EMSOTM 34 - Modern Pre-Hospital technology in the back country

[Music] Welcome to the EMS on the Mountain Podcast, a show for those interested in austere and wilderness medicine. This podcast provides insight into the unique aspects and challenges of bringing modern EMS into wilderness and austere environments. [Music] All right folks, welcome back to another episode of what is this show called EMS on the Mountain. Forget what we were doing there for a minute. Today we're going to talk about some we'll call it technology. I don't know if it goes we would call it it is technology that is evolved to a point where it's now available in a much more compact form factor and is usable and accessible to guys operating in the wilderness and austere environment. This is a lot of stuff that normally would not be found outside of an emergency department and occasionally critical care transport whether helicopter or ground but it's making its way into the woods and other austere environments. So with that technology is cool and Mike told us I love technology. Mike's all about his technology. I'm a little more old school grease pencil on a piece of laminated paper. You are old school. Mike's got an iPad. So I do have an iPad just one. Yeah. Just the one in front of him right now. I think before we get into this just remember despite the advances in technology and the stuff that's available out there and this would apply I would say to EMS and even medicine in general is don't let the technology become your focus. Your focus is the patient. The technology is just there to help you assess and refine some of your your diagnostics and help guide you in treatments. So that's my little caveat. You're cool out there. It is important right? I believe in school they call that treat the patient not the mom. Yeah which really it's treat the patient not all the other toys that we're talking about today. Yeah that phrase is getting to the point of annoying but it's a valid thing and so we let it go. I'm annoying so it lines up well and here we are. All right so all right let's do this. So yeah let's get right into this then okay so the first device we're going to talk about and this is found it's way into a lot of pre-hospital environments not just the wilderness area but point of care ultrasound or focus not just have who focus focus right. Isn't that the president of the United States. No that's POTUS. Yeah yeah. I was you confused me but okay so yes ultrasound right so some of the things we can do with the ultrasound is the common or I guess it's not necessarily common but one of the most common things done with portable especially is the fast exam or a beef fast exam or no wait that's a stroke. So your fast exam what is a fast exam? I think you're looking for e-fast there. E-fast. Yeah. Yes right so essentially you know these are tests usually conducted in the ED by physicians kind of getting those we'll call them quick rule outs looking for free fluids in the admin and before looking up into the chest as well. So focus for us I think depending on where you work in the austere environment so this will obviously vary if you're working a remote base camp when the Antarctic or on a glacier somewhere at the Everest Base Camp Hospital right it has a different implication similar you know same application but it can be used a little bit differently I think for application Mike and I are generally talking about today or backcountry type providers working in a truly austere environment or the wilderness as it were. Use of a focus device is going to let you determine how bad your patient is and whether you need to really be working towards evacuation or not. Yep so it's like you had somebody took a significant fall maybe even involved in some sort of recreational vehicle or a horse roll over right horses do roll over horse and people kind of chuckling a horse roll over oh yeah if you've ever been on a horse and it's decided not to stay on all four legs it's a horse roll over it's a horse roll over and when a thousand pound animal rolls on top of a human it's generally not good for them. That's the human best right for the human. So that's not great for the horse either but oh yeah I mean yeah depending on why it fell but so a portable focus device or ultrasound can be used to do that quick exam like let's look at the abdomen all right do we have any blood or other free fluids in there that shouldn't be oh yes we do okay that is not a good sign we need to expedite our evacuation or give us a higher priority same with looking up in the chest can we see pockets of air or blood up in the chest you know looking at the new mose or the hemos you can even look at cardiac function is the heart beating does it look like there might be fluid building up around the heart etc so these I think are really good in helping to prioritize evacuation needs I think a lot of people want to get wrapped up into some of the other tricks and things you can do with it like looking for fractures which cool if you've got the time but if the mechanism is present and the patient presents with the appropriate