The Paramedic's Mistake in Wildland Fire Environments

The fire line doesn't care what you trained for. In wildland fire EMS and wilderness medicine, paramedics work hours from a hospital — and standard ER thinking breaks fast.

In this episode, we sit down with Dr. Miguel Pineda — emergency physician and wilderness medicine fellowship-trained doc — to break down what wildland fire EMS, wilderness medicine, and prehospital care actually look like when the calls are unpredictable and definitive care is hours away. Tree strikes, seizures, unstable SVT, cardiac arrest — sometimes on a patient who happens to be your own teammate.

The thread running through it all is simple: stay calm, act decisively, and never confuse busy work with patient benefit.

What we cover:
- Sick vs. not sick — the read that drives every other decision in remote medicine
- Building confidence as a new paramedic in solo, critical-access settings
- Trigger points: when to stop tinkering and start moving toward definitive care
- Prolonged field care during 12–24 hour extrications — what changes when help isn't coming fast
- Helibase medic realities — cramped cabins, altitude, and what actually fits in the kit
- Non-narcotic pain management and the changing prehospital regulatory landscape
- Ketamine for acute pain — dosing pace, laryngospasm risk, emergence reactions
- Why a clean call-ahead report and a written handoff note can save a patient across multiple transfers

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0:00 Trauma Is Not The Only Risk
5:03 First RSI After COVID Training Gaps
9:06 Evac Plans And The Trigger Point
12:50 Medical Direction For Long Extrications
16:25 Helibase Medics And Kit Planning
20:10 Remote Medicine Dreams And Reality
29:50 Cleaner Handoffs And Better Scribes
32:58 Final Thanks And Sign Off

Transcript

0:00

Yeah, I think that's the hard part of what you guys deal with is of course you're dealing with trauma the majority of the time between you know tree stykes, hot rocks, you get your broken limbs, you get your head trauma and all that, but you forget that it's like it's still humans operating out there, like medical things go wrong too. That's the weirdest thing about fire, it's like you really never know what you're gonna get. Again, there's those ones that everyone's aware of, the hazards that are known hazards, the trees, tree strikes, snaps, breaks. And I think that's a really important piece of being a paramedic out there on the fire is understanding the most expedient process to get that patient into definitive care. And the ambulance driver is gonna come after us. I can say what makes a good paramedic to you, or what are some of the qualities of some of the favorite medics you've ever worked alongside? Yeah, yeah, right. Of course. Come on. I think it's walking that kind of fine balance of like I'm not panicked and freaked out at the slightest thing that's going on, uh, but I'm also like competent and executing and not kind of down calling every single thing that's going on. And that's hard because that's like both a knowledge and like a tolerance-based kind of thing of like, hey, I'm comfortable and confident in my skills that I know what's going on, and I'm not too like afraid to execute and start interventions when needed. I think that's like a that's a big ass because that both takes time, experience, uh, exposure, and confidence. But I think that's the biggest thing is like, hey, when I see something going wrong, I'm cool, like starting interventions and doing everything. Uh, but I'm not absolutely freaking out at the slightest thing that's going wrong. Yeah. It's scary when you're new and like pulling the trigger on some of those interventions, especially if you're by yourself. Like you can speak to that. Being at the critical access hospital, we've worked places where it's pretty much just you and now you're new and on your own. And it's and it's a terrifying experience because I I had one experience when I was working out in uh El Centro, California. Um, my first uh so I was in Wilders Medicine Fellowship uh out there at UCSD. They would send us out to work in El Centro, which is not a freestanding, but small kind of central SoCal Desert uh area, awesome hospital, awesome people. Um, but it's like lower coverage and was different going from working at like an academic center where I had every specialty at my means. I had an attending over my shoulder telling me I'm doing a good job, pat me on the head, telling me good boy, you know, to be like, I'm on my own. And I think I had my first overnight case where I was solo doc, didn't have APP, and I get this older guy comes in and he's like goes into SVT, respiratory distress, his blood pressure's dropping, heart rate's like 200, and his sats are dropping, and he's like 90 years old and does not look good. And it was right as the other doc was walking out the door, and I literally went and grabbed her by the arm and I was like, Can you please come and stand over my shoulder? I know what I need to do. I just need somebody to tell me I'm doing the right thing. And she like looked at me and like laughed, realized it was like my very first year out of training, and she's like, Yeah, absolutely. And I don't think I anything I said that she was like, No, I'd do this instead, or no, I'd do anything different. She