's one of the only actual recorded deaths from black widow bite was from the anti-venom because they had an allergic reaction to it. Yeah. So yeah, the the anti-venom that's I don't think we carry it here. I think they carry it in some regions of the country, but it's really rarely given. Most of the time, we're getting people's pain medicines, we're getting them like heavy-duty muscle relaxants, like Valium or something along those lines. Um, occasionally, if like their muscles on their stomach are locking up so much that they can't stop puking, we have to keep them in the hospital overnight. But that's a pretty rare minority of the cases. Most of the time we're getting them some meds, being like, hey, it's gonna suck for about a day, then it's gonna wear off, and then getting them home. So neither of them do you have to be freaked out about getting bit on the field. Now, both of them are gonna hurt, you're getting bit by something, um, but nothing that you would necessarily have to be extracted from the field for it. Nice.
SPEAKER_02That's good to know. I mean, we had a guy last year that had a pretty good spider bite on his hand, and you know, again, he's beating it up because he's got a hand tool and he's just like repeatedly hitting the ground with that hand, and it was it was it looked angry. Good amount of uh edema going on, redness, uh super painful. It was their last day on the line, so I was like, yeah, dude, just let's get you out of here. There's no point in making you suffer for the rest of the shift. Um, but I mean, is there anything in in terms of like outside of infection that we should keep an eye on that we should be worried about with spider bites in the field as well? Yeah, not too much really.
SPEAKER_03It's basically like, hey, has it gotten swell enough that it's gonna start getting infected? Um their fangs aren't big enough that they're gonna leave enough of like an actual bit of their fang in there to cause an infection, so nothing that would need a surgery. And short of them having either an allergic reaction to the venom or developing like a cellulitis or skin infection from the venom, nothing that we would do specific or any different in the hospital. Cool. Really good to know.
SPEAKER_00On allergic reactions, uh, we were talking at a training with our medical directors recently, and I'd love to hammer home the point of on anaphylaxis treating early and aggressively, because I think a lot of EMTs and paramedics are kind of gun shy about giving epi. They just think you're gonna put them in a cardiac arrest or something.
SPEAKER_03Yeah, you're not gonna do that with uh epi pen or an epi shot into the muscle, you know, if you're starting an IV line on them and giving epic way like you shouldn't be doing it. Yeah, yeah, now you're screwed and now you're like, yeah, you really messed up then. Yeah. But yeah, as far as doing an epi shot, that's something that there's different practice styles for the doctors and the ER, but I definitely have a very low threshold for giving people an epi shot, um, simply because it's like I can't tell how long until this starts to lock up, because sometimes can progress rather quick. So usually kind of my threshold for allergic reactions is if the person feels like their throat's starting to tighten up or their tongue's starting to swell, anything that's kind of concerning on their airway, just go ahead and give the epi shot. Doesn't mean that you have to transport them to the hospital, doesn't mean that you have to do any of that crazy stuff. Because after the epi shot basically makes their body start producing uh natural, uh natural internal steroids. So basically it's you almost stimulate your body to start producing your natural response to fighting off the allergic reaction.
SPEAKER_00It's weird how subtle it can be sometimes too, because sometimes it's just uh GI upset and the soft blood pressure, maybe, and that's anaphylaxis, but you're thinking it's something else.
SPEAKER_03Yeah. And so it it can it doesn't always have to be like your stereotype, like, oh, I think it's these organ systems. If it's hey, I'm potentially having an allergic reaction or two something, medication, a bite, whatever, and it's hitting two organ systems, you know, even if it's stomach, low blood pressure, uh, even if it's hives and like, hey, my lungs feel kind of tight, that qualifies for anaphylaxis. So go ahead and do full treatment.
SPEAKER_00Yeah, any two symptoms, hives and airway and GI and uh one thing our medical director said I thought was really cool is like because some new EMTs maybe never given an IB or not IV, IM push before.
SPEAKER_02IV one to one, baby. Super sick on this trouble.
SPEAKER_00Yeah, they might be nervous, and she's like, don't be nervous. If you're gonna be wrong, be wrong on the high side. Like the protocol's 0.5. But if you're not sure, it's okay to be 0.7891 even.
SPEAKER_03So and it's it's nothing you're gonna send somebody into uh you know into cardiac arrest from. At most, their heart's gonna be racing for a little while and it's gonna wear off.
SPEAKER_04Yeah.