signs and symptoms just call it a fraction be done with it which I mean if it seems like a broken limb it's probably a broken limb and even if it's not broken you should probably be doing the standard BLS broken limb protocols because if it's awee treat the patient not the ultrasound yeah right so the ultrasounds are great right because now there's a lot of them that there are some wireless Bluetooth models out there now that you can connect right there with your cell phone or a tablet tablet would be better give you a better screen better view but you know they're small they're handheld they're portable the relatively lightweight so these are making their way into a lot of ambulance services particularly the critical care side in flight and ground transport they're finding their way into just regular 911 ambulance systems but it's one of those I think things that it's just giving you a confirmation of something you're already suspecting right like oh they have some severe abdominal pain with some distension and a bit of bruising here probably bleeding in there oh yep sure are so depending on your environment it's giving you that confirmation of yeah this is definitely bad you can use that to provide a pre-hospital transport like yeah hey and on ultrasound I have this which might give that hospital a little more confidence in the nature of the injuries you're reporting to them and be better prepared other than like we'll see what these field monkeys have and if it's the right one they get here we'll figure it out yeah that's my only what you're doing in a knee fast exam is looking for fluid in the abdomen and the pelvis right that is probably the most applicable use case for the wilderness as Sean mentioned a bunch of people have tried to do a bunch of other cool things the other thing that is commonly talked about in pre-hospital that I hear is difficult IVs which you can make the argument for it in the wilderness but based on my experience you got to be really good at ultrasound be able to nail IVs with ultrasound it's not easy well in most of the the portable ultrasounds aren't really set up for that particular no they don't have the occasion what's cool yeah they're not quite detailed enough yeah it's a useful but let's say it can't be done some of the new ones I guess are probably getting a lot better than older versions out there but yeah IV access you can look through looking at interocular pressure for possible TBI you know brain swelling and stuff so there are some really good I mean a little ultrasound guided needle into the heart drain and fluid yeah pericardial yeah there you go yeah right and it is it is funny its way into confirming Ross or excuse me Ross confirming cardiac arrest yes absolutely but in the in the wilderness setting I think the the number one thing is it's really a driver for decision matrices hey this dude needs a helicopter ride right now because there's fluidness abdomen and I'm not a surgeon yeah and I would say this really honestly I don't know if if you gave me one tomorrow if I'd really want to carry in the woods for what I do sure it could be both no I would yeah might might absolutely would I see this much like a like a swells down the trail so he did it once once one time this what I think is probably better suited to something like say at Everest the base camp there or one of those out in the Arctic where calling in on aviation asset actually is as serious deal it's not just like we have an issue we have some suspected significant injuries and we just call for one of the local Hems Resources and they either say yes or no they can fly and we do all of our prep work and we get them out whereas if you're calling in a helicopter to the Everest Base Camp or you're working in one of these other remote austere settings gas oil platform whatever might be getting a helicopter out to you is not just a quick radio call in a 15-minute flight right some of these things can take hours to not just coordinate but a significant flight time to and so you don't want to waste some of these assets necessarily and depending on the weather conditions you don't want to necessarily force something that could lead to a worse outcome so I think it's a bit more applicable in those instances where it's definitely like oh yeah Bob here definitely has flew in the afternoon we absolutely need to kid him out and then you can prioritize the risk and the need for getting some of these resources a little more difficult to get yeah I would agree yeah it's it's a confirmation of what you believe is already going on and I don't think that's a bad thing necessarily I just think people need to use it for what it is and not try to make it into some sort of magical device that's going to tell them exactly what to do yeah I agree as you know I've had a scenario that I could have used ultrasound look at interocular pressure but the reality is that I would have to practice that so much for the one or two times I would use it for confirmation for what I suspected that in my opinion it's a great tool but it's not the only tool and there's a lot of