was literally was like, Yep, yep, at a head of everything. And it was because I had to cardiovert the guy, so I had to sedate him, had to shock him, then he stopped breathing, so I had to intubate him, then I had to start him on pressers, and I had to shock him again. And every time I was like, I think I have to do this, she's like, mm-hmm. And it was just having that little bit of like, you know, voice over your shoulder, giving the confidence. And so I think it's like that, especially when you guys are in the field. And hopefully I don't know, I I know all our um, I know all our box crews usually have a medic and a tech, but I don't know if you guys are like solo, if you have like a tech or buddy over your shoulder, just be like, hey, I kind of trust your knowledge. Stand over my shoulder and tell me I'm doing the right thing. I think that's like a big thing, or even a lot of times when you guys call in for medical control, like, hey, I think I need to start this. Almost always I'm telling you guys, like, yeah, yeah, go for it. Yeah. You need the yes to go ahead. I trust you. Yeah. Because 95% of the time when I get calls, I'm like, they're doing absolutely the right thing. Either one, they need boss man to tell them yes. Yeah. Or two, they just need the confidence to be like, yeah, you know what you're doing, go for it. So yeah. It's an interesting thing because again, like we on fires, you'll meet people that are brand new medics. You're like brand new medics and EMTs. Wow, okay, welcome. Uh have you touched a patient before? And again, it's not it's not everybody, that's the minority for sure. But it is a worrisome feeling when you're like, you know, we're four hours from a hospital out here. If something happens, please call me. Uh, because we're definitely going to need extra hands on this, and they just they haven't done it yet. Yeah. Um, interesting point. Like for me, like my first innovation ever. I went through paramedic school during COVID. All the ORs were shut down. All of our ED shifts went out the window. Never got to innovate anybody in paramedic school. My first one was on Pine Ridge Indian Reservation, and it was an RSI. I was like, this is not right. I know this is the right answer. I don't want to do this. Yeah. And so, you know, I had an EMT with me and that was it. I was like, we're send it. It worked out. I I and luckily, like, I just got down to New York, right? Yeah. Doing five months in the ICU where I had seen RSI after RSI because of COVID. And so I understood the steps and I did it. But man, having that at least some experience under your belt if you're getting into wildland, so important because again, it's a different set of rules out there, too. So I was gonna say, and for you guys, yeah, it's like you're saying it's it's wild. Like you're not, you're not really, you don't have your backup, you don't have somebody over your shoulder, and you won't even have light sometimes, which you guys are dealing with. So yeah, having the experience going in is like super beneficial. Uh but even if you don't being able to have that, like, all right, I exactly what you said, like I don't want to do this, but I have to do this. And so sometimes it's just you need that kind of kick from behind of like, I have no other option. This is what I gotta do. So yeah. We're all right, we're doing this. Yeah. I remember my first innovation as well. It's just like, holy shit. All right, we need to do it, it needs to be done. Here we are at the plate for the first time. It's uh a bit nerve-wracking, but the more you do it, the better you get, like anything else. So for sure. Trying to think, uh, I mean, the wildland environment, I think the most critical calls we probably work are gonna be things like tree strikes. Um, those always end up being red patients. Uh somebody has a brain tumor and has a seizure on the fire. Yeah, let's talk about that later. Um To be fair, we that you guys, I think Jeff talked about it a little bit with the the lead medic on he he and Colin were like one of the reasons they did they stripped you down trauma naked was they were afraid you got bit by something. They didn't know you were just chilling in the grass, you know. Nobody knew. Yeah. I don't think I've told Miguel. So Tyler had uh No, I was like, I'm out of the loop on this. What's going on? Tyler last year. I mean, we're past six months now, just over. Yeah, September 16th was the the incident. And so he was out on a fire with us, uh R and one of the guys on the Rams team, and I was sitting down the road, and we hear an IWI, or it's called an incident within an incident, it's a medical emergency on the fire line. And uh all of a sudden, like over command, I'm like, oh, an IWI up there, seizure's going on. Okay. Uh I was like, well, Tyler's up there, Jeff's up there, Colin's up there, another Ambo crew. I was like, they got it. So no worries of the world, right? I get up there uh past this because they were I was doing a falling operation and I had texted Tyler. I was gonna say, didn't you text him? I was like, hey man, do you want that call? I'm like, I'm going to done. I'm like, he hasn't texted me back. I was like, all right, whatever. And then I go up to where the helicopter takes off, and I'm like, where's Tyler? Colin's in the back. He's like, it was Tyler. I was like, texted him