SPEAKER_03Um, you know, short of the person already being in, you know, AFib to start or already have an abnormal rhythm to start and throwing them a little bit extra. And even then, it's not gonna send them to cardiac arrest. It's gonna make them feel uncomfortable.
SPEAKER_00One of our medics chimed in and was talking about how maybe it was his first experience with anaphylaxis, and he was the same thing, nervous, called medical control. He's like, I think he has a little arrhythmia going on, so he's nervous about the epi, and the doctor just told him, Well, his arrhythmia is gonna be a systole if you don't push the epic.
SPEAKER_02That's gonna change. What's worse? What do you want to do with? I like it, dude. I like it a lot.
SPEAKER_00I mean, what are some of the things that you guys have seen on the line that I mean I've seen bee stings to the face, mouth, lips for sure. They didn't progress. Yeah, they didn't uh end up progressing, even on the tongue. So you're like obviously watching that person, you're not going back to work.
SPEAKER_01Kind of saw on the devil's knob with some airway and some swelling things was inhalation of poison oak. Like, because they were in a heavy poison, ivy poison oak and they were doing burns, but then they were inhaling it. And so they felt, yeah, they they were obviously busted out in hives all over their gloves, you know, where it was exposed, but they a couple of them were having like, oh, it feels itchier, it's had a little bit of difficulty breathing. I didn't know if like the oil from the poison oak burning inhalation-wise could do anything.
SPEAKER_03Yeah, it actually does that. So if you already have like an allergy to it, or you're more prone to it, or even if you're not, sometimes if you're getting enough, yeah, burning poison oak, burning poison ivy, poison sumac, all that stuff. It's uh was it aruchiol oil is the allergen that's in there. So yeah, burning it and inhaling it both can cause swelling to the face, the tongue, the mouth. Uh, but yeah, you can get a bit of that allergen into the lungs as well. Won't necessarily cause the lungs to like swell, but it will cause almost like a bronchitis kind of reaction. So it definitely can cause them to feel kind of short of breath and can cause that kind of swelling. I wonder how that oil would do in a vape pen. I could see some guy on the bottom.
SPEAKER_02Probably squeezing it out of the leaf and get her rip for this.
SPEAKER_01Yeah, I think I just gave him a neb and he felt better afterwards. But I it, you know, I was newer at the time, so I didn't quite know. But yeah. Any treatment or specific things with it that you could do to make it better?
SPEAKER_03Like, it's most of the time it's uh it's kind of all your allergy treatment, like your your benadryl, your neb, sometimes your epi. Now, our our body, our adrenal glands naturally make our own internal steroids that are start combating that. That's why if you start getting like a mild allergic reaction, eventually your body will take over. And it's just trying to prevent that kind of danger window until your body does start to take over. Um but yeah, like I said, I think you guys carry Benadryl in the field. I know you carry epi, you know you carry nebs. Do you guys carry any like steroids, any like solumed drugs and other decks? Perfect. I'm a huge fan of DEX and those kind of cases. Um, and you guys can give, so I do a lot of times just the liquid dose orally if it's somebody that can swallow and they don't want you to give them a shot of anything. Um and most of the time, even if it's just most of the time, we'll start with like 10 milligrams on a full-grown adult, and that's enough to kind of start your body naturally kicking things in.
SPEAKER_02Nice. So, I mean, we see a lot of poison o cases out there. I mean, you got these Sawyers in there that are knee deep in it, right? Just throwing bars in there and it's kicking back, and all that oil is going everywhere. Um, you know, we've we've had a quite a few that we've had to treat and stop the spread in a way, like the best we can. Um, what's that? Man, it's in a gray packet. I'm blanking on the name of it right now. It starts with a Z. You just hand out. It's a topical steroid that you can put on. I've got it in my bag. I'll come back and get it later. We'll edit over. Um, but in in terms of like poison oak, or like some of the best treatments for topical, if we're out there spiked out, we don't want to send the guy into camp to get steroids.
SPEAKER_03Topical steroids work great. Yeah. Now uh they're not gonna necessarily penetrate deep. If it's like, hey, it's hit my lungs, it's hit my face, everything else. But as far as like, hey, I'm just trying to treat this rice that's on the skin, yeah. I mean, that's what we do for 90% of your rice is some kind of topical steroid. And it's may not work as fast as like Epi, but it's uh it's still gonna work. Yeah. Especially if you want, like, hey, I don't want to pull you out of the field, I don't want to be giving you any shots of anything. No, that stuff works. Yeah, sweet.