stuff we have to keep up with and to maintain that skill set for the rare time I would use it is probably going to result in a degraded skill set to the point where it's not useful. Yeah, yeah, that's yeah. Ultra sound is one of those things where you've got to practice it and be good at reading the ultrasound because it's not just as simple as like looking at an x-ray because you're looking at only segments at a time depending on the type of ultrasound you got. So yeah, you've got to be proficient with it. All right, well, I think that's enough on point of view. Yeah, so now that we've belabored point of care ultrasound let's talk about point of care, AVG testing. Yeah, these are actually used in in wilderness settings in some environments. I know that are used at West for like Grand Canyon to look at sodium levels and such. There's really the big one out there is called Nisat. It's kind of the most common one out there. If you've been doing EMS for any period of time and you've taken people to a trauma bay, it's quite often used to get early perspective on any abnormalities in critical systems. Here's the kicker with these. They're useful, but the good ones to get an accurate thing, you need an arterial blood supply and it's not super hard to get arterial blood supplies, but it's not pleasant for the patient and that was sarcasm. It usually hurts pretty bad. And quite frankly, at the end of the day, this is another thing. I mean, they're they're quote unquote handheld. They're portable, but the supplies that go with them are relatively sensitive. The many take a point of care testing unit into the field. You have to care about the test strips and the little cassettes and all the things that go with it. In my opinion, wilderness setting, again, this would probably be useful at like a base camp, places where you're managing people for weeks days or days weeks. I don't think months would be appropriate most of the time. A while for emergent wilderness or rescue. Maybe you could make the argument that it would be functionally useful to be able to draw labs for extended care. But again, is it going to ultimately change your treatment modalities? And I'm going to argue on this one probably not. The reality is that the depth of information that we are able to attain and acquire from point of care lab testing is somewhat offset by the number of medications and other tools we are carrying with us into the wilderness, other than a bag of mask to maybe work on as the base balance problems that may arise or that are indicated by the I'm going to stop stuttering now and cut all of this out. You might be able to gather more information, but I don't think you're going to be able to intervene in all a lot of it in a wilderness environment. Yeah, exactly. It's like it'd be cool to pull up your basic labs and be like, oh, neat, here's my stuff. But the reality is what are you really acting on with that? You know, it's like, I'm not carrying that many vials of bicarb to do anybody any good. I mean, most ambulances only have one one or two bicarb. Yeah, right? So it's like, I'm not moving the needle on somebody who's severely acidotic. Let's be honest. I can't say we wouldn't use bicarb for things, but no, but I'm just saying like protocols are very much like bicarb if you need bicarb. Yeah, you're you're not doing a lot of lab testing for any emergency. Yeah, see, that's just it kind of almost be just like you said, it's like, okay, good baseline, you know, and if it were for us, it's like, okay, eight hours later, probably haven't moved the needle much on that. And like you said, unless you get some that can do essentially, venous testing, which they make those, you know, haven't it? It's just not as accurate, right? Well, yeah, it will, they can't be. It's just it's it's a different algorithm that's set up to test venous blood. It's things are a little off because yeah, they want to pull from straight fresh arterial blood, but beside the point, yeah, I don't think this is one of those things that super beneficial to what we'll call the EMS response side of children and testosterone stuff. Certainly for people working in the austere environments, yeah, this is certainly be something you could have again, confirmation of certain things like, do we think Bob's getting septic, you know, do we think he's got something else going on? Yeah, these can help me confirm my working diagnosis and say, yeah, most likely. And then depending on what you get going on, they could help guide like, yep, he's now coming around treatments are doing what they're supposed to be doing and things are looking better. So yeah, I mean, I can make a argument for the value. There's always a dichotomy in the wilderness, like how much stuff are you going to carry with you for the majority of patients? And I exactly. PortiCare lab testing devices are not cheap. Now, if I had all the money in the world, sure, great, I'd love to own one good for that corner base, right? But it is it is not an inexpensive endeavor to carry it around in test blood labs in the woods. And there's a lot of, a lot of