Altered Addison's

All right. Yeah. I think we need to mark this moment here. Moment. Yeah, we need to mark this moment. Is this a momentous occasion? This is a momentous occasion. Do you know why Chris? No idea. You're holding a water cup. Oh, yeah. No, I've done it before though. We started a few of them. We started a few and then you even say, you even say, that you even made a comment. You're like, "Who? Who are you?" Yeah. I don't remember though. Sounds like a bunch of lies. Yeah. I'm going to ruin your moment. So I don't know why I forget, but I always forget how much no sleep just screws with you. So our base is undergoing a renovation right now. There was some water damage and so the company is like, well, if we're going to take the front of the building off, we might as well do some work while we're there. So we are in a single white trailer out front and there's just no sleeping in this thing. It's made of paper mache, the whole thing. Yeah. Yeah. If someone goes to the bathroom, we all just get to kind of go to the bathroom with them. The best part about it is that I screwed all the. So we have pilot's room, nurses room, medics room. The medics room, so we were all kind of figuring out who's going to be in what room. So our boss comes in and he says, "Here you do a coin toss, heads, nurse picks, tails, medics picks," which room they want. It was tails and I got the pick. So I'm like, "We're taking the big room. We're taking the big room." Boom. Yeah. The problem is the big room has windows and no curtains. Oh. Yeah. Yeah. So I went back into the under construction base, found some curtains, and I got tape and I made makeshift tape hooks that go around the bar that then tape really solvably to the wall. And so far, like, they're not budgeted and it looks fantastic. All this to say, the best part about these rooms is that the light switch controls are outside the room themselves in the living area. And the best part though, and this is where the medics went out, the nurse's room is controlled by a light switch right outside of it and another light switch all the way on the other side of the trailer because that light switch also turns on lights at the living room. So if you flip it on, the living room lights will turn on and so will the nurse's room. The problem is that's the door where the pilots come in on the other side of the trailer. They're not necessarily aware that that will turn on the nurse's lights in the middle of the night. Yeah. So one of the nurses was trying to sleep and one of the pilots like got up to like use the bathroom or something and flip the lights on and the lights and the lights and her interlockers like, what the fuck? Oh, man. Anyway. So yeah, I've sleep deprived. But plus we were running calls. That's the other thing. So there's that. But with that, let's go. I just woke up at 4.30 and that was it. My body was just like, there's no reason I need to be awake. Like I was at work. We didn't do a single thing. But so you know, I'm suffering with your body. No, you're not. Come on, my own. Let's roll the intro. This podcast is hosted by Chris Vincen and Spencer Oliver. They are both experienced paramedics. They've done everything from 911 ground ambulance to volunteer fire department work and are both currently flight paramedics. This podcast review scenario is based on real calls run by real out of hospital conditions. Details are changed to protect the privacy of those involved and to present educational opportunities to the listener. This podcast is EMS 2020. All right. Well, welcome to EMS 2020. This is the show where we do real out of hospital calls and occasionally we have celebrities on. And it's pretty big stretch in the occasionally there. But you know, once every 200 or so episodes, you know, so we'll see you guys again in five years. And love another one on by that. Although actually, I'll hint at it now. We may have somebody else coming on. Oh, yeah. Yeah, actually, we have a, we have quite a few co labs that I think are going to be coming down the pipe. We do not, they're not all like celebrity collapse. It's, but yeah, we do have some co labs coming down the pipe. That'll be, that'll be exciting. Of course, if you want to support the show, the best way to do that is head on over to flightbridge ED.com or ems 2020.com gets lined up for a subscription service where you can get continued education just for listening to EMS 2020. And if you want your call to be on this show, ems 2020, EMS 2020.com scroll down. You'll see a link. Click it. You can submit a call. You guys are finding that really easy. So that's good. We're getting lots of call submissions. So that's been fantastic. But yeah, with that Spencer, what you got? All right. Baby, I got, I don't know. It's going to be all right. I am so sleepy. This is going to be ultra realistic. Yeah. Yeah. Talk to me. This call happens at midnight. Also social media, ems 2020 on Facebook at ems 2020 show on Instagram. Oh, at our merch store shop. That ems 2020 podcast.com death goat shirts. I'm selling really, really nice. Yeah. And the death go I would get death goat coffee mug. That's what I would totally get it. I think I'm going to get one. Yeah. I think I'm going to buy one of my own. You don't have to buy it. It's our stuff. But I want to support the show. Yeah. Yeah. You do. All right. Aside from making it. Yeah. Okay. Yeah. Support it more. You haven't done enough. All right. So let's talk about who gave us this call for this week. Well, this call was submitted to our online forum by a paramedic. We're calling Vincent Valerie. And I'm shortening that to V. No, the theme is not V for Vendetta. Yeah. Let's just get that out of the way. I'm not over here valiantly vocalizing for both variations of valid V vocabulary. But, you know, good thought. So, man. Back to V. V is a paramedic. That's a good one. That's a good one. That's a good one. All right. V is pretty new at the time. And their role is a paramedic. They've got about four months under their belt. And it's worth pointing out that they are a real zero to hero medic. They started their medic program with negative one days as an official EMT. How do you become negative? Oh, so this was, oh, oh, so they were in before they actually got the EMT cert. Wow. Yeah. This system needs paramedics. I can tell you that right now. That's a, that's a mean thing to say. So, if anyone's not sure what the zero to hero route is, because you have some people that maybe not sure. These are people that make it all the way through to their paramedic certification without ever spending a day on the road. It used to be pretty rare. It's a little more common these days. But yeah, it's pretty much you started out. You went to school. You got your EMT. You plowed right on the medic school and your first day on the truck, your first day as a paramedic will also be your first day on the truck. Now, some people will kind of say this is not advantageous. It has its challenges. And the biggest challenge is that you're going to be learning a lot all at once versus the nice thing about starting out as an EMT then moving up is that your scope of practice is limited and that's still a lot to learn. But then you get to learn things like your bedside manner where shit is in the truck. My goodness is that ever important. It's amazing on how like you be like, yeah, I know exactly how this call is going to go. It's like, okay, grab it. Oh, shit. Plan fell apart. You know, like that's, you don't know where stuff is. How to use radios, how to talk on a radio and be confident in it. All those things. And now you do zero to hero. You get to do all of that plus an expanded scope of practice all at once. Yeah. But one of the advantages to zero to hero is that you get to start off with that like all of your EMS experience starts with your full scope of practice. You know, and so you're likely to obtain a higher level of experience with the ALS scope of practice in fewer years than you would if you went the other route. But you may be lacking in some other departments. And it can be a bit chaotic and you may be very stressful. So and this one. Oh, go ahead and finish your thought. Well, and the other hard part is that in many systems, it's not just that you're zero to hero. You're zero to hero and now technically in charge. So that's the other. Yeah, no, for sure. Yeah. And you have EMTs that are going to be like, do you do you know how to lead a scene? I'm sure I don't. PSI scene safe. Yeah. And that was one of the things that V said that they, you know, like that that made this path very hard. And they were like, I wouldn't recommend this. And I get it. Essentially what they said is like, it's hard to go out there and not know like, hey, what is this supposed to look like? Like what am I going for? And I think you hit it right on the head, man. Experienced EMTs becoming paramedics have a leg up that they typically already have that flow established. They know how to deal with the variety of situations. They just have to work on adding in the ALS stuff that they've learned and maybe having to unlearn some of the shit that they've learned. But yeah. So anyway. So they are partnered with Takamura, a long time paramedic and a preceptor. Oh, I know. I know exactly what you're saying about. You shut your mouth. I know exactly what this is for their agencies. Yeah. I. Oh, okay. I'll keep my mouth shut. But dude, awesome. All right. Cool. I very rarely get this excited. I want to talk about it. You'll have to wait. You're right, though. This did make me happy. Yeah. Cool. I do it. What? All right. So they are partnered with Takamura, a long time paramedic and a preceptor for their agencies F-TEP. They get along great. And at this time, V being the new medic, very much values their partner's input and recommendations for treatments on calls. And these two know each other actually from like before they were on shift together. So V is pretty happy with this arrangement. So let's talk about the system that these two are working in. The crew work for trauma team silver medical rescue for Night City County. This is a transporting ALS fire department with multiple stations throughout their mix of urban suburban rural service area. They staff about six ambulances on during the day and they utilize a static deployment model each ambulance responding from a station. The crews work 24 hours and are staffed medic EMT except when there is a medic going through their FTO period where they will work with a medic FTO. So then it's a double medic shift, right? The crews run about 12 calls in a 24 hour period. Hospital choice isn't a consideration for this call. And there are no other agencies involved. So we don't need to focus on that. It's worth noting here that in this system, the fire engine doesn't respond to all medical calls. They will get dispatched on request or if there's like a cardiac arrest or a call involving entrapment, etc. then they'll go on that. It's also, I guess I should also point out like RSI is not an interventional option