back, plot twist, you are the call. Get better. Nobody knew anything that was going on. That's when you, yeah, you sent us those uh CTs later that night, and we're just like, oh yeah. My favorite part of that story is that if you would have known it was me, you would have came, but Nick got called over the radio, a male in his 40s. It's like, well, it's not 20. It's like these 20s for sure. Uh it's just that's the weirdest thing about fire, is like you really never know what you're gonna get. Again, there's those ones that everyone's aware of, the hazards that are known hazards, the trees, the sprains, the breaks, the occasional like hot rock coming down, and you get a burn in different areas. Yeah. And but occasionally we'll get one like there was uh IWI on a fire I was on. I didn't work the call, but they some gal was heating up a can of soup on her jet boil and it exploded and she had facial burns. Uh so it you're like, all right, let's go, man. Like, and I think that's a really important piece of being a paramedic out there on the fire is understanding the most expedient process to get that patient to definitive care. And DMT. And and sorry, buddy, and the ambulance drivers. You're gonna come after us. I can say it because I'm one of them. Uh just understanding that, like, hey, what do I absolutely need to do right now? And where am I passing the point where now I'm just playing and I'm causing possible detriment to my patient because I don't have them on their way to a hospital. Uh it's it's an interesting piece. So that pre-planning you've talked about before too, it takes a lot of that. If you if you're in a low frequency, high-risk area, and then that IWI happens and you are trying to figure out all those other fevac plans. That's no, you're just focusing exactly on the time. You need to be focusing on your medicine and your skills, not where is he going? Like you should have that all planned out by now. And there's been dumpster fire calls for sure. Um, I think Andy Palmer is the perfect one. The inception of Rams Dutch Creek protocol and the fact that they had they called the bird, then canceled the bird, and then called the bird again, and he coded in the bird. There's no need for it if you've got it all dialed in. Improper tourniquet placement. Yeah, this is my trigger point, this is what we're doing. Get them gone. We've passed the trigger point. They need to be out. So what other injuries out there? Well, we get asked all the time, what what injuries or what what calls am I gonna be running? And it's like it's it's everything. You know, there's still older folks out there. Cardiac arrest is one or two every year, or like cardiac related cardiac arrest, uh, along with tree strikes and uh auto accidents. So it's it's everything, man. Less of what you think it is and more of the other thing. For sure. Sorry, I had some uh some nicotine spit hit the back of my throat just then. I'm trying to recover over here. Yeah, I think that's the hard part of what you guys deal with, is of course you're dealing with trauma the majority of the time between you know tree stykes, hot rocks, you get your uh, you know, you get your broken limbs, you get your head trauma and all that, but you've got it's like it's still humans operating out there, like medical things go wrong too. So I think that was one of uh one of my good buds from residency. He was uh went to the Navy after residency and was uh stationed out there in SoCal. And one of the first cases that he had to deal with, he was like out on the ship with one of his guys. You got a 20-year-old kid, kid gets testicular torsion, and he's out there in the field trying to treat this thing and trying to get his surgeon back on the main ship to be willing to take this guy. And he's like, you know, I'm out here thinking I'm gonna be taking care of like gunshots and trauma. And here I am sitting there in the middle of the night, trying to try to untwist this guy's nut in the middle of his sack, like over and over. It was like even worse because he's like, it kept going back and then re-slipping, and he like started uh started ivy ketamine on him just for like pain control, and his surgeon just kept being like, nah, just untwist it'll be fine. Nah, untwist it'll be fine. He's like, It's happened three times now. If you are not willing to accept this guy, I gotta cut open his sack in the middle of the field and untwist this because that's my go-to protocol. But it was like both dark and hilarious because it's like one, you have that protocol in your mind. Two, I you kind of cut open this kid's sack in the middle of the field, okay. But I guess if that's what it takes, man. That's the next step. That's horrifying. Yeah, I haven't hit that one yet on fire. So just so you know, might I might come up, you know? Yeah. Medical is medical. Gotta know. How long have you been doing the the wild and fire EMS medical direction portion? And have you learned anything or like have things come up uh in that time that you maybe weren't aware of or you found interesting? Uh what have we been doing it with you just a little over a year? Yeah, year and some six months. Year and six months, yeah. Um I think just learning what you guys deal with in the field, both like the injury profile, the time for extrication, because even like a lot of times that uh we