factors when it comes to doing pointiCare testing that really are mediator. It makes the tool less useful in the wilderness, right? I mean, temperature matters, dirt matters, environment matters, all that stuff. Yeah, yeah. All right, so that's it on ABGs. No. Yeah. Yeah. No. Catenography is, I'm a huge fan of, of, of, catnography, as I call it, catnography, catnometry. There is a device out there called the, the Emma. I forget what it stands for. I don't know if you know of the type of hedgeon. I don't eat MMA. Don't eat the most small, I believe. Yeah. It's a little portable. It looks like a little, looks like a little pocketable ET test device. Yeah. You can google it. The kickers, they were designed for ET monitoring for intubated and, well, tube patients in general. They do work with superglotic areas as well. Yeah. But they're designed to be adapted to be placed on a tube. There are teams, we know of, there are folks that attach them to a mask, like a CPR style mask. Yeah. Well, basically like an NRB mask. Yeah, like a non-rebrother style mask. Sean and I were just talking about this before we started recording. They're great. If you have an unconscious patient that isn't intubated, it's certainly a baseline. But they're designed to go into the tube and monitor, you can actually get waveform on the newer ones. I think it's called an Emma 2. If you're using narcotics sedatives, if you're, you know, you have a seriously injured patient, I do think there's some value in using an Emma for intubated folks for sure. Especially if you're trying to not overbag them, which is a common common occurrence. This is like the one piece of technology that if somebody was like, do you want one, I would jump at it and be like, yeah, yeah, absolutely. Like, I would, this is the one I would certainly take. Yeah. Because even if you have to do the kind of field adaption and kind of get it placed onto like an NRB or anabilized mask to get it up in there to get some sort of sample, I think even though it might not be as accurate as if it were on the end of your ET or your King Airway or whatever, it's still right to provide a good baseline, a good set of numbers for you at least to work with to help determine if you're going up or down in the right or wrong directions. Yeah, so yeah. I would definitely be all about having an Emma available. Yeah, I would too. Unfortunately, I don't think we're going to get one anytime soon, I would be, I would be a big fan of having an Emma. Yeah. All right, that's about it on the Emma. It's the one thing I think I'd buy. What about AD Sean? Yeah, so this one gets a lot of, I don't know what the right word here is. So there's either a love hate with it when it comes to wilderness EMS, right? Either you definitely want one and you want to carry one or you're like, at this point, by the time I get to the cardiac arrest, you know, three miles down trail, me bringing an AD whether portable or not is going to be of minimal value, right? So this is and with that, so folks understand, there are some very small compact, relatively speaking lightweight AEDs available out there. All right, and we're talking AEDs automated, external, if everybody's not cardiac monitors and any sort of straight up AED, right? It's not going to do anything, but push the button and it's going to tell you to shock or no shock. There are some very good ones that take very, very little space. You can almost put them in a cargo pocket of a good set of pants, a large cargo pocket for something, but right? And they could be of good value to you, but you have to weigh the, okay, if it's going to take me 30 some minutes just to get there, the value of them placing an AD of somebody staying in one of these shockable rhythms for 30 plus minutes, and I'm talking 30 minutes is on the fast side. Yeah, that's that's being quick, right? I think it's a limited use case proposition here, not saying certainly it shouldn't be available or needed if that's the case. I think this would be more applicable, not to a field cardiac arrest than the wilderness environment, but more to the, you have a patient whose, at least your initial reports are kind of those chest pain, shortness of breath, then acute viral cardio issue, right? So any of the ACS type issues that you could have and say, well, we should take the portable AED just in case this guy happens to arrest while we're already with them and given them the best shot they've got. I think that is its use case for wilderness responders. Otherwise, I'm certainly not going to carry one in my pack just for the sake of carrying one around in my pack. And again, if this is a report of a cardiac arrest down a trail somewhere, and even if you had a good salt like micro-iwa right next to this guy and they went down and we immediately like, okay, no pulse CPR, CPR only with no other interventions is only going to get you so long. Like if you haven't hit that rosk at that 30 minute point showing up at 30 minutes plus and then with an AED, I highly doubt there's still going to be a shock rhythm. Strange your things have happened. And I'm