EMSOTM 50 - The Nine Essentials

EMS on the Mountain is an entertainment, educational and commentary product recorded by Sean and Mike and produced by them. Nothing recorded by Sean, Mike or any of the guests of the show is endorsed, nor authorized by their respective employers or agencies unless explicitly outlined. All commentary and statements made are their own. Always follow your respective medical protocols. Nothing said on this platform should be considered medical direction. Now, on with the show. [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] Begin. Buenos Aires. >> Buenos. >> And that's pretty much where I end. All right, and welcome back to another episode of EMS on the Mountain. And Mike is impressed with my espanyol, which is not very good, by the way. And let's see, I thought I was going to work. >> I thought I was going to work. >> He had those good too. Holy crap. It's late in the afternoon and both of us are probably shouldn't be doing this, but folks here you are. This is why you love us. All right, so today we are going to look a little bit more wilderness specific as far as wilderness EMS stuff. And this is, I'm not going to be shy about it. So, if you've been involved in the military, special operations side of long field care, they have this big essential capabilities matrix spreadsheet that's minimum better best of specific areas. And then, you know, the Ruck truck plane building kind of model. And I've taken that and I've tried to adapt it to a very simple version for wilderness EMS. And it's labeled the nine essential wilderness EMS capabilities. And those nine essential areas are monitor and that's monitor your patient, recessive date, ventilate and oxygenate, control the airway, sedation, analgesia, physical exam and diagnostics, nursing and hygiene. Telemedical consult and package and prepare for feedback. So, those are the nine overarching capability areas that we're going to talk about today. And this list is, I kept it fairly generic. Not everybody has access to all of the finest of technological tools and equipment pieces that are out there. Some people might not even have access to some of the stuff that's on this list. So, I tried to keep it as a base levels possible just so it can be as applicable as possible across the board. After this episode releases, I'll also be posting this list on our social media stuff. So, if you guys want to actually see, you know, the physical version of what we're talking about, take it, use it, mutilate it, make it your own complaint about it. I don't care. But today it's just going to be a launching point. With that, we're going to start off with capability area number one, monitoring. So, these are listed then and we're going to go through this in this order, the minimum, better and best. So, when it comes to patient monitoring, your absolute minimums should be your blood pressure cuff, stethoscope and a portable pulse ox. That should be something that basically every provider, if you're working in the wilderness, EMS, we'll call it environment arena. That's the one thing that all of you should have to move into the better section. You would add in capnometry and blood glucose monitoring. And to be the best at this, obviously we're talking about a full vital science cardiac monitor kind of set up something that, you know, those folk who work in a zole or a life pack. Almost full capability at that level. There are some smaller versions that do essentially the same things. So, whatever you've got, that's going to be your best. And as we're going through this mic, if you have any comments by all means jump on in, I think we're, I will. I will. Just to make it a little, it's on what you were saying so far. That's what I said is I think we'll get more discussion as we talk about actual field versions and what we should be carrying around with certain things. Basically, it's pretty simple. Yeah, right. Like taking a blood pressure. If you do quit medicine. Alright, so for resuscitate our minimum is either lactated ringers normal saline, your standard crystal, Lloyd fluids, not much to that. The better. There's not much that's better than that until you get to the best, which is obviously blood products. If we could all carry them all the time for as appropriate administration, not everybody needs blood work or blood products, right. But if we could all have access to that would be fantastic. And that's why there's not much in the middle ground between crystal, Lloyd's and blood. You have individual blood components. Of the like mindset to most people is is giving somebody just plasma or platelets isn't doing a whole lot, right. PRBCs, the oxygen carrying piece is probably one of the better things you could do if you're just somewhere in the middle. But again, if we look at that under best that straight up blood products and the best of all blood products is whole blood. So is it bad if I call it a water? What plasma? It's basically yellowish water. Yeah, I guess it would be there is other stuff that comes with it. Like I'm being snarky for all of you that are going to get mad at me now and send me a note on social media that's oh my god, you don't understand what's in plasma. Yes, I do. I'm just being snarky so don't get mad at me. Yeah, but it is essentially yellow water. But anyway, anyway, let's be honest. If it's not clotting and it's not transporting oxygen really is it any good. People are going to nerd that one. So ventilate oxygenate. This one again at the simple minimum