get like our life flight team that does a scene call or whatever, it's like, yeah, patient goes down out in the field, they're out in a res, and it's like they go to the scene call, they land, and they're like in and out with you know, a couple hours at most. It's a you know, like a six-hour transport to get them back. Whereas talking with Brandon's like, you guys are dealing with like 12 and 24 hour extrications sometimes to like the time frame of like how long it takes somebody to get out of like this really remote area, both by ground and then by chopper, um, was like incredibly eye-opening of like, okay, this is not like all right, broken leg, let's get the chopper in here and get him out here in like an hour. It's like, no, we have to get them to a point where the chopper can even get to. And the weather may not even permit it for a while. Exactly. And so being able to figure that out and being able to talk about I think me and Brennan have talked a bunch about like prolonged pain control as far as like we can't just keep hammering this guy with fentanyl the entire time. Yeah, one, we can only carry so much, two, we got to find other options. And then three, on top of all that, like in the process of extricating this guy, like what other injuries or illness am I causing, or what am I ignoring? I got this guy loaded up in the litter, but like, you know, maybe he's got like a femur fracture. It's like, is his pressure starting to drop because he's bleeding out to the thigh? How long have I had him on there? Um, so the amount of uh kind of because of that time frame, the amount of additional things that can develop during that uh during that prolonged extrication. No. I mean, in my case, I was fortunate enough to have a helicopter, but it wasn't a life flight helicopter, it was just an agency helicopter configured to medical. Then they flew me to another LZ where I got on a proper life flight ship, but if that wasn't available, it was gonna be three push and four hours by ground to the hospital. So and I had uh I'm assuming by the character still talking to me, you weren't seizing the entire time. Uh, it was stopped with Brissette. I had a second one, so yeah, they gave me brushed and then uh you know, pissed myself the whole thing in front of my friends, but it's okay. At least you were doing it for appropriate reasons and not other reasons, so you know. Yeah, of course. Yeah. Yeah. I was gonna say, even with that, I mean, I'm sure the whole terrifying for you, but also whoever was with you as far as who jab with you for medical provider because you were the main medical guy. Oh, there is another medic who's far more two other medics that one was far more competent than I. Uh and then there was an ambulance there too with the super stud medic. It was probably the best place to have a seizure. Okay, good. Well, one of them, uh you know, it could have been an urban area closer to the hospital, but uh right in front of people I absolutely trust, and they did it. The alternative was I was gonna go do the R because there was already two medics, and you would have had it, you would have had your seizure in a campground by yourself. Like Thank God I was greedy that day and just like I want to go. You were greedy or I was lazy, one of the two. It worked out. You know, the hello base medic has always been something that I found really interesting. So for your awareness, Miguel, like they will put aside a helicopter that's they have a vendor that provides the helicopter, the mechanic, the fuel truck, all of that. And then they have a hello tac crew that's assigned to that helicopter from that vendor. So I don't I forget who lifted you out, but I've been on so they'll take a mint a medic from the incident and say, Hey, your new assignment's at Hello Base. You're gonna sit at Hello Base, hang out with the homies that are there until an IWI happens, and then you're gonna hop on the helicopter with those guys, and you're gonna fly out there. And it might be like a bell or something just super small. And they're you're gonna go fly out there, they're gonna reconfigure the bird on the ground, you're gonna get the patient, then you're gonna fly into wherever. And you're like, okay, but where is wherever? So oftentimes, like this medic that's assigned to Hellbase, uh like you're the one deconflicting, like, hey, if something happens, I want to tail the tail with this life flight agency that might be here around the fire because I cannot do good interventions when I've got you you're bringing your shelter, your fire pack, you're bringing your tool. It'll that will probably be in the side bin, but there's no room to work in there. So I've been trying to be kind of coming up with systems, and I was just talking to Brandon Di Wiccelli about this. He works for Reach down in uh like Torrance, California area. He takes uh he's got the Spiritus Delta bag, and I'm like, dude, that is perfect. Like just how small it is. But again, like I've got to find a way to configure a shelter on it if I'm gonna be within like what do you want to call it, like regulation or playing by the rules, right? So, and again, I'm not FPC, I haven't ever actually worked for a lifelight agency uh doing flight medic stuff. So I'm like, all right, man, we'll we'll send it. There's a lot of guys that do have that experience on