talking, I mean, the reality of this is an over-once or twice, but that 30 minute response is the absolute ideal situation. Mike, oh. We happen to be just driving right next to that trailhead and you were only a half mile down and I could jog there real quick. The reality of that happening is extremely slim. And again, this is for the portable, like, well, most 80s could be put in your backpack. Let's be honest, but I'm talking about the small ones they've made actually for this type of purpose. I, yeah, I just think it's a, it's a use case thing and you've got to take it out for the right call. So if you're responding to 62 year old gentleman with chest pain in the middle of the woods, yeah, take it with you because you might get lucky, but then if you get rossed down trail, that's a whole nother problem. Um, but perhaps we'll do a whole episode on cardiac arrest in the woods, right? But anyway. So think about it before you just rush out and buy a whole bunch of them. The reality of you using them are they worth it. Something else you got to remember is if, especially if you go with the smaller lightweight ones, they've only got so many shocks in them because of the, yeah, the size and weight thing is in battery capacity. So some of these give two, some three, some more. So it all depends on your manufacturer, right? It's not like something you're going to have that's going to give you half a dozen or more shocks at like, at a full 360 jewels. So just, I would agree. I'm not anti them, but the reality is that cardiac events, right? We, we, we measure cardiac events in pre-hospital EMS in minutes, not hours. The reality is that it's going to be more than a couple of minutes to get on scene of a cardiac arrest. Now, that doesn't mean we shouldn't try, but unless you have bystanders doing CPR right there, and it's good CPR, and they're in a shockable rhythm for an extended period of time, which is statistically unlikely, kind of limited value in this one for me. I'm not against it. If I got a guy that's all gun hole about carrying it and it's a cardiac event, I'm not going to say no, but the reality is I think it's going to be a pretty low return on value for the weight and the complexity of carrying another tool. Yeah, I agree. So that leads us right into the portable cardiac monitors. When I say portable cardiac monitor, I'm not talking about your Zoll X series or your life pack 15 or even the new Phillips. I don't know what they're called, jammers that are kind of more tablet based. Yeah. I don't remember what they are right now either, but so realistically what we're talking about for wilderness EMS, backcountry type response, and right now I think the only one that's kind of out well cardiac wise, there are a few of the options out there. There's a couple of European companies that basically make four lead and 12 lead ECG capability that can connect up to your tablet or phone. If all you're going to do is just look at cardiac rhythm. Which is a cool. I mean, some of those are cool, and there can be certainly some benefit in having those and we'll kind of discuss that. Mike and I have often varying yet complimentary opinions on some of these things. Again, just having a ability to look at a four liter, 12 lead in the middle of the woods is kind of like cool. Now what? Right? And we can talk about that more in a minute, but piece of technology we really want to talk about and and don't get me wrong. If you offer me a couple of these for me and Mike to have, we're all about this one too, but it's the the Athena GTX, the WVSM. Basically, it's the, so if you haven't seen these, I think they originally developed for the military, primarily probably for the PJs or the soft community. And so the current version basically does four lead ECG monitoring plus blood pressure, pulse ox, and I think the older ones had an entitled I know the new ones definitely have entitled monitoring capability. I think the old ones had a kind of a funkier entitled system they used. And so this is a relatively small again. I don't have as my dimensions in front of me, but if you had a large cargo pocket underpants, this thing could bundle up and fit inside there. Right? So yeah, easily packable. This of all the technology we've talked about aside from the Emma, but if you have your entitled monitoring with your GTX, you're in, right? So yeah, basic cardiac monitoring. The new ones are going to have 12 lead capability, which cool, but at least have able to have a four lead on the current ones, having a blood pressure, you know? So just like on your life pack or your soul, you can push the little button and it'll do a non-invasive blood pressure right there. And pulse ox, right? So it's all built in. Think of it as a your little mini life pack. But the best thing I'd like about this one, and this is why it was very popular amongst the military and why most of us backcountry type guys would want it is I can put this on my patient, bundle them all up, have them in the stretcher, and then through the Bluetooth connectivity to my smart device, my phone most likely, I can see all