for the system. The paramedics can't intubate but they do not have parolytics. Okay. Yeah, this county would need to upgrade to the platinum package for that kind of service. Oh, you're hitting it well. Yeah. Additionally, the cyber cycle crisis has been quelt. So that is an effect on this call. Are there any questions before we proceed? Okay. Here's the thing. If you don't know this theme by now, you're not going to. You either know this, you either know exactly what this is right now or you don't. What it is, it is Cyberpunk 2077, which I will say. I like video games but I typically see them as kind of a kind of a pastime here and there. I try not to get too involved with them. There is one game that I will have to admit. Took up way too much my time and I haven't played it in a while. That may change now and that's cyberpunk and it's your hitting it so well. I didn't know you played the game actually. But I have I have gotten about past the beginning twice now. There you go. Yeah, no, very cool. All right. I don't even know what the calls about. I know nothing. It's all washed out. Okay. All right. But he's a single. Our guy is a single zero to hero medic. There's no other medics. I have singles a weird way to put that. No, no. I'm busy available. He's working with another paramedic. All right. Yeah. Yep. And he is being FTOed by another paramedic. So. Okay. All right. That's right. I mean that. Yeah, you did. All right. Yeah. It's roughly 14 or two hours on a cold dry overcast day in Night City. V and their FTO Takamura are at their station. The day hadn't been too eventful so far. They get dispatched emergent to a 50s male unresponsive at 2077 Phantom Liberty Avenue. The crew head out to their ambulance to learn more and V makes a comment about needing a cyber and it got great to deal with the weather. But this job's not paying enough to make that happen. So fuck my sinuses, I guess. There is an ambulance response only. An engine crew can be added if needed. But in the ambulance, they see the following notes on their CAD. This is a 50s male who's awake, but not alert, not talking. The patient has a history of Addison's disease. So Chris, interesting. What would you make of this dispatching? What would you do in this situation? All right. So the way we need to really look at this one is there's so having the history of Addison's disease is interesting in the sense that that's that I don't know the dispatched card that's like and ask if they have Addison's disease. So my my guess is that somebody offered this up over over the phone or it came across like this. Okay, it's never happened to the patient before. Yeah, he's got Addison's this happens. You know, whatever it is. Addison's it's a kidney disease or is it endocrine disorder of some kind, isn't it? Yeah. It's with the adrenal glands. Yeah. And so I think it's just more of a hormone regulation issue with with a couple hormones. And so my understanding with Addison's is typically you see like extreme fatigue. There's like muscle weakness. I think people can go through like periods of like extreme weight loss from time to time. And hypotension is kind of another thing that's associated with Addison's disease that I can remember off the top of my head. Which by the way, if I seem familiar with Addison's disease, I had a really interesting case review during my career that involved Addison's disease. So if you're like, yeah. So if you're like, the patient had Addison's the case review didn't it's complicated. But anyway, it's so if you're out there like, man, I always try to apparently I haven't learned enough about Addison's story paramedic school. There's no Addison's disease chapter in paramedic school. Yeah. Like I mean, maybe like in endocrine disorders, there's like a little chapter. Yeah. Yeah. But if you forgot it, don't, don't keep yourself in the nuts too hard here. But anyway, so that makes me kind of curious why is Addison's disease being brought up? But otherwise, we got to be careful in that those little, those little biases that can get dropped in through dispatched information can throw us off. And so what I want to make sure that we do and what I would want to talk to if I was the FTO in this case, if I was not V, if I was Takamura, I would be coaching and being like, hey, Addison's disease thing is neat. But let's not get tunnel vision with these with these biases that are being sprinkled in. And let's start with like any other ultra-dolo-C call. So anyway, and I'll I'll I'll go over my ultra-dolo-C checkbox a little bit later. But anyway, that is my yeah, that's my take. All right. Well, V does what I would do in that situation. And immediately go, I think I know this. I'm going to Google it. Google Addison Disease. And they learn it is an endocrine disorder related to adrenal insufficiency. And one that could potentially cause a low blood pressure. Their Google is the same as mine. Because that's just like, yeah, what is it? Okay, high-potention. All right. So they decide in this moment that it could be a potential contributing factor for this call. But the chief complaint could be related to something else entirely, right? So this could be a red herring. So they're going to they're kind of talk this away. And they'll proceed with the call assuming that maybe it's a part of this. Maybe it has nothing to do with it. So, I don't know. And so, V and Takamura arrive at the address about 10 minutes later. The residence is a trailer park. A nice one. But one that has a huge fucking problem for every EMS person ever. The fucking layout of the place doesn't make sense. This is one of those like that is built out of intersecting rings. So it basically it's an effectively a maze that needs to be navigated. Right? So these rings that are intersecting perpetually. It's one of those things that I'm like, who designed this and why? Like is this someone a pilot? And they're just like, everybody just wanted to look good from the sky. Because it doesn't fucking look good from the ground. It doesn't work. Yeah. Dude, do you remember the movie Galaxy Quest with Tim Allen? Yeah. Yeah. And there's this part where so if you guys are familiar with the movie Galaxy Quest, it's basically where these actors are in like a Star Wars or Star Trek kind of show. And they're actors in the movie. And then it turns out that there's this alien race that's in real life that has been watching their show and thinks that they're real and built them a ship like the one from the series. Thinking the series is a documentary of things that actually happened. Yeah. And so the problem is is because it's based off of a movie series. There are things that are designed to the ship for dramatic effect. And there's a scene where Tim Allen is going through the actual spaceship. And there's Flamethrower's bursting out the wall. He's like, why would anyone design it this way? Yeah. Why? And it's like, well, it's based off of, yeah. Anyway, it just reminds me of that. Here's the thing, GPS works for this in this call. Like they have GPS, you know, and most people have like Google Maps or Apple Maps or you know, whatever maps you wanna use. And for a lot of these places, that'll work. It'll get you to the spot that you need to get to. But that's not true for every fucking place. 'Cause there have been many times where I've plugged in an address and it just is like, welcome to the front of the trailer park. You know, like. - Right, yeah. Yeah, good luck from here. And then you're just driving around going like, man, I hope they're not dead. - Or it has a directory that does not make sense. Or people are like, who are you looking for? - Yeah. - As they flag you down. And it's like, I can't tell you. What's the address? Still can't tell you. How about it's space 19? Where the fuck is it? Just give me the right. - I don't care. (laughing) - Anyway, so they get to the place and they park it for the address and they exit. And Vee and Takamora grabbed their primary kit. It's their bag that has like airway breathing circulation and a D cylinder. So ABC and D. - Oh. - Yeah. - A disability cylinder. - I mean, if you hit someone hard enough with the insurance. - That's true enough. We've created disability now. - All right. So yeah, this kit has their ALS and BLS airway and breathing equipment plus some vital taking equipment, et cetera. They also have an ALS bag, which has their medications, IV supplies and the kutramins along those lines. They also fetched their cardiac monitor and they put all that on the stretcher, bring that over to the front steps and then grab all their stuff off of it and hike it on into the home. So there's a male who answers the door, claiming to be a friend of the patient. And essentially he tells the crew like he's in there and points to a bedroom down the hall. Takamura enters the home, well V failing to duck low enough, smashes their head onto the door frame. So they're like, this is a great start. - I hate. - Yeah. - I wish I could help you, Todd. I wish I could say I had done that multiple times. But yeah. - All right. - Oh, by the way, we had a conversation here today. There may be a point where we repeat themes and we don't know if you guys can find it out. We'll come up with a prize or something for you. - Oh yeah. - Yeah, yeah, yeah. 'Cause-- - If you guys ever are like, hey, you've done this before and you can name the episodes where we've repeated a theme, then we'll do something. Something. I don't know what it is. That would be something. (laughing) - All right. So a few minutes later, after recovering from that unexpected system reboot, both T and V enter the bedroom and they find the following scene. They enter a room that is filled with stuff. Now, it's not all necessarily garbage, but it's like a small dragon's hoard of random belongings, things close, and of course there is some garbage, right? There is a small trail that leads to a sheetless bed and atop the sheetless bed is a five foot six, 140 pound male wearing sweatpants in a t-shirt and they are curled onto their side in a fetal position with their eyes open and just kind of moving around aimlessly. Their eyes moving around aimlessly. They're just pretty stuck in a fetal position. The patient is occasionally groaning, but not talking and does not appear to notice the crew as they enter. V notes that the patient appears pale, especially in their face, and for our metric folk, 64 kilograms and 167 centimeters. All right, if I get around him a pause for my water, you get a pot of applause for doing the calculations prior to recording. That's a, there you go. All right. Well done, we're about turning over new things. Yeah, here we go. All right, it's also worth noting that the ambient room temperature is comfortable, so it's not blisteringly hot or like, oh, I know why he's altered because he's hypothermic as fuck. So, all right. It's also worth pointing out that the patient doesn't appear unkempt. So this is a person who appears like they take care of themselves for the most part. All right. All right, so V, whose patient