the fire, luckily, and generally they're the ones that are gonna get picked up to go be at HelloBase. But finding new systems that try to dial that in so that if they're in that position and that's you at HelloBase, you know what you're doing, what you're taking, what you're gonna leave behind to treat somebody who might have just had two seizures and you're flying them 35, 40 minutes to the hospital. Uh, what do you have in your kit? Like, did you bring everything that you actually need to manage an airway, possibly give more narcs, taking vitals? Uh, can't you're not gonna be able to take manual with the bird? Yeah, because you can't hear anything come through the cuff. So what are you are you thinking ahead? Are you making these plans in case that worst case scenario happens and you're actually flying somebody? And you were fortunate, you got a pretty sweet role at Lake Tahoe at Hella Base. Oh, that's right. Yeah, and that's uh well you were there too, because you I got flown out onto that, so I got to like shake hands and take your helmet, and so I didn't look like a complete nerd and then and then go out. But you were chilling there, and it's honestly one of the better gigs you can have because you probably sell service, and then if you go on a call, it's probably a serious one. So sign me up for that. Yeah. But again, I think some people might be ill-prepared for actually treating a patient in a like I mean, how big is the back of one of those birds that you've been on? I think it was not large. I mean, barely enough room for you, the patient, that's for sure. Aren't there even consider I'm not a medic, so I don't know. And you've done the the FPC class. Are there aren't there also considerations with practicing medicine at altitude? Yeah, definitely. Um things with uh the ET tube and stuff like that. Luckily I was not intubated in the field, so that didn't come into play, but I long since let that uh knowledge lapse. Uh the certification and the knowledge lapsed, unfortunately. Where did you fly? Was it like Fiji or Tahiti or something? Fiji. Fiji. Yeah, it was a volunteer gig. It was mainly BLS transports from outlying islands to the main hospital, but it was still a cool experience. No, for sure. Yeah. Yeah, it's awesome. So I don't know. Have you been to some radical places doing medicine other than Nogallis? Unfortunately, unfortunately, no. Yeah, I actually interviewed straight out of uh fellowship for a couple jobs and I was stoked and I was like, yeah, let's go practice somewhere world. So I checked out, I think I checked out one job in uh it wasn't Guamba, it was small Pacific Island. I was like, yeah, it'd be really cool, really remote medicine. Everybody that comes in is really sick. And then I started interviewing with a couple people that lived out there. I'm like, so when you're not working at the hospital, what do you do in your off time? They're like, yeah, there's not much. And I'm like, yeah, it sounded less sexy now. And then for the same reason, I uh like was checking out jobs because they're always looking for super rural jobs and Wilderness Med trained people. And I looked up in Barrow, Alaska, which is like northernmost settlement in the US, northern Alaska, and I was like, that's awesome. It's total end of the world. And then I was like, what would I do when I'm not working at the hospital? I guess freeze in my hut. Okay, yeah, I'm not doing that. So I've got some buddies that gone up to Barrow and they've got the houses like on stilts, but then they've got bear cages on their patio because polar bear come through. And just yeah, if you're out there, you're getting you're a snack. Same way in our cabases too, right? Yeah, I you know, I don't know about that one. I know like Svalbard up near Norway, because I went up to Tromso a couple years back. They've got it like it's awesome out there at Svalbard's research station. But uh Barrel would have been dope. Yeah, but yeah. And then I I got to and in no way was I ever in a place to interview because it's actually an insanely desired job, which is insane. But the Uh Antarctic research stations because they always have to have a doc on staff and they have to have a full year staff. So even yeah, like McMurdo and any of the other stations down there. So even during like the what is it like five months of complete darkness down there during their winter? And uh I at least got to not interview but chat with one of the doctors that had work down there was like funniest little like five foot tall woman. She's like, Yeah, it's crazy that kind of stuff you have to cover. Like, oh, like the injuries or illnesses. She's like, No, you're the end person for everything. So when my lab machine breaks down, I have to do the research and figure out how to fix my blood chemistry machine. And when the x-ray machine breaks down, I have to research and figure out how to fix the x-ray machine because there's not somebody else to do that. So it's like you literally had to be this insane jack of all trades, not just medical, but all like uh all like the peripheral medical stuff that's like we have such awesome staff that takes care of it in a hospital most of the time that you never think about it that they're like, yeah, no, we have to take care of all that too. So they're just like this insanely multi-talented person that