level bag valve masks right and I did include it with a peep valve. So your minimum level BVM with a peep valve. And for those of you who don't know yes, they make peep valves for BVM's. You're not using those. You're not familiar with them. Better attaching them some portable O2. So now we can attach give out oxygen. Now, remember folks, this is in the context of wilderness or austere type environments. So not everybody has oxygen with them. And then of course the best would be some sort of portable transport ventilator. And of course that depends on your environment and how big you can go. And I guess duration because battery operations are limited. So control the airway. Minimum is obviously going to be your BLS airways OPs and NPs that's really not anything shocking that anybody should be too blown away by. Your betters, your superglotics. If necessary, you can include some sedatives in there. So if you had that patient now, obviously we're not going to RSI the superglotic airway, although technically you can. You can be as technically you can. Generally that's something most people think of, but it could become a thing for wilderness folks. Not the best, but go for it. Yeah, the strange whispering is, I don't know where I should feel about that. Yeah, I'm not sure how I feel about it either. I should probably quit doing it. So if you have some, it's got a superglotic stuff in their face, you might want to if we're considering the extended patient care timelines often associated with wilderness stuff, you might want to consider some sort of sedative. If you believe the superglotic is still necessary. And obviously after that straight endotracheal intubations or if necessary a surgical airway. Those being the most definitive and the thing that we know is going to yes, this is a thing in the airway. There are the complications and concerns that go with that, but we're not really discussing all of that today. So capability number five would be sedation and analgesia at the BLS or not BLS minimum level would be your OTC meds, right? I'd be profan and to see the medicine. So you know, a fan of these two, especially in the wilderness environment that Mike and I work in most folks that work, at least North America, wilderness true backcountry woodsy stuff. You should be a fan of the ibuprofen and acetaminamine, especially if giving conjunction. Even the acetaminogen too. Yeah, that too. This is late. I'm tired. I need an mild man now. So better than that would be opiate analgesics, titrated through an IV. Obviously opioids are good. And I would also toss in there, not just with the opioids, but things like torridol slash catoral ac. The supern said I'm a huge fan of that one, especially for those pretty common. lower extremity musculoskeletal injuries, no need to throw down with some fentanyl or morphine or even ketamine if you can get it done with something like that. And then lastly, this gets really more into the sedation piece, but sedation with ketamine or your benzoyl of choice. I have on my list, Medazolam, just because that's what most folks are carrying these days as a benzoyl, which is verse ed if you're not following along with its more common name. And of course ketamine is an excellent analgesic as well. So something I'm just going to throw this out there while it's just in my brain with using something like tourdol. A lot of times if you're going to splint something, it might not be a bad idea to give that initial bump of fentanyl or maybe morphine, maybe a little of the ketamine. While you get the splint all in place and then you can follow that up with either your OTCs or some tourdol just as more of the long term management. So you can take care of that initial pain, help get them through the stabilization process and then transition them over to something that's a little less concerning when it comes to airway management and such. Yeah, I'm just trying to be a shwacken for long bone injuries or spierly painful things. They're going to be in a discomfort state for a long time. So while we're manipulating things and trying to get to a position where we can get them out like I'm totally down for a little bit more aggressive management if you have it in your repertoire. To avoid the experience of having broken bones manipulated in position before excitation. Yeah, I hear it hurts. Yeah, me too. All right. And with that, take us into a capability number six, the physical exam and diagnostics. So obviously the minimum is your old school traditional physical exam, right? Just hands on looking and touching your patient. Better than that would be if you have ultrasound or some sort of point of care labs device you can have with you that might get you a better idea of what's going on with your patients. So ultrasound, many uses, they're waxing and waning every year it seems in EMS. I think a lot of wilderness folks are embracing it more than the urban side these days. We're not going to get into a big debate on the pros and cons of ultrasound right now. I think we did that last year before we talked about some technology and wilderness EMS stuff. Yes, but it is a tool. It is out there. And obviously having ultrasound is better than just your hands and your eyes. Anyway, we'll just leave it at that. And of course, if you've got some sort of like epoch, eye step kind of point of care lab capability where you can draw some bloods and put it in there and get some better, I guess metabolic and physiologic information off your patients that can help