this will be, goes to the patient's side, they lean over and say, sir, while shaking the patient's shoulders. The patient, weekly withdraws from painful stimuli, and there is no other verbal response. So the GCS is a four plus two plus four, right? So four for eyes, 'cause their eyes are open spontaneous too. They're saying that the groaning is gonna be incomprehensible speech. Okay. Sure. Yeah, it is. I mean, it's not comprehensible, I guess. And then a four for the withdrawing. And we'll get to see more of that as this call unfolds. So, airway is patent. Breathing is about 14 times per minute. There's no increased work of breathing noted. The patient's just shugging along with their breathing. And a pulse is 70 beats per minute via radio pulse check. It's not weak, earth ready, it's regular. Tachymorra is asked to place the patient on the cardiac monitor and to like to get a full set of vitals. And while Tachymorra starts that process, V checks lung sounds and they are clear. All right. So V looks up after doing that and sees that the blood pressure on the autocuff has come back as 80 over 40. And they tell Tachymorra, hey, go get the stair chair from the ambulance. We need to start working on getting the patient out of here. And so Tachymorra goes, okay, and goes to do that. By the way, the Spo2 value was 98. I know of kind of bread crumbed vitals in here. Yeah, that's good though. Yeah. Yes, okay. So while Tachymorra is out getting the stair chair, V decides to do a 12 lead to see if there's like an arrhythmia or an MI that could be the cause of this hypotension. And so they do that and there's not from what they can see on the monitor. It just says sinus rhythm. They also check a blood glucose level and learn that it's 38 milligrams per desolator or 2.1 milli moles. So what are your thoughts here, Chris? Well, I'm glad they checked the blood sugar because that was a question that was coming up. So let's kind of go down my altered L.O.C. checklist. And the first thing we're going to see is, okay, and that is, let's take a look at the fuel. First of all, do we have, is fuel getting to the brain? Do we have the blood pressure for it? 80 over 40 is low, but I hesitate to feel that it is so low that someone would be this altered, especially if they're in a laying down position, right? Yep. So I feel that while the hypotension is certainly there, and it's something that we need to correct, I don't feel necessarily that that is going to be the sole cause for this person's altered level of consciousness. That would seem odd to me. It's not impossible, but it just, it seems odd because the other thing we have to remember is that blood pressure is, and I rant about this all the time of the show and that is, the biggest thing I hate is when someone takes a radio, they're like, well, it's at least 70. You have no, no, that has been proven over and over again, to be incorrect because the problem is, is everybody's different. And while it's important, like if someone has a radio pulse, that's still a very good finding. And it does lend itself to hematomic stability, right? Because if your body's like, make sure the wrist gets blood, it's probably making sure that vital organs are getting blood as well, right? Yeah. So that is good that you can feel it there, but it doesn't give you a blood pressure because the problem is, is the amount of pressure that takes you to create a pulse at the radio assessment site is going to be different in every single person based on their vascular resistance. And we've proven time and time again, study after study, that there is no baseline pulse, baseline blood pressure that we can find that consistently says this will create a radio pulse. It heavily depends on a vascular resistance, body habitus, you know, that plays a huge role in being able to find a pulse. So anyway, so I say all that to say that any over 40 should be at a blood pressure to have someone who's not this altered in laying down position, but without really knowing more about this patient, it's not impossible that it is the, or that it's not the cause. So, but it is lower on my list. So I'm going to say we probably have enough blood pressure to get fuel to the brain, but does this fuel have oxygen and does it have sugar, oxygen, yes, sugar, no. So we need to correct that sugar. That does need to be corrected. I'm not going to give it to them by mouth because, well, they can't really protect their own airway right now, they'd be a pretty bad move to be like, well, I could probably gum this down. So, so, so, nebby lies the sugar and have them inhale. I'm going to do that. Do not do not do that. That would be a take. Could you imagine, you think they aspirated? Oh yeah. Yeah. I actually had to aspirate in the worst way. If you thought popcorn lung from vaping was bad, try sugar lung from me anyway. So, anyway. So this 38 needs to be corrected. I'm curious though, someone with an endocrine disease is that going to be kind of layered into this. So, what I would probably do is I would start with correcting [BLANK_AUDIO] sugar, but the other things we need to watch out for is my next step and that is like, okay, so we just did does it have fuel? Is that good quality fuel with oxygen sugar? Is anything broken? Do we have a history of trauma? Because someone else is there, you know, where there are any falls recently? Yeah. Those kind of things. And so then, you know, we try and see we can like assess for stroke by even if they're not responsive, are they favoring one side or the other? When we do move them, those kind of things. And then after that, we'd start looking at things like intoxicants or sepsis rather, and then intoxicants. And with sepsis, I would look for things like tecipnia, do we have a low ETCO2? Is there a reason the patient could be septic? In other words, do we have a cut or a wound? What about urination lately? Have they been peeing more frequently? Has it been odorous? Have they said anything to you about their peeing odorous? Those kind of things coming through? And then you could even check a temperature. No, I agree with you. The concern here is I'm like, yeah, the blood pressure doesn't really explain this level of altered mental status. I've seen people get not altered, but just kind of like, I don't feel like I feel dizzy, that's slower to respond maybe, but not fetal position non-responsive. Right. So the blood sugar is definitely a culprit. Yeah. And here's what I would do if you want to know what I do. I'd say, hey, start two IVs. Let's give d10 in one of them. And let's get 25 grams of sugar in that way with d10. And then let's give a fluid bolsen in the other. Yeah. Because that's the other part is like, okay, but the little blood sugar, why is the blood pressure low? Like that? Those don't, I don't know. Those don't. Could be addison disease though. Yeah, could be. Yeah. So, all right. Well, now typically, hypoglycemic patients are treated on scene at this, and I think most agencies, but because of the state of the room, the fairly limited access to the patient, just with all the stuff in the bed, they decide, and plus the, you know, like, yeah, there's still this hypotension piece, they decide, hey, we're going to continue with our plan of just moving the patient down to the ambulance and treating them out there. So the patient gets lifted from the bed onto the stair chair, they get secured and taken out of the room down the hall and out down the stairs to where the stretcher is. Now, on the way out, the friend, maybe roommate, I don't know, the friend roommate person, hands, the, the crew, some discharge paperwork, which includes past medical history, medications, and allergies. The patient, Jackie, has a history of addison disease, hypothyroidism, and more, but V didn't have the photographic memory, cyberware, so they were unable to recall precisely what else was on there because as many people are figuring out, it's taking, it's taking some time from the time your call gets submitted to me, getting back to you. So don't give up hope, but, but also, I, and I will forgive when you're like, yeah, man, if you'd asked me a year ago, might have been able to remember, but not necessarily that we're year backed up. Yeah. Yeah. Yeah. We don't, we don't go in chronological order, just so you know, not always. Nope. I always. So, yeah, the same situation with the meds, they recalled that the patient took a levothoroxine, but they don't recall anything else on there. They, they do ask the roommate questions such as like, hey, when was the last time you saw the patient normal? And the roommate recalls saying the patient earlier this morning, and noted that they were acting funny, and maybe a little odd last night too. So if we're, they said like, make less see normal normal is probably like 12 plus hours ago. Well, this is a really good question because especially if we start going down that is it broken list? And I'm talking about trauma and stroke. That's a really good question. The other thing we have to ask is if the patient doesn't have a history of diabetes or they don't or hypoglycemia, not only why is the blood pressure low, but why is the blood sugar low? Mm-hmm. This is another very huge question. Typically, blood sugar, the low blood sugar patients are diabetic patients who take their diabetic medication that low that will lower their blood sugar, but then they don't usually eat enough to then to balance that out, right? And the blood sugar kind of plunges in the other direction. So we over correct with with our insulin administration. So that's usually the path to severe hypoglycemia like this, but it doesn't sound like they have a history. We don't remember what the history is, but I would like to think that if that history was there, they would have remembered that part of it. And also in 2077, Jackie, things don't go well for that character. They go pretty horrifically bad. So I'm curious to see if that. Yeah, well, you just hold on there, buddy. All right, so it is also work pointing out like V doesn't recall asking the roommate or friend or whoever they are. If they know about any complaints that the patient might have had prior to being found unresponsive, or if there are any changes in meds or other recent medical events or just events, illnesses, whatever. So there is a missed opportunity there, especially if you can't get any information from the patient, but there it is, missed opportunity. Once Jackie's loaded into the ambulance, V and Takamura connect them back to the monitor and then immediately start looking on both arms for possible IV sites for the administration of some intravenous dextrose, both of them attempt three times without success. And the patient, it's worth pointing out like the patient doesn't. their meditation hasn't changed at all. They are still making it like they're still withdrawing pretty strongly from the painful stimuli of having IVs attempted. So that may have complicated this as well. They decide after both of them have made three solid attempts at getting IV access. So