of those data points, right? Yeah, I don't have to stop the basket for moving, pull out an arm, get a manual BP, I look at my little portable pulse ox that's on their fingertip, you know, turn it on, wait for it, pull up part rate, and an SPO 2, I can see all of this data while we're moving down trail. So I can, for me, as a care provider, especially ALS if I'm providing some pain management or sedation while we're moving, I can monitor all of those things while we're still going, we don't have to stop progress, get another look at all these vitals. I'd say, and this is my opinion, the only drawback to it is battery life. I think it's about a 68 hour battery life, and I think a lot of that will depend on how much blood pressure you cycle in such. Yeah, but for your average, like, for Mike and I, an average backcountry response, that's 68 hours, it probably do us pretty well. Now it's some of the longer ones, maybe not so much. I might, depending on patient condition, I might hold off, I'm putting it in until we get later into the rescue, but we'll see, right? So that would depend. But this is definitely a piece of technology that I think if you could give, give a bunch of these to every wilderness, EMS team out there in the country or across the world right now, this is probably one of the things that everybody would want to have. The ability to do, you're pretty much standard, ambulance type, patient monitoring from a small distance with remote connectivity to a smart device. Absolutely top notch. So yeah, if anybody wants to donate some to us, let us know. We're all about this piece. Yep. I mean, I would love to have them. For nothing else, it gives me monitoring capabilities without exposing the patient or stopping the rescue, right? I can get blood pressures and watch pulse oximetry again, right? I'm not super duper into the, I've got a monitor of the vitals every seven seconds because of what of this that and the other, it is more important to extricate them and spend a little less time fighting to get blood pressures and such, but this is the happy medium. I don't have to stop working while I'm going to stop the extrication while I can still monitor the patient. And if I'm giving narcotics or other medications, that can affect vital signs, which is pretty much all of them. I mean, you can even make the argument that you should be doing cardiac monitoring when you're using Zofrain. I mean, probabilities are low, but it can have an impact, right? This is a really, really spelt system. They're not astronomically expensive, that they're not free, but again, they fit in a cargo pocket and they work. Yeah. These are, these are a pretty cool tool. I would definitely be all in for some WVSMs in our cash of equipment and we'll continue to advocate to do so until we have them. Yeah. Like I said, of all the technology, this is the one being the most useful for us average, well-nissed EMS providers. This is a simply a good piece of kit, well-designed, fairly robust, and provide you, I think all those fundamental pieces to help you trend your patient conditions, right? Even if they're relatively stable, you know, it's just good to know that they're staying that way. So anyway, all right. That brings us to portable ventilators. I sit on the fence around portable ventilators. I'll tell you right now that if we're talking wilderness, there's a bunch of stuff, Revell, Hamilton's, you know, there's a lot of fancy ventilators out there. Zoles, I was going to get to Zoles a second, but there are him systems that use them. There are some new devices that will come to market that are more EMS focused from those manufacturers, but primarily they are hospital-based or critical transport-based ventilators. Zoles would be the only thing I would look at in four-wheel-litters use, and again, we've got two inherent problems. One, they're a little bit bigger than a pocket, right? This is the thing that's going to take up a good honk if not the entire space within your backpack, by the time you've got tubing and everything with you. And two, battery life, right? They don't go forever. There's a couple of them on the market. I think the new one's called an EMV+, which is built to millsback. It was made for overseas use in non-permissive environments. That would probably be the way I'd go. There are about 10 grand give or take, and that's if you're got an amazing contract for like a lease. If you're buying them out right, they're about 60, I think. But they are super durable. The new Zoles can do some things that make it, quote-unquote, stump simple or, you know, parametric friendly. But they're big, right? They're chunky. They're heavy. I think they're still measured in the 8-10-pound range, if not more. And I think that's before you put batteries in them, but I'm not sure. I'm sure there's a Zole rep out there somewhere that's going to send us a note and be like, no, they're actually lighter, but they're kind of ungangly. Now, the flip side is, if you have a patient that requires ventilatory support, that's really hard to do while extricating them from the woods. So I