you as well. But that's something not a lot of folks carry prehospital. Just especially back country folks. Are a few places that are doing it? But I would say that's much fewer than there are that are than there are that are doing it. Yeah, my English is great today. So with that, we're going to move on to number seven. What do you got? I just want to say if you get ultrasound, you probably got eye stats as well because you've got unlimited money and unlimited desire to use cold toys. If possible. Yeah, potentially. Yeah. So number seven, this is nursing and hygiene. And this really is applicable on the prolonged patient care piece, right? You're going to have to start considering and when we say nursing, we're not talking about going to nurse school and such, right? But this is a big part of being a nurse. This is patient care for a long, prolonged period, right? So the minimum, you need to be able to keep your patient clean, warm, dry and padded. I'm going to I'm going to toss in there that not only is this a quote unquote nursing thing, but this is part in parcel with being a backcountry provider. Yes, like this is not just slap them in the back of a thing and drive them to the hospital like nursing care as we refer to it is really it's a component of being a good backcountry provider and you should probably keep this in mind and do these things because they're important. Yeah. All right. Better would be being able to elevate head of the bed, elevate feet, things like that change some basic patient positioning. Now this requires you to have something probably better than just your a close cell phone pad and some rocks hanging around. But it's stuff you can simulate if you've got it available and your environment allows. And obviously the best here and this one's kind of this pops up in a couple of places is the experience in all nursing care concerns, right? So this is where truly if you have nursing experience, you're going to be much better than guys like me and Mike, right? Where we understand the fundamentals we've been trained in these things, but where not is attuned to them as we'll say actual nurses who this is part of just their daily duties for a lot of patients, right? I have to think about it. They do. Yeah, say that's the thing is it's that experience piece like nurses like have you considered rolling them to a different side? No, good. Because it turns out bed sores pop up in hours, not days or pressure ulcers, I guess we should say. So that moves us on number eight, telemedical consults. All right, so this is you're calling back to some sort of medical control telemed consult, depending on where you work and what system you have set up. This could be some very elaborate via satellite and video links and things like that or could do just over a radio or a telephone. So basically being able to at the minimum be able to present your patient a good description of your patient through your assessment and present their key vital sides and where do we get those key vitals? Your BP cuff, stethoscope, pulse ox. Okay, so being able to relay that information, oh, if we have that, but that's under better. That's fair. Because obviously you could add on all the rest of that, like under better where we could add labs and ultrasound and maybe some video where we can give additional information. And obviously the best would be some sort of real time live video teleconference between you and a physician or the physician could look at your patient, look at an injury, perhaps, and give you a better assessment and recommendation is to follow on treatment and what your next actions should be. And lastly, number nine, package and prepare your patient for evacuation. So at the minimum, you really just need to understand what the stressors of the flight or evacuation process are going to be for your patient and try and help your patient, if they're conscious and able to comprehend what some of those things are going to be. Like if you know you're going to put them in a helicopter, everybody should know there's going to be a lot of vibration and a lot of noise and depending on how they're loaded or moved into a helicopter, there could be a lot of wind and other crazy stuff. If they're going to be hoisted or you're just going to walk them in while it's a hot load and that thing's still turned it. If you're being carried out, just know, hey, you're going to be kind of laid out on your back here. We'll try and make you as comfortable as we can, but you're just going to be laying down for the next few hours as we carry you up and down this trail. It's going to be a lot of bouncing. It's going to be feeling like you're going to get tossed left and right. You can promise them. You're never going to drop them. Be careful. Just don't drop them. Yeah, I never promise that because I usually drop them. I've never dropped them. I have never dropped them. But I've seen patients getting very close to getting fully dropped on their sides. Some crazy stuff. Anyway, not the better than this would be if you as the provider are trained in critical care transport and you are familiar with helicopter, flight ops, ground transport ops, etc. And the best, of course, if you have a fair amount of experience doing these things. I can go out and get a certificate and tell you I've got my international board, especially certifications in critical care, paramedicin. And if I don't have the experience in critical care, paramedicin, it doesn't really matter. So again, the experience piece