six total attempts? Six total, yep. Oh, okay. That okay, this isn't working. It's probably time to like, there's no point in staying on scene and continuing to fail. Let's start moving towards a hospital and continuing, you know, like to try and treat the patient in route. That way, if at least we continue to fail, at least we're making some sort of forward progress in the call, right? And so, and you know, and at this point, V's like, it felt like we had been on scene trying for like 30 minutes. Yeah, I know it was only like 10, but it felt like we were. it's like, oh my god, now we've been here forever. And I think that's the inner dialogue that everybody has of like, not only did you fail, but you wasted so much time doing it. Yeah, well, the problems they probably use the send of a stand and that's what comes with the stretch out. So totally understand that. Yeah, nice. All right. So, vitals at this time, the level of consciousness has not changed. It's still a four, a two, and a four for a total of 10 on the GCS scale. Heart rate is still 70. Blood pressure is 96 over 50. Okay. So, the best blood pressure intervention ever recycled a cup again. Yeah. So, Spo to 98% on room air and the respirations are 14 and non-labored. The hospital is 20 minutes away. V knows something still has to be done for the patient in the meantime, but what is it going to be continuing, attempting IVs? So, here is kind of one of the things that I. yes, that is what I would say. Here's kind of why. The blood pressure has come up, but not because we did anything, right? What it would be. We did. We poached it. Right. Right. Well, and that's what it very well could be is that we have an increase in sympathetic tone. And so, there's a chance this blood pressure could go right back down again. And so, without IV access, there isn't much you can do. I hate to say it, but we should probably be thinking about I/O access, because it's not. There's some other routes to fix the blood sugar as well. We could do glucagon, for example. That's on the menu. But I wonder if adolescents this season glucagon have a problem. I don't know. But anyway, so, Google, anyway, or O-L-M-C. So, glucagon is on the menu. The other thing we got to start, you know, kind of worrying about here is sometimes it seems like patients who have been stably in their bed in the fetal position for a while and then you move them. Things have a habit of going to shit sometimes or vomit occurs. It may feel like sometimes people like, did vomit physically assault you at one point in your life, Chris, because you seem to bring up vomit a lot. Yeah, it has. Okay. Vomit has made its debut in many calls that I've been on. And it's done things that are freaking terrible. And so, I tend to have a bias to worry about vomit probably more so than the average bearer. I do work with a nurse that if you even say that you were once nauseous back in 1996, so for any of you getting like that's what I have. Like, yeah, I threw up once as a kid. Yeah, Here's some zone for it, there you go. But anyway, so yeah, so there are IV accesses really needed for this patient because they are still altered. And so we really probably start thinking about possibly I/O access needs to be on the menu. So yeah, I think IV access, I/O access is probably needed for this patient. - All right, well, so here we are, IVs considering continuing attempting IVs in route. And at this point, more IVs, V, really, look at this gunk. They look like they're flatlined on a bad brain dance. I/O drive that needle home. No more this corporeat approach. And this enters the call, V's personified conscious Johnny Silverhand. (laughing) - Oh wow, but V isn't sure about this. 'Cause they've placed I/Os before, humoral and tibial. But those previous situations were a cardiac arrest and cadaver labs. They have never placed one in a semi-conscious patient before. And as the patient does withdraw from pain, they're worried about having to manage that. And then possibly having it like, then I might have to sedate the patient, their blood pressures, kinda, I don't know if I wanna do that. And by the way, this is all internal because of course Takamura, who is obviously not privy to the conversation between V and their conscious Johnny, they suggest, well, hey, how about some, I am glucagon. Now, glucagon is retrieved, reconstituted and administered to Jackie as the crew departs, non-emergent towards St. Ripper Dox Medical Emporium. (laughing) Now, V does have doubts about the glucagon being an effective treatment. Glucagon is a hormone which causes the liver to release stores of glycogen into the bloodstream as usable glucose. But for it to work to raise the serum glucose levels, it requires that the liver has stores of glycogen. And V doesn't think Jackie has those stores. What are your thoughts here, Chris? - I agree. I don't think that's a reason to not give it, but I agree that I wouldn't anticipate it being a very effective either for that exact same reason. Because again, this isn't a diabetic patient. And so in somebody who is, is this hypoglycemic, it's kind of odd that there's, and it could just be that I have a limited knowledge of avatarsine disease, and maybe this is something I can expect with avatarsine disease. But it kind of makes me think, if you don't have a reason to be a hypoglycemic like your diabetic who uses insulin, then the only other reason to be a hypoglycemic is just not eating. And so, well, that's gonna be the main way, which means your body will have burned through with glycogen stores already. - Yeah. - And so there might not be anything to shake loose. The reason Glucicone works well on people who are using insulin is that insulin goes throughout the blood and it grabs sugar and it helps shove it into cells, where it can get used, right? 'Cause your pancreas isn't making enough of it naturally. So that's what happens. But your glycogen stores that are sitting around your liver, they're gonna stay there. And so, if someone has just taken too much insulin, and it's just taken their available blood sugar and shoved it into the cells, and the glycogen stores haven't had time to break down yet, then Glucicone's gonna work great, 'cause it's gonna go in there immediately, break down those glycogen stores, and the person's gonna wake back up, and then we can get some food in them, and those kind of things, you know? So, there's that, but in this case, my concern, I agree with me that, yeah, I think this patient very likely is not gonna, the Glucicone probably isn't gonna work very well for this patient, so that's my thoughts. I think here too, and I wanna point this out, flag it really is not necessarily the treatments, but there's a lot of conversation that is occurring in a head, and not one that's out loud, and I think I just wanna put a pin in this moment for later. So, there it is, flag on the play. All right, now, the patient's condition remains unchanged during the majority of the transport, but V is very uneasy. They spend time, as they describe, they're just scrutinizing the patient, wondering if there's something they're overlooking, continuing to second guess the decision, not to do an I/O, and this is stressful, like they're looking at the monitor, then looking at the patient, like, you have a change to have you, what are you, and then looking back at the monitor, like, you have a fuckin' change, you know? And so, it's not great. They are anticipating that something is going to suddenly get worse, but for the transport so far, the patient's condition just kind of stays as is. So, there are a couple minutes out, they notify St. Ripper Docks Medical Emporium of the incoming patient, including the low blood sugar, the borderline blood pressures, and multiple failed IV attempts, and they are asked by the hospital. I believe the doctor got on and said, "Okay, have you thought about doing an I/O?" And she's like in a. - Yeah, seems pretty obvious to us, kind of way. - Yeah, and of course. - I admit I'm with the doc on this one. I have been in the same spot with that hesitation of like, oh, this is gonna hurt like hell, and this conscious patient, but in this case, you have treatments that need to be done. You should be doing it, but anyway, go ahead. - Oh, so now that some gonk doctor, she'll tell you to do an I/O, you're gonna do it. - Shut up. - Shut up. - I said it earlier, Johnny. - Johnny. - I said it earlier too. - Shut up, Johnny. - Oh, gotcha. - Just a dood a bit. - All right, yeah. - Yeah, cool. (laughing) - Sorry. - Yeah. - With the hospital's response, V feels a lot more certain that starting an I/O is in fact the thing that needs to happen. So they grab out their kit, they get the equipment set up, and then they look up and see that the blood pressure on the monitor is now 56 over 30. They go to feel a radial pulse, and it's now absent. The patient is still looking around like before, and they are still moaning, but with the blood pressure and the loss of the previously felt radial pulse, this causes V to kind of go, oh shit. So they tell their partner, we gotta get there now. This is going south, and their partner kicks up a notch, and they arrive at the hospital a few minutes later, and in this panic, V says that they forgot about the I/O, 'cause now they're fixated on the solution being like, we gotta get to the hospital. - Oh yeah. - And I get this, you know, and when I was talking with V on the phone, I get that, you're like, all the effort, like this is the thing that needs to happen, we need to get there, and all effort should be focused. You keep driving, and I'm just gonna keep focusing, and we're both going to get there. I'm helping by focusing. - Yeah. - It's not a real, it is a real thing that humans do. It's like, this is the simplest solution, this is the best solution, let's just get there. It's just a thing that is unhelpful. - It's a permanent solution. - Yeah, it's a solution that also gets the problem out of your hands. I think that that's another strong part of it, is it's like, this gets to be a way from this, and I, 'cause I don't wanna be here right now. - Yeah. - And this will make that happen. Wait, which give it, I wanna make sure that I'm not lobbing an accusation, this person doesn't wanna treat their patients. I'm just saying that there's a natural, if unconscious, want to just get done with the bad thing. - It's panic thinking, and I think everyone in EMS has experienced it, and if you haven't, you will. - Yeah. - You will find yourself in this same spot. Just, you won't recognize it until probably, after the fact you'd be like, fuck, that was panic thinking. But, don't feel alone. And, this is part of, I think, why we train, and why we should get comfortable doing interventions. - This is your why. - Yeah, put it, next time you can do just a simple IV, never mind, it's gonna be an I/O. (laughing) - There you go. Now they're gonna go the opposite, they're just gonna I/O everybody. - Everybody, I/O, I/O, I/O. - For everybody, yeah. - Yeah, you've got an abdominal pain, you've