can definitely see the value in having them. The problem is that size and time for use is still limited, right? So I'm going to drop transport ventilators in the bucket of wood. It would be awesome to have probably low use, high acuity events, sort of scenario. And this would be something on my list of stuff that would fall further down the list, unless all the money's were available because it's a, it will potentially give my patient a better chance if I've got someone that is severely injured or needs ventilatory support to get out of the environment. However, it is not something that I would put at the top of my list because, quite frankly, you're having a bad day if that occurs in the woods. And for will there just rescue they just. feel a little too big and unwieldy. And to kind of, I guess, double down on my comments earlier about point of care testing, you have to maintain proficiency with ventilator usage and you have to really be good at them. Like you can really, really hurt people with a vent. - No. - If you're not practicing it and maintaining that skill set and getting quarterly refreshers and maintaining your knowledge in that space, it can be detrimental to your patient. The other thing I will mention, what are they called the SAVE II? - Yeah. - Military, those things could go into a large cargo pocket. - Like a very large cargo pocket. - Yeah, that's not a large cargo pocket, but yeah. - But all they do is really breathe, right? Not a whole lot of options. They're really the last ditch sort of thing. They were originally designed for the military so that if somebody needed some intramventilator support, they did not have to tie people up with them. I would consider them for like cardiac arrest type events in the woods, but again, as we discussed, like what's the probability you're gonna get rosk and then maintain somebody all the way out of the woods? - Yeah. - Well, what are your thoughts? - You're basically, I'm in line with you, right? And so we talked about this one, but I don't know, a few episodes back when we talked about advanced airway management. If you've had to intubate somebody or a crike if they're not breathing on their own, or a superglotic device, you being able to maintain BVM ventilations throughout the duration of a rescue, even if that's only a 30 minute carryout. Unless you're walking across the football field where you can have three people on either side of the stokes while it's on a wheel and you can just casually walk in the head and squeeze that thing every six seconds. It's not happening. That's why I think our position before was like, if you have to go to that advanced airway level, some sort of transport ventilator almost becomes mandatory. Just the reality of studies that have been out there, like how good CPR is while going in the back of an ambulance, it's shit, right? So same thing, like if most providers like study show that most people don't do BVM ventilations well, while just sitting next to a patient in a static happy environment, good Lord, they're gonna be even worse when you're trying to move and evacuate patients. So I think that's the only use case personally for me. Obviously, I mean, you're not gonna put a transport ventilator on somebody with a BVM, right? So if you're in a place where you see regular use of advanced airways, then yes, this is probably something you should put your money towards, at least one or two good decent ones. Even the safe two, I would take a safe two over nothing, right? - Oh, for sure, absolutely. I gotta wanna give the impression I think the safe two would not be useful. But, I mean, defense is the measure, right? What's the value proposition against what I'm carrying? And how often am I gonna use it and maintain that skill set? - Yeah, so again, yeah, this isn't interfacility, critical care transports where use of a ventilator occurs almost daily for these ALS crews, right? This is the once a year major person who took or was involved in a very significant incident, whether that's just unlucky in a built up area of some wilderness area in a motor vehicle accident or they took a big fall or a bear mulling, whatever it might have been. - Yep. - Yeah, so anyway, I think that's really, again, we can go down that strange, strange hole of advanced airway management in the middle of nowhere, but yeah, so compact transport ventilators, if you need them, absolutely, it's someplace you want to invest good money in, but don't forget, as Mike said, you gotta invest that training. - Yep, absolutely. - And I think the last thing we were gonna talk about, and a lot of people don't think about this one necessarily, except for the folks that really do more expedition-based things or provide support to some of these events, satellite communications, right? So, or Mike and I are at cell phone use is spotty at best. Elif and Mike and I are radios are often spotty at best. So, our ability to communicate with our, what we'll call our dispatch center, can be a little bit sketchy at times. Normally, it's not too bad, right? We can usually it works, right? We'll give it a 85% of