is the best one. And I experience experience. Not just I did this once before. While that is some experience, it's not really what we're talking about here. No. All right, Mike. So any other comments in what we'll call the basic nine and just their standard minimum better best? I think most of the comments sense. I was just going to say that, right? This is just logic. You should brain. There's a lot of stuff we can do for people. There's a lot of cool tools out there. But at the end of the day, like in as with most things in life, you got to get the basics right. And if you're coming from a system that is like super resource depleted and has no money, right? Do the basics. BLS before LS is a thing, right? If you have all the cool toys that we're talking about and like the best of ever, right? If you have blood products and you have ultra sounds and all of those things, none of that matters if they're like cold. or you're not like taking care of them or treating them like a human. So some of this stuff sounds cool and I know we've got a lot of folks out there that listen and then it come from systems that are like, "Well, that'd be cool to have, but I'm never going to see it." Do the basics and you're going to do well by your patient. I mean, I can't even agree with that anymore than I already have. All right, so with that, so we've talked about just the the minimum, better best of those nine key areas. Now we're going to try and transition to that to what some people are here to listen and tune in for. And we're going to transition those same things and we're going to put those in three areas, right? Now I have taken the military model and I've modified that a little bit and it's going to be your backpack, right? Whatever your response bag is, truck or a UTV type thing, the next thing up from your backpack that's going to bring you stuff but still not a full-level capability. And then I've capped out at an ambulance, right? Because for most of us, either getting them into the ambulance then means we're going to the doctor place or we're transitioning care to another provider and they then will transfer them from ambulance to that. So that's why we're going to peak at ambulance vice, taking them back to some other interim facility or clinic. Although I know some like national parks have clinics and things like that on their premise to do this sort of work with, but that's not really what we're going to talk about today, right? So we're going to start back over at the beginning with monitoring your patient and the things that should be in your backpack and not surprisingly, here's the big three that you're going to see blood pressure cuff, stethoscope and pole socks, right? Shocking. Here's the one thing we've added for your backpack though, a headlamp because it turns out if it's dark and you're trying to monitor your patient and you're using your BP cuff, it's cool if you can actually see the numbers, right? So a headlamp is absolutely imperative if you're working anywhere in the back country pretty much any time of day because you started out in the morning, now it's dark, but you didn't bring your light because you didn't think you'd be there all day. That just makes you an asshole. Don't be that guy. All right, now moving on to the trucker UTV, this I have put some items that could absolutely be transitioned to your pack. If you have them available and you have compact versions and that is capnometry and blood glucose monitoring, as well as a small portable type of monitor, because not all trucks are UTVs or you're necessarily going to want to put like a bigger heavier life pack 15 in your ZoltX series are pretty small in light. I guess they take about the same mount space as life pack as just considered later and there's funky pouches where your ECG prints in Tanarnia. I love that. That's my favorite thing I've ever heard. So it's possible that you could have small compact monitors. This also includes like the Athena GTX WVSM, little portable guy, and that could also be something that carries in your backpack. So if you have the space and you can tolerate the weight, tossing some portable capnometry, which could be something like the Emma device, obviously a blood glucose monitor, super easy. I have one in my pack just because that's a very simple piece of information you can get off your patient that yeah, the ways that ounces make pounds and it takes up a little bit of space, but in my opinion it's worth it. Moving on from there, obviously if you get into an ambulance, we're talking full-size cardiac monitors with full EKG, patient monitoring capability, capnopulse ox, BPs, where you can actually do some cardiac work if you need to, pacing, D-fib, etc. Again, that's something that a large full-size monitor could be transitioned and brought down via truck or UTV, but for the sake of this list, we've kept it on the ambulance. So moving on from there, I'll resuscitate items. So in your bag, you should probably have at least one 500 ml bag of your crystal-loid of choice. Most of it's normal saline, some places do run with some ringers as their primary go to, but you should have at least that one 500 ml bag. I think Mike and I right now have a 500 bag and then we also think most of us are we're usually trying to carry a 100 ml. Little guy just if we're having to do a drip of some sort, very short infusion, usually for like ketamine. But again, that's a very special use thing. If you want to carry more in your pack, by all means, this would be one