has to be the docs down there. But yeah, that was the only other one I checked out that was like, yeah, I don't I don't think I want to go six months with no sunlight. I think I go insane. Maybe top, but cool to say he stepped on that con. Oh, yeah. Can you imagine how fucking pale we'd be after the five months? I can't get any more pale. That's just it. This is the base layer. This is it. This is blows a gun. This is deading zero. Yeah, that's cool. Well, what other questions you guys got? Any other medical things, I guess? Um We've been really diving down the rabbit hole of non-uh narcotic pain management due to some uh DEA, potential DEA uh regulations that might inhibit us from carrying that. Have you had any experience or what's your experiences with non-narcotic pain management, especially uh Nubane? Yeah, especially on the ER, we get it, we get a fair amount. I apologize, you said ubane? Nubane. Nubane. Uh Nalbufene. Nalbufene, Nubane. Okay. No, that's an opioid, but not a controlled one. Yeah, but not a controlled one. That one has just now started getting pushed to it. So I think I've used it like once or twice that I've prescribed it for patients just because my pharmacist has brought it up with me. So unfortunately, I got pretty limited experience on that one beyond the fact of I think it's going to become like that new hot ticket with the fact of, hey, it's not a controlled opiate that we can start prescribing for some of our chronic pain patients. Um, as far as like in the ED or in the field like acute pain beyond opiates, a couple of the main things that uh we use one, which I wouldn't necessarily recommend, but we've used occasionally like crazy kidney stone patients, is like IV lidocaine, which runs the whole risk of you can cause this crazy like abnormal heart rhythm and rhythmogenics. So it's like I've used that maybe once or twice with the pharmacist over my shoulder, be like, yeah, you're good, go ahead. And then like push it. Um, but the other one that I think that we use more commonly that I think is lucky, is becoming more and more kind of common, both in the regular world in addition to us is ketamine. Um because we always used a fair amount of it for sedation, for you know, setting broken bones or for bigger procedures, but it's becoming more and more common to start using it for just IV pain control, um, for um uh for kidney stones, for broken bones, or for your chronic pain patients. So it's like, yeah, opiates are not gonna touch them. You'd have to give enough to kill an elephant before you even reach like a level and then they're gonna stop breathing. And the benefit that you get with the ketamine is like, yeah, it's not gonna suppress the respiratory drive. Usually works pretty well. And for some of kind of your more abnormal pain or your chronic pain patients, does tend to work pretty well. The one thing that does scare me with ketamine, because I've seen it happen once. And so, because of that, I'm always the one that's pushing it in like sedations. If you push that stuff too fast, you can cause the ringgospasm. I've watched it where like the cords just completely close, they stop breathing, and then you've got to bang them pretty hard before you're able to pop those cords open. Um, so the one thing that I'm always super cautious with people about with ketamine is one, don't push it fast. That is one thing that you just push slow, slower than you think you should. And two, if you ever do start a drip on them, also from one time and experience, do not let it run wide open and don't let it just like run into them. They'll get a bigger load than you think, and they will go apneic. Um, and it's not from the same like opiate apneque where it's like, hey, I can hit them with some Narcan, wake them up and bag them up. It causes just some scary stuff with like the uh vocal cords to close. So that is the one thing that you definitely want to be careful with with the ketamine. It's great for blood pressure, it's great because it doesn't suppress the respiratory drive, but just one thing, yeah, just don't go fast with it. So good to know. I've made some ketamine mistakes before pushing it too fast, so the lady like came out. I was giving it for pain, open ankle fracture. And I think I gave it a little too fast, and she was just came out of it. So I probably maybe gave too much too fast, and then she's like, Don't give me that ever again. So then I had another guy who loved it, he was like stoked on it. So some reemerge phenomena or something. That's one of the other big things with academy. It kind of because it does play on some of like the sedation weird parts on the brain, it plays on whatever your mood is at the time. So before you start giving it, in a in a kind of creepy way, set the mood. Rub their feet, set the mood. Why are you lighting a candle? Yeah, sometimes before we do it, we literally pull up a phone and play. Uh we did this several times. We play Enya on the phone. And just like literally, and just get them chill. And always be almost always before I put them out, I said, Hey, your your only goal is to have a good dream while you're out. You know, and it like sets their mood. But if you're like super freaked and there's a bunch of like craziness going on around people are shouting, like they'll have a bad trip. Um, because it is like more