the time, it's no issues. The trick is, - 85% of the time, it works 50% of the time. - That's right. Made with real bits of panther. - Uh-huh. - But when you need some medical advice, like you're trying to get a hold of online medical control, or if you work with a system that has other telemedicine consult capabilities, you want reliable comms, and satellite communications is really one of the few things that's really gonna guarantee you that, right? Unless you work someplace that actually has a good built-up area around it, has good reliable cell service, investing in satellite communications devices, garment and reach, or buying an actual iridium, or other phone that you're just literally making phone calls with, that could be a worthy investment. Especially for the folks, I mean, they already know this guy's that already work, and Gels, that's a bit history-minitory, that work in these very remote places, they already have access to these devices because they know they must have them. Like, you know, you work in Ever Space Camp, there's no cell service, well, at least that I'm aware of. If there is, I'm sad and very disheartened now, but, or you're working these other remote offshore places, and other just anywhere, right? Lots of places, there are plenty of places here in the United States where, if we could have a sad phone in the middle of the back country, where Mike and Hyrant, for most time to call the hospital, talk to a doctor, that'd be beneficial. - Okay, cool. - So this is just one of those areas that you're getting into this world, or maybe you do this under certain contract support gigs that are out there to go and support some of these events, check and hey, what do we have for communications? What's the comms like? Do we have satellite communications available? 'Cause like, hey, what if I got a call back and talk to a doctor because I need to use, go a little off label with one of my drugs, or I got to step out from this protocol and do something else a little bit different, and I just need permission, or I need to just consult with somebody and say, "Hey, this is what I got, this is what I think I have." And this is what I want to do to treat it, and just that confirmation of somebody at the end are end going, yeah, I think I would agree with you, let's do that, plus do this, right? You want to be able to have that conversation and be able to do those things. So something to consider is just, that satellite communications piece, no matter what it is, whether it's via voice, or if you're using some sort of data terminal to basically send text messages, and then some of the systems out there to allow you to send short video clips or pictures. Excellent, right? Just to consider. And that's really all we're gonna say about that. There's pros and cons, not a lot of cons, but it's a cost and a bit of weight. Right, but I think the benefits, if you're one of those communications degraded environments, you already know the value, and you're probably investing in it already, or whoever you support is. Yep, all right. Anything else, Mike? No, I mean, I think that pretty much sums up the cool tech. I will mention that technology isn't always evolving situation. Are we summarizing all the cool stuff out there? Probably not, if there's other cool stuff you're listening to about, I want to hear about it. There's a ton of other cool things out there, but these feel like the top list, and just reiterate, all the cool tech in the world doesn't make your patient better if you don't know what you're doing. So, trick your patient to understand the situation. Yeah, that about summed up for me. All right, and I think you did get there, right? So again, is that technology's awesome? Use the technology available to you. Don't let the technology be the focus of you, right? It's like, well, just go out to most urban metro areas in the US and just stand there and watch people and see how many people just stare at a screen. Don't be the provider which just stares at the screen. So, look at that. Yep. And lastly, hey, if you want to donate some kit to us, let us know our agency's broke and doesn't do a lot of good support. They're lovely people, but they're broke. And with that, I think that wraps up this episode and stay tuned for the next one coming out. And we'll talk about how to do a lot of this wilderness EMS stuff if you don't have all these cool tools with you. And with that, Mike, we'll let you finish this 'cause you like to finish last. Hi, hi. (laughing) All right, yeah. Well, thanks for joining us. I look forward to any conversation or other technology people put out there. If you have any questions or comments or ideas for show topics, you can send us an email at the show at emusonthemountain.com or here to us up on social media. We can be found on Facebook and Instagram at EMSonthemountain, Twitter, at EMSOTM, or you can engage with us in a whole community of wilderness EMS professionals at locals.com/wildermusemus. Until the next episode, thanks for joining us. And until we see you on the mountain, train hard, be safe, and do good work.