got an abdominal pain, at least stable, you've got great vascular. Oh, it's just I/O that fucking left arm, let's do this, let's nail it. - Stop moving, all right. So, on arrival to the hospital, there. - Sure. (laughing) - On arrival to the hospital, they're taken right into the room. Keras turned over, and the point of Karr Glucos comes back at 16 milligrams per deciliter, or 0.88 millimoles per liter. - If anybody wants to know a point of Karr Glucos, that's a super fancy way of just saying CBG. (laughing) - But you're in a hospital now. - Yeah, but it's, yeah. you know, a thousand dollars instead of. - Yeah, yeah, 100%. - Yep. - The vice didn't come from Walgreens. It's just works less well and it's somehow more expensive. - So what are the nurses? You're not wrong. - No, I'm not, I'm 100% accurate on that. You see the dumbest most expensive, that it's huge too. It's the size of like an old school light calculator that looks like the ribbon paper that comes up the top. - Oh yeah, dude, yeah. - It's the stupidest thing of the planet. - And it does that irritating thing. - It's like you need to enter the patient. It's information in here first. - And you need more blood. You need a bigger blood sample. - Yeah. - You need a whole tube. (laughing) - You need one unit of blood. (laughing) - Sorry, all right, go ahead. - So one of the nurses was able to get an IV in this patient and the patient got an amp of D50. And within 10 minutes, Jackie is conscious, alert and oriented. And that is where the call ends. - That sucks. - So I really feel for our crew. So quick end of call summary guys. They get this past 250 year old male. It's awake but not really responding. They got a history of adolescents disease. And they arrive and they find that male lying in the fetal position in a bed in a kind of a filthy room. Apparently the guy looks like he takes care of himself, but just not the room. The patient is unresponsive. It's a EMS, has a blood pressure in the 80s and a low sugar. So the crew is like, "Hey, let's get him out of here to treat," which I agree with. If a room or an area is in such a condition that you can't effectively treat, then what are you doing? So anyway, they are unable to get an IV despite a lot of attempts. Vee starts thinking about an I/O, but kind of waffles. And you know, 'cause of the pain bit, talking about the FGOS, is, "Hey, try some glucogon," which is administered. Vee doubts that the glucogon's gonna work and die agree. But, you know, they give it, which, that doubt is not a reason to not give it. It's just, you know. Yeah, anyway, so Vee spends the trip, stressed out and kind of worried about the patient 'cause they should. Dr. at the hospital upon reporters like, "Hey, how about an I/O?" And Vee decides, "Yeah, I'm gonna do that." But then he writes, "We're about to do that." Patient's blood pressure goes to shit, which causes them to essentially panic think. And says, "Hey, dry faster." And then they don't end up doing the I/O. Then they get an arrival, CBG gets checked again. And it's a 16 milligrams that does the leaders. And you know, I'm not gonna convert this again. It was, I don't know. Yeah, it was like, it was less than one millimoles per liter. I want, let me convert it into my head really quick. 0.88, I think is actually what it was. But anyways. So nailed it, boom. Anyway, so the patient didn't get some D50, I might have written it down. But anyway, so the patient didn't get some D50 at the hospital and then they become I/O. But they don't say anything about the patient's blood pressure, which I'm kind of curious. But yeah. But anyway, it could be related to the, I'm kind of thinking in my ways, how good blood sugar be related to blood pressure. But anyway, so yeah, I think I'm curious about Addison's disease being an endocrine issue. And blood sugar regulation being also an endocrine issue. And there's that. I'm interested in that kind of nerdy part. Yeah. But also I really kind of want to break down the panic thinking and like where did we get hung up on not providing an intervention? That probably should have been provided. Yeah. So now what are you kind of looking forward to talking about? I think I hope we talk about Addison's disease 'cause otherwise I did a lot of fucking reading and watching videos for nothing. Gotcha. I wanna bring up CRM. It's something I flagged earlier in the call. And yeah, we can talk about Glucagon and all of that. So yeah, absolutely. Well, Addison's disease. Let me tell you what I have learned. All right, so this is an endocrine disorder affecting the adrenal cortex. The cortex is the outer layer of the adrenal glands and those the adrenal glands reside on top of the kidneys. The inner part of the adrenal core, the adrenal glands are the adrenal medulla and those release cataclylamines. This kind of fucks me up 'cause I think cortex is like, I'm it's the core. It's the inside, the core. It's not, though. But it's not, it's stupid. Yeah. The medulla, I guess, is the inside. It's the core, it's the cortex. Yeah. On the outside. Well, whenever I hear medulla, I just think from Water Boy, medulla, amangada. Yeah. Oh, yeah, that's right. So Addison's disease is an insufficiency. So it is a, they're not producing the hormones that should be produced by the cortex layer of the adrenal glands. Q who reviewed this call said that they have a simple way of remembering this versus like cushings 'cause if they have Addison's, then you need to add some more hormone. And if they have cushions disease, which is a excess of cortisol, then they have a cushion of cortisol. So I don't know if that will help you in the future. Yeah. But yeah, it's like, okay. It makes more sense than cortex. Yeah. So, all right. So how does this happen? How does it, what's the cause of Addison's disease? So in developed countries, it's primarily caused by an autoimmune disorder. So the body is attacking itself. In developing countries, the most common cause as of 2017 is tuberculosis infection. So, no interest. Infection from the lungs spreads out and lands itself in other parts of the bodies. Additionally, cancer can be another cause of damage to the adrenal cortex. So there's always that one. But regardless of how the adrenal cortex is damaged, it's worth noting that it requires a lot of damage to become symptomatic. Several sources that I've read have indicated about 90% of the cortex has to be destroyed before you start becoming symptomatic. But that brings us to the big questions of like, "Okay, so what the fuck does the adrenal cortex do?" And I'm with you, 'cause I also have questions. So there's three layers and the functions are kind of based on what layer? So the outermost layer, layer one is the Zona Glomerulosa. The primary hormone here that gets released is aldosterone. And aldosterone is one of the things that is part of that. Hey, we're gonna keep fluid, we're gonna cause thirst. Like those, it works together with that to increase blood pressure, right? The angiotensin to the system. Yeah. So what aldosterone does is it decreases serum potassium because it helps excrete potassium into the urine. And it pulls back sodium to increase blood volume and pressure because water also follows sodium. So if there's issues with that, you can have hyperclemia and hypolimia. Interestingly enough, patients who are experiencing like symptoms of this are nausea, vomiting, dizziness and a craving for salty food. So layer two, the Zona Fisciculata. So the primary hormone here is cortisol. And look, it's got a variety of functions. It's part of the immune response. It provides energy in a stress response. It's also a key hormone in gluconeogenesis and limiting the creation of glucogon in the body. And gluconeogenesis is how you get glycogen stores. So in a stressful response, it's what's providing those stores, right? Okay. So issues with this are hypoglycemia in times of stress because the body relies on those glycogen stores to help support the energy needs in those times. Like, hey, it's a rainy day. Let's pull from our, let's pull from a rainy day fund. Fuck. There's no rainy day time. Yeah. Well, Addison went ahead and pulled all the glycogen out. So we don't have it. Yeah. So hypoglycemia. It's just the collection of beanie babies that a kidney and they're just like, dude, we're gonna sell these. We're gonna get all of it back. It's all the junk that you collected, Cyberpunk 2077. You're like, all right, I don't know why I'm collecting this, but someone will buy it for some time. So the inventory just break it all down, use for upgrade parts anyway. All right. So also, I don't learn anything medical, but I did learn. There's really a thing. Chris had a really good tip. So this also creates kind of an overactive pituitary which leads to the creation of hormones that stimulate the production of melanin in the skin. So hyperpigmentation is especially in like spots that have, that get a lot more sunlight will become darker. So that's one of the other signs of this. Additionally, patients are gonna be weak, tired, potentially disoriented, like you would expect with hypoglycemia. So, layer three, the Zona reticularis, it's primary hormone is testosterone, and of course primary function there is secondary sex characteristics. So pubic care, etc., sexual drive. This is more of an issue interestingly enough for women, less of an issue for men with testes, because the testicles are the primary source of testosterone for men. But loss of this function can lead to a loss of pubic care, decreased sex drive fatigue, etc., especially in women. So there's two pathways that addisins can take. The primary adrenal insufficiency is a very slow, progressive disease. It's very easy to miss, because again, 90% of the cortex needs to not be functioning anymore for symptoms to start showing up. So, yeah, it's one of those that it's like, "Ah, maybe you should sleep more. "Have you tried drinking more water?" And then eventually they're like, "Ah, now we know, it's this." But that takes time. Another way that it can present is an adesonian crisis. And this is caused by a sudden stressor, like infection, surgery, injury, that leads to a profound cortisol depletion, which then boom, hypoglymia, possible hypoglycemia, it's a life-threatening condition. And the only treatment for it is, hormonal replacement. - Yeah, hormonal replacement. - Gotta have more calvo. - Gotcha. - So, yeah, that's addisins in the nutshell. There's a really great video on YouTube that I thought was pretty helpful in insuring up a lot of this. It's by a doctor who does an, I don't know, osmosis, addisone, addisins disease, or adrenal insufficiency. And there's nice little animations. It keeps it simple. So, you don't have time to go to a call and watch that video, or you shouldn't. But. - Probably not. - Yeah. And then I think that brings up a downside here is, there isn't a cliff notes for paramedics version that I could easily find on Google. You know, like I'm like, "Hey, just, like I don't need the exact, like all the mechanisms and all the