of a psychedelic drug in that standpoint. So it is something important, set the mood with it. With adults, you can get that re-emergence phenomenon where they come out and they start freaking out. So nowadays I've started getting a little more uh comfortable with if I am gonna do ketamine, I at least have Verset or Atavan or something on standby. So if they do start waking up and freaking out, they start grabbing at stuff, trying to pull out their line. I'm ready to like narc them a little bit. So it's awesome. I think uh there's a lot of people that are fans of ketamine out there online, but with this new DEA uh thing that might be happening, you know, we're like, all right, it's gonna be more difficult for some companies out there to get a proper licensure in each state. Yeah. You've always or we've always preached patient, it's a patient, right? Or like they deserve it out there and non-narcotic options. When you're talking about patient advocacy, it's like, yeah, you've got a femur fracture because you just got hit by a tree. I want to give you pain management. Sorry, but I don't want tortol. Yeah, exactly. I heard lavender oil's great. Fix you right up. So we'll see what happens with that. You know, it's uh a lot of unknowns surrounding it. And it's the government, they're a little more retroactive than proactive. So uh some case studies will have to come out and some advocates will have to be made and hopefully they'll see what we actually do out there and make some changes. Something bad will have to happen, unfortunately. Uh even for those who are able to carry it, I think everyone still has this thing in the back of their mind that am I alright? Are we legal here? But I think we've determined it's worth whatever risk. Uh as long as the risk is on us and not our providers or medical directors that we want to have it and implement it. So well, let's close with this. Uh, if you could give one tidbit about what you wish paramedics would improve on, what would that be? Love that. We'll get to EMT's next episode. Yeah, right. Drive the ambulance faster. Um, let's see. I'd say probably one of the biggest things that I would like to see from the medics that like I get super stoked when the medics do good, that even my good medics, I'm like, I wish I could clean that up, is when they're bringing people in, being able to kind of like give that like concise story and figure out like, hey, what knowledge is important, what isn't, and being able to give kind of a smooth handoff, like, hey, this is you know, this is what injury or what illness we're coming up with, this is what uh this is what was building up, and this were our initial vitals and our last set of idols. Um, because I'll get sometimes with some of my medics where they get uh they'll give just a whole bunch of extraneous information. They're trying to be helpful, and I'm just like I having to like pick and draw stuff out of there. So uh almost being able to be like, hey, this is kind of this is the important stuff that they're gonna be finding when they get to the hospital is like, hey, this is our illness, this is our vitals, and this is kind of like a uh important or uh a concise recap of like the what was all going on, the situation that led up to it. That's that's I like that a lot. Positive negatives or uh pertinent negatives. I when it comes to wild end fire, you've sometimes you'll be the guy, treat the guy on the mountain, and then he gets short hold to an ambulance crew. I was gonna say and then the ambulance crew goes and rendezvous with the local EMS crew. The local EMS crew takes him to the hospital. By the time the patient gets there, he's like, I've told this five times and nobody knows what's going on. Right. So I think to expound on that, the medic who's taking initial care is writing down very detailed notes to then put in the patient's pocket. Make sure people understand there's a piece of paper in that pocket that has everything that you need to know that's pertinent to be handed off to the next crew. So it's it's more of a whole picture, and you don't have just individual puzzle pieces that might not necessarily fit together by the time the handoff is being given to the provider. Like yeah, like you said, it can be from a line medic to uh Ambo assigned to the fire who then rendezvous with the the local ambulance to take them to the hospital. That's two handoffs there. One of the unsung unsung heroes of a serious medical emergency is a good scribe. Like I always try to establish that right away. Like, hey, write down whatever I tell you. And then that they don't even have to be a medical person. Be better scribes. Understand what your medics are doing and how to write down the pertinent information so your medic can focus on the patient. You actually have to learn how to read. And write. Okay, now we're we're past that point. Cool. Well, hey, thanks for coming on. Thank you guys very much for having me. It was great. Yeah, I know you worked last night, you're working tonight too. So hopefully I don't have to see you guys. I'll be at Hurricane ED tonight, so I'll have to be all day. Hopefully not. For sure. But yeah, seriously, thanks again, Miguel. And uh much appreciated. We probably will do it again sometime. Sounds perfect. I'd be happy to come on whenever you guys got time for me. Cool. Thanks.