hormones." - Yeah. - Like just give me the, give me the cliff notes version, you know? Like. - Yeah. - Exactly. Well, it's, did you imagine though, like, getting out of someone's seat? Hey, do you have a list of their medications? Also, what's your Wi-Fi pattern? (laughing) - Just, I mean, there are, I've heard many stories of people asking, like, "Hey, and also, where's your bathroom?" (laughing) - Yeah. - I feel like a Wi-Fi, at Wi-Fi list, you know? - Well, that's more understandable because I think like very few people have responded to emergencies, they're like, "Why are you asking for a Wi-Fi password on an emergency?" But everyone's been like, "No, I've had to ship myself before." - Yeah, that's not the whole way. - You know what I mean? Like, like, I think there's gonna be more sympathy out there for someone to be like, "No, I get it." Yeah, down the hall, man. - What I think you do then is you just make sure you're carrying a tablet or a chart like, and you're just, (laughing) - As far as, (laughing) as far as I'm done, I think this system's fine. I didn't see, it's a dual-parametic system. We know that's great. - Well, at least in the FTO phase, - Yeah. - There are some, 'cause there's that if you're gonna go zero to hero, then it's better to be able to go zero to hero and at least be trained by another paramedics. There are systems out there that, well, you and I not only have taken calls from, but have worked with where, oh, you've got your paramedics, sir. Yeah, day one, you're in charge. Like, you're gonna go through Neo and learn how you get paid, and then you're in charge of the next call that comes down the pipe. - Not your paramedic. You know what you're doing. - Yeah, you went to school. - What else can I possibly teach you that the college couldn't, you know? I don't think that this episode really leaned on analyzing the system a whole lot. Nothing really seems broken from my perspective on it. There are challenges, of course, with any system, and you have fewer resources here and there, but at least in this call, I didn't see any system issues where they're ugly head, did you? - No, not that I could see off the top, no. - Yeah. - There's always gonna be kind of that limitation, you know, when fire doesn't auto launch to everything, I understand why, by the way, I'm not saying they need to, but, you know, with that, it's gonna come to the territory of being like, do I really wanna, I look at it as kind of like, do I go code one or code three? Like, do I wanna make a big deal out of nothing kind of thing? And you've added another opportunity to accidentally make a big deal out of nothing, and for a lot of paramedics, there's nothing worse than making a big deal out of nothing, right? 'Cause you feel new and like, you don't know what you're doing, you know, like you're scared, like you're scared, little baby medic, which in this case, you might be, but, you know, yeah, that's kind of, that's gonna be a natural barrier in a system like this. So, that's there, but at the same time, there are trade-offs, right? Like, if we're a community, we really need to be watching our resources and making sure that we are allocating them appropriately, then the trade-off may be worth it. So, I'm not gonna say, I'm not gonna sit here. I'm very hesitant to tell everyone that, nope, you need dual-Aless cars and dual-Aless response on every call, because that's not realistic based on resources, 'cause I'm like, okay, how many fire stations you want? 'Cause we can do that, but then you have one to cover an entire county, 'cause that's expensive shit. You know, so it's kind of like, there are trade-offs. So, anyway, so that said, moving back into the crew, I like the pre-game. I like that they Googled the Addison's disease thing. - Yeah, yeah. I think that's totally fine. Hard part, sounds like it's pretty complicated. You may not be able to get all the info you need off of a quick Googlin. - And that's gonna be, I think, a variety of, like, not just Addison's disease, but there's probably a bunch. There are diseases I've never even heard of that I'm gonna go on and I'll be like, "Well, that is like Googlin." And probably come up with also not great helpful, you know, like I'm like, "Oh, okay." - Yeah. - 'Cause they walked away with, okay, maybe some hypotension, but you have to kind of dig deeper to see that the blood glucose issue could also be a factor in. That is not just put up front. That is not the first suggestion by Google. So, yeah, there are some things that were kind of buried back in deeper in the notes that you have to kind of work to get to. - Yeah. - So, now, here's kind of the, oh, sorry, go ahead. - No, no, no, go ahead. - Now, here's kind of the other thing. What I didn't hear from in their pregame was talking about, "Hey, let's make sure we have it all," that we're going to the author's LLC route, but they may have. I mean, it's just, I wasn't in the ambience with them. - Yeah, and I don't know how much conversation they had. I don't recall from my conversation with V, but I do know that they said, "Hey, it could be this, but let's keep, we'll just, we'll keep this in the back of our heads and we'll just see what's going on and what we find and treat it as we find." And I think you brought up a really good point earlier on the biases with dispatch. We can tend to anchor in on the initial information that we're given. And so, it's like you're told Addison's disease is in here. And so there's sort of this like, "Oh, it's gotta be." And honestly, maybe in this case, this could be, we don't know, we don't have follow up from the hospital to where they go like, "Yeah, they needed cortisol." And we were able to give them hydrocortisol or whatever. We were able to give them treatment to help fix that and their blood pressure. So. - Well, Addison does seem like it would impact both blood pressure and blood sugar. So, yeah, we have that. - So, yeah, I mean, so in this case, probably wouldn't have been harmful, but I do think your point is apt, which is, we wanna be careful with information 'cause sometimes information is volunteered that, well, it seems like it's helpful. It's just kind of distracting. So, I think this is the great way to do it is like, maybe this plays in, maybe it doesn't. - Because one of these you have to understand, like, and you'll go on calls where you'll have someone who is a friend or a family member who's gonna try and direct what you need to do based off the patient's history, but they're not responsible for this patient's outcome. - You are. - Yeah. - And so, there is a customer service thing here, and I'm actually gonna do a two points here. That is, so while Google may not be a good source of information, family members may. - Yeah. - And so, your pregame can kind of get pushed into your arrival assessment where if someone's like, yeah. They have X, Y, Z disease. I helped them manage it, particularly like parents with kids who have more unique or less common diseases or like kids who are on ventilators chronically. You know, the parents are gonna know a lot about those things. And then you can kind of use people on scene to help fill you in on what could be going on and those kind of things. However, a lot of times, people who are bystanders on scenes are really, really good at knowing a lot about the disease, but they don't know about other diseases that can look exactly the same. So it's still on you to both acknowledge the concern of the people on scene, but also make sure you're doing your full thorough exam. So if you get on, see you, you have someone be like, oh, this, this, this patients, you know, they have Charlie Chapman-Buller's Hat disease. And it's, it's really serious. There's a lot of things. It's gotta be this again. You might have to be like, all right, cool. We're gonna look into that. We also need to make sure that it's not anything else because, you know, everybody's vulnerable to all these other things. But yeah, so tell me more about that while we start checking out vital signs and we're gonna start down that path, you know. And so you can always, what I always like to do is, I don't lie to people, but I make them feel heard and tell them that I'm gonna do, that I'm gonna go down the path, that I'm gonna investigate the thing they want me to investigate. I'm just not gonna tell them what I'm gonna do that. So I'm just feeling like, hey, it's this, this, this, this, make, all right, cool, awesome. Thanks for that. We're gonna get on that route. We're gonna check a couple things with vital signs and whatnot. We're gonna get an IV and tell me more about that disease and then get them talking while there's stuff's going on. And they'll be distracted enough that by the time you rule out, like, yeah, hearts not pumping. We're gonna start CPR, you know, like that kind of stuff. Yeah, you know, yeah, you can kind of get there. So what you don't want to do is give people a wall to push against what you don't want to do is do the whole 13. It's like, hey, we're gonna get to that. We're gonna do my thing first. You know, you start doing that and people are gonna be like, all right, Dick, or some people will respond well. That's very true. Some people are gonna be like, okay, I understand. Not everybody. Yeah. And so, but a lot of people respond, will be like, oh yeah, no, thanks for that. Yeah, we're gonna start double checking some things on the way there, but yeah, what, what, what did we do last time this happened? What, what does this, what normally happens with this patient? Tell me about it. You know, and be interested. Be interested in what they're saying and then just do something else and then get to that if you need to because they could be right. Be prepared for people that aren't you to be right. So, with that, let's move on to their arrival and their assessment. So, well, they kind of want to point out, sometimes new medics kind of think that if a preceptor isn't recommending a treatment path or something, that it's then not necessary, especially depending on what phase in training that you're at, right? So like, if they recommend one treatment, but then nothing beyond that, like, I don't know, glucogon, then the treatment they recommend may be the only one that is needed. And that can really occur in training as you're transitioning from, 'cause a lot of training programs, you start out, I would say more observational. Or at least as an FTO, when I first meet you on day one, that first call, I'm probably gonna be making a lot of recommendations to you, okay? And if I'm not, you know, to marking clear transitions to different phases, being like, hey, I've served you for today. So for tomorrow, I want you to be taking the lead more often, okay, and I will only interject where I need to. And let them know that, hey, I'm not the end all be all on your information anymore, you're gonna be taking a more active role in the treatment plan. So if you're, if you are an FTO, then make sure you're, notify your training what's expected of them. And these kind of problems can be avoided when expectations are clear. One of the other things that I always like to integrate into my training, that will actually help maintain expectations throughout. It's these three questions that I talk about them frequently. And that is, at the end of every call, no matter how simple the call, if you get time, if you're an FTO, turn to your training, you'll be like, hey, so tell me, what did you not like about that call? What did you really like about that call? And what would you do differently next time? And they must answer first. If you answer first, they're very, very likely to agree with you, not because they're lying 'cause they don't agree with you, but because they will suddenly see things from your perspective and be like, oh yeah, they're right. But that's gonna take away that window into their mindset. And knowing what the training's mindset is, when they're in these calls, is so valuable as an FTO because you can start correcting problems, you can really kind of get like, okay, what are they seeing? What do they see unseen? What distracted them from the truth? Or what led them to success on this one? And someone can say, everything went great, nothing went bad, I'll change nothing. - Yeah. - Let me back it up. - But they can say that. And that's gonna help keep expectations clear so that people know where they are in their training so that they don't assume, make the assumption that may have been made here, you know, with the Glucogon. Because in this case, the FTO didn't have a ton of input. I think, and again, I backed the Glucogon decision. I think it's a good decision. But there may have been some more input. Yeah, and so I think from the FTO's perspective, they may have assumed like, yeah, it's hypotensive. Of course, they're gonna go ahead and start the IV or start the I/O and start treating this, you know, and then they didn't. - Now you think that's the thing that, this is the thing that I think is tough. And this is something that I started doing as an FTO on the ground, which is, you know, if it's gonna be my partner's patient, I'm gonna be up front driving and, you know, not able to kind of keep an eye on what's going on in the back as well as I'd like to. Then one of the things you do before you leave is like, hey, what's your treatment plan for this patient? - Yeah. - Yeah. - And just-- - Very good. - Get start that conversation. And, you know, like, if I'm, if I, like, what do you think about this? I and I tell people, you know, I tell trainees, or I've told other medics that I work with, like, hey, if I suggest something, it's literally me going, like, hey, what do you think about this? Not necessarily a, hey, I think we should do this. I'm just exploring an idea with you. I could be wrong. You could have a better idea. But let's have a conversation so that we can have those, like, so that, you know, everyone's kind of on the same page on how we should treat the patient going forward. And so I think, you know, if you'd say, like, man, I should I do an I/O in this guy? Then his partner could have gone, yeah, right? You know, like, yeah, I think so. Or, no, I mean, as blood pressure is 96 over 53 now, or, you know, whatever it was, I don't think it's necessary. But then you have a little more, you've had, you've at least had that conversation. And then if things change, you can go, hey, man, I think we need to revisit that I/O. Their blood pressure is worse and we still haven't had any luck with the glucon, you know, like, well, yeah. And I think this is where we pull that pin out that you placed earlier. Because remember, you placed the pin earlier where you're like, a lot of conversations going on in my head that aren't coming out out loud. And this is kind of one of those times, especially when you're in training or with your with a new partner. I like to do this with partners I've even worked with. Yeah. Just say what's in your head. Yeah. Say what's in your head out loud and then that kind of lets other people chime in. You know, don't say everything that's in your head, obviously. You know, where it EMS, there are things that we probably probably shouldn't always say. There are some things that are just inside voices, you know? Yeah, exactly. But, you know, but treatment things, you know, say those things out loud. Like, hey, like, hey, like, I'm seeing this blood pressure fall. I've seen this type of leukemia, you know, issue that's, that we're not able to resolve. I'm really thinking we need to be doing an I/O. Now everybody's clued in. That can be hard when someone's at the front of the ambulance and you're in the back. It's not, you know, yelling up front sometimes can get difficult. But, yeah, this is where I like, hey, if you're having a bunch of inside conversations, it's okay to make them outside conversations. This is actually something that I will do on a lot of calls. We will load patients to the helicopter, I'll look over at them and be like, okay, they're chemodynamically stable. If they, if they're not going to be chemodynamically stable, what do you think about starting with a fluid bolst and then moving to a presser? Or, you know, if they've had, you know, four liters of fluid and they've got urine output, like, what do you think about going straight to a presser? You know, like, yeah, those kind of things. Have those plans where all I'm really doing is stating what we already know about the patient, you know, I'm not just reading the monitor and then keeping my conclusions to myself and assuming my partner has the same conclusions. I'm reading the monitor and being like, okay, I've got a patient who is, their blood pressure is good, but they're very tachycardic. So I'm concerned that they're trying to compensate a lot for that. So we may have to intervene. How should we intervene? This is what I'm thinking. You know, don't just look at the monitor and sort of picture your head and stay quiet about it until shit hits the fan. Have the conversation out loud. Yeah. No, I think that's perfect. All right, great. (imitates drumming) Let's move on to a treatment. So I initially, one of the notes I had for this call was, you know, hey, if you've identified a life threat, you know, like, for instance, hypotension, maybe start working on that. And then I realized, you know, I realized as I was going through the call with you that, you know, that if you were multiple people there, then yes, I'd say immediately assign somebody to start doing that. But they recognize like, hey, this is a person who, you're like, you know, this is, they have hypotension. We don't want to treat them here. Let's expedite trying to get them out to the ambulance. And in the meantime, then they did a, they're like, well, I have time to kill. While I'm waiting for that intervention to happen, I'm going to do the 12 lead. I'm going to check a blood sugar, et cetera. And when I think about it that way, I'm like, they did identify that there was. need to, you know, like this was a sick patient and that, you know, that they were going to try and reverse that piece. So I, I think again, if if you're in a situation where you have more people there, you know, benefit to having other responders there to help you can start trying to address that piece early, because I typically am one, I'm like, hey, if you've identified somebody that is as type of a leemic, start treating earlier because like Chris said, there are times where, yeah, they're, while they're there, they're relatively stable type of a leemic if that makes any sense at all. But then like, but then you like nudge their toe and suddenly, VTAC or VTAC, you know, yeah. So, yeah, I think in this case, I retract my, my like, criticism would be a strong word, but I guess it qualifies I would retract my criticism here, but I think the point still stands like if you recognize that there's a potential life threat, like hypothermia or, you know, hypotension, excuse me, then start working on treating that, you know, right away. But I think the, I think what it comes down to is, you know, moving a patient versus doing a treatment is, and that is, is that is, is trying to attempt this treatment where they, where they sit right now, is that going to be a detriment to accomplishing the treatment and then a detriment to, to helping the patient? If the answer is yes, then even in a, like we've talked about a, oh, the IC dead people episode, which is an old old episode, but I really like that episode where we have a paramedic who just runs in and she's just a boss and runs a double code. Yeah. And what I think she does is she's like, yeah, pull them out of that room. I know they need to see PR now. Pull them out of that room because if they stay in the room that they're in, I think that happens in episode so old. I was literally five years ago, but you know, if they, if they stay, it's more than five years ago, shit. Anyway, if they stay in that room, and they get pulled out, or if they stay in that room, then we're going to, that's going to be a detriment to the patient, because we're going to terrible interventions and we're not going to get good chest compressions and all that stuff. So in that case, it's like, yeah, we don't want to wait, but pull them out. No, that yeah, I don't know that that was the situation here. Again, I wasn't there. It's kind of a cruddy room. I would imagine so if you're trying six times to get an IV and you're not able to, like, ask your ex-mites suck. So yeah, no, that's a great point. That's going to be an optimal lighting conditions in the back of an AMLs 2, because there's one thing the AMLs does do well. Well, typically the ambulance does that really well with lots and lots of light. So yeah, anyway. So let's talk about some of the treatments they had. Let's, do you want to talk about the glugigon first? You want to talk about IO or not doing an IO first? I want to talk about an IO, because this was a point that Q brought up. And their point here is like, this is a good example of why everyone should be comfortable with their pain management for IO protocol. Usually, super low doses of light of cane do the job very well at numbing, and then you can add a little bit of fentanyl or something along those lines as well. But we've had a couple calls in a row here where, you know, hesitation has been, or there has been some hesitation in putting an IO in a in a wake patient. Do it. It's fine. Yeah, it sucks. Because here, I'm right there with you. And maybe this isn't exactly what you're saying, but I think it is. Yes, you need to be okay with your pain protocols like the lidocaine, but you need to also be okay with causing pain sometimes. Yeah, it sucks. I don't like it. I hate it. And I think that's what the hesitate that that's why I think I related so hard to the hesitation one to do in one of the do this year is that I hate it. I would be wary of fentanyl on this guy, because I think the only spike in blood pressure we saw was with some sympathetic tone after moving the guy. Yeah, and then being like, here's the fentanyl to make sure you feel no pain. But you know, you got an IO and now you can first inflow it in there. Yeah, hopefully it get works. Yeah, it's exactly. I mean, which honestly, once we got the blood pressure up, I'd be like, I fuck in the fentanyl over. But yeah, the one thing about fentanyl, as I will say, what I do like about it is that it doesn't cause a histamine release like morphine does. And so you don't have the profound hypotension, but anytime you reduce someone's sympathetic tone, you know, because remember, like when we're when we're in pain, the typical response from the body is to get a little tachycardic, get a little blood pressure up, though that is not always the case. So please do not presume that just because your patients are not tachycardic that they don't have pain, that's bullshit. It's been proven time and time again. In fact, I think we have an episode where a patient had a heart rate in the 80s and they got ignored for pain control and they ended up having like a ruptured ovary cyst, ovarian cyst or something like that. I think we have an episode somewhere like ovarian torsion. That's what it was. Yeah, remember that one. Yeah, that's where it was. And they weren't tachycardic and the person said, well, you're not tachycardia, it's horse shit. But anyway, but understand, though, that the fight or flight response is a real thing and it is a response to pain in some patients. And so if you take away the pain, you may take away the sympathetic tone that they've been generating from that. And so you may see a blood pressure dip. And if someone's right in the border like this, like this person is, especially when you move them, that's the only blood pressure spike you get. I will point this out. There's kind of a funny thing about like in my mind, and this is what I caught during my cell. This is nothing to do with a V in this is that when I heard the first low blood pressure, my immediate brain, because I really like to put myself into the call, right? Like mentally. And my immediate brain was like, oh, cycle it again. But you know what my brain didn't say that when we got the one good pressure, when we got the one good blood pressure, my brain was like, no, that's acceptable. It's fine. It's fine. I like that one. I'm so willing to accept, I'm so willing to recycle it on the lower ones, but then the one that's good. I'm like, don't touch it. It stands. The place stands. Let's change that. Blackjack. Yeah, let's let's change that from every five minutes to every 15 now that we got a good one. I don't want to see a different. I can do it the hospital. I won't even have to know this. I feel like blood pressure is like blackjack. Every time it comes up, you're like, hit or stay. Yeah, yeah, totally, totally. Oh, good, stay, stay. Yeah. I going back to I/O. Sure. It is really hard to blaze new trails with interventions. And I think that's again, that that plays part of this hesitancy here. You know, it's like I haven't been down that road. I haven't done, you know, like where I've put this in in a semi-conscious patient, or I haven't done it in this situation before. Is that the right thing to do? This is totally totally an understandable thing to do. And again, you can bypass that by relying on, you know, if you're working with another paramedic or another partner, talking with them and having a, you know, that conversation or contacting online medical control, you know, like not intended here, but you know, when the doctor comes back and goes like, "Hey, man." Yeah. What about this other thing that you can do? And, you know, that those are all things that can help you decide, you know, whether it's like, who is it worth treaching down this, you're forging this new pathway, this new neural pathway where I could do this now? Because, you know, like the eighth time you do it, you'll feel you'll be like, "Yes, no big deal. We're just going to do this." So anyway. It'll be just like IVs, except a little bit worse. And I will say this, that whole thing like real like actually, I would just really hurt just when you flush it. It hurts both times. I've never given an I/O to a conscious patient and they're like, "Well, not that bad. It's never been the case." Yeah. So which given, I haven't done a lot of them. I don't do a lot of conscious I/O. It's not like a daily thing. I'm not just like driving down the street being like, "Topein, you know, like that's not the case." But it hurts both times. Just be beware of that. So with that glucagon. So I think V was right on the money on this one. Yeah. Like you're saying, like we've already been making withdrawals from the rainy day fund. And so it's gone. And now we need to make more withdrawals in the rainy day fund. And it's not there. So kudos to V for knowing glucagon well enough to anticipate that not working. You know, however, in anticipation of that not working, probably more evidence to go start that I/O. But also I'll put out there that it needed to be done. Yeah. I think it was absolutely a worthwhile intervention. I just agree with V in this case that, "Hey, like, because here's the thing. What I would really like for this is like, yeah, it's not going to work." And then they're like, "But I'll give it." And they're like, "Oh, fuck it worked." Like that's always nice. Yeah. That's a good time. But it's just not likely in this case. But you know. Yeah. I don't see it downside. I mean, I think if I were, you know, order of operations, you know, if we can't get the IV, okay, maybe this is one where we do the I/O. And I can understand someone one's thought of like, hey, we normally get refusals on diabetic patients. Like, do we really want to put in a high-o and a person who's then going to be like, why are you doing this? You know what I mean? Because that's typically the way this goes. But in a patient who doesn't have diabetes, who also has hypotension, I think you are more than justified to go the route of the I/O. And with that, then you can do, you know, dexterous solution. And I think that's where I would have gone with this and be to do the I/O and then to do dexterous. But failing that, if I can't get that either, then yeah, like I might not think, I might I would have the same thing. I'm like, I don't think this is going to work. I'm still going to fucking do it because I don't have anything else. Short of just opening their mouth and squirting. Which is a bad idea. I think my Nebulized D50 was a better idea than I don't think it would be a good idea. I just hold their jaw and make a chewing motion, you know, as well. I like they're protecting it. Could you imagine the mess that that would make a aerosolizing D10 or D50 fucking sticky? That would be all over the place. You would feel sticky all over. I kind of want to do it now. I'm just to say, yeah, I want to ruin someone's room just to. Not mine, of course. Go do it in some house or that problem. You know who has really good lighting? The nurses room in your place. Yeah. I do it in there. Do you want ants? Cause that's how I get ants. Anyway, so yeah, I think you're right. I think the glue gun was worth a shot. So let's kind of look at this from a BLS perspective. This is going to be a difficult one BLS wise. The things that we would watch out from a BLS standpoint, because I'm pretty sure glue gun is not in most BLS protocols. No, I think oral glue cost is it. Yeah. And in this case, we don't want to give this guy oral glue cost. That would be a really bad day. If you are in a BLS system that puts IV access and IO access into the BLS scope, then amen. I don't know a lot of systems that do IO in the BLS scope. But definitely worth the IV access on this patient. Even if it's one of those systems where you can establish it, but you can't push anything through it, then the IV access is needed. I'm really curious as to what if this patient's hypotension resolved with the added sugar, I don't see why it necessarily would, but I'm just I'm curious. But we don't get to know. No, we don't get to know. Welcome to EMS. Exactly. Accurate. So with that, this would be somebody, depending on your ETA to the hospital, this would be someone that would probably be a good candidate for an ALS intercept. I'll kind of state my mantra for ALS intercepts and that is like, don't think of it as time to turf, you know, like as in like time to eat the patient to somebody else. Think of it as time to intervention, right? And because a lot of people will kind of get into this false thing where they'll be like, well, I can get to the hospital in, you know, in, I'm 10 minutes away from the hospital. So it's, it's going to take five minutes for the paramedics to get to me where I met and then they're going to have to go 10 minutes. So that's 15 minutes and that's longer. So let's just go to the hospital. Well, if there's a life saving intervention such as airway management that can be accomplished in those, when the paramedics arrive, then what you're really looking at is time to intervention. And if paramedics are the fastest route to get that, then depending on what you need, it may be worthwhile to take the extended time to hospital and trade off for a small, a shorter time to intervention. That is, that is one of the ways to say it. Now, if, if the hospital's five minutes away and the paramedics are five minutes away, then yeah, it's kind of hard to justify not just going to the hospital because the time to intervention is the same, right? Except one ends at the hospital where they need to be and the other doesn't. That's a hard justification. That case may be better off going to the hospital. But that's just kind of the way that when I think of ALS intercept, that's how I, that's how I think of it. One of the other things too that there's a flight bridge ed episode and I can't remember the one that it is, but they're talking about how like, hey, there's nothing magical that happens just because you go inside of the ER doors, you know? Oftentimes there's an internal delay at the hospital that prevents things from happening rapidly. So it's not, if there's an intervention, the patient needs and it can be done in the field, then it needs to be done in the field because there is a lot of Jimmy, the EMS Avenger, has something that he is pointed out in one of his TikToks and that is that proximity to hospital is not an intervention. So, yeah, that's right. Put it in action. Inaction is an action is. Yes. Yeah. Yeah. I disagree. I think this minute you touch, you go through the double doors. You basically are like, hot potato of liability. It's now your problem. I'm done. You're not a 100% wrong. I can't, you know? Well, I think there is a little bit of truth to that. It's not the wrong thing that's ever been said. But anyway, well guys, it's been to get anything else. No, I think that's it. Oh, what a fun episode. No, it's an impact for this one. Yeah, no interest elbow is going to come in and in there. Anyway, so with that, everybody, thanks again for listening to yet another episode of EMS 2020. 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