where I would be tasked out on a some sort of mission for a patient. And if I think I'm going to might need more than my single 500 ml bag, I'll just grab another one or make sure whoever's coming with me, they bring another bag or two if I think it's really going to be needed. Yep, that makes sense to me. Let's think about it folks, right? I'm not a big fan of thousand bags in general, but you've heard me well before. I'm not afraid of a thousand bag in this instance, right? We've got to think about for most of our patients, even if you're called for the dehydration, you don't know what's dehydration until you get there. And if you really think it's going to be dehydration, then grab another 500 bag or grab a thousand bag and you or somebody else can carry it. And if you need it, if you don't, cool. Yep, but let's be realistic with how we're using crystallized these days, right? If you haven't heard folks, the two large four IVs wide open has been gone for a long time and I really don't understand why people still talk about it like we do that because if you're one of those agencies that really is still doing that, like 1995 called they'd like you to stop. So given your patient a 250 bolus and seeing how they do and if they respond to that blood pressure wise, etc. and you give them that other 250, then excellent. Good work. And if you really need more fluids, all right, well, they really need it and you can give it to them. But again, if this is going into what they really need is blood, come on folks, if you're given more than a thousand or 1500, you're wrong. I get it. There are certain circumstances where you got to do what you got to do to maintain pressures and keep people alive. But let's still try and function like we're not trying to do bad things anymore. So with that in your truck or your UTV, you should have probably another at least two thousand ML bags or you can have them in collections of 500s, whatever you guys stock. But this is where you're going to want to have your additional fluids available to you. That somebody can bring out to you, follow on people trying to assuming you're going to be walking people out, you might need to carry out people. Somebody else can grab another bag or two and bring them out to you if you really think you need it. It's not that big a deal. And of course, in your Ambo, more bags of ringers. And if or a normal saline, as I guess I should have said, more crystal lights, keep it simple. And then this is where if you are lucky enough to have blood products, your blood products are going to be probably with your ambulance just because cool as right, you got to be able to keep that stuff cold. Could this be brought down the trail to you? If you work in a pretty progressive wilderness environment and you have blood that's going to be available to you, maybe a flight crew landed. And they're going to send blood down the trail. Yep, sure thing. But this isn't something you're going to carry on the regular in your bag. Yeah, it's up at your ambulance level and you could toss that in or there with the air and both folks. You can pretend that you're going to carry it, but you're not. A lot of the stuff is we're getting to the point of talking about normal things we would do in a standard transport environment. But yeah, the people that tell me they're going to bring all these cool toys to the wilderness, you're not making an appreciable difference. The goal is still to extricate and get headed toward a hospital. Yeah, so don't overthink this one. You don't need to bring every cool toy in the world into the woods. And I will say, and I'm just going to throw this out there, is if you're if you were agency does no kidding do regular wilderness response and you do have the small portable coolers for blood products that you can manpack pretty easily. Good on you, I'm jealous. So those things do exist. Where are that? But just for the rest of the shit, 98% of US civilian EMS. Yeah, that's going to be at least on an ambulance or a helicopter. So anyway, moving on. Back up to area number three, your ventilate oxygenate in your pack. Obviously, BVM and PEEP valve. At a minimum, if you got a breathe for somebody, this is what you're going to need to have. Really nothing too exciting about that. What else are you going to bring on the basic level? So with your truck, this could be where you have your portable vents and your O2. Something that's going to have a little more space. Be able to transport a little bit more. And again, yes, folks, we get it. Some of these truck things can be brought down trail in a backpack. Just accept that we've broken them up because it's something that's not going to be in your pack at all times. Right. So you got to think about it this way. These things that we've talked about that are going to be in your pack should be things that are in your pack always in your response kit. And then those things that are in a truck UTV could either be added to you to be carried down or somebody else could bring them. And then lastly, on your ambulance or your helicopter, your full sized full-on transport vent with all the capabilities. Moving on. Yeah, I've never seen it back. They make quote unquote backpackable vents. Oh yeah, there's plenty of small vents. Just Yeah, I was going to shave. But if you're like at the end of the day, if you're bringing you a vent, into the woods and ventilating somebody. Hopefully it's not a very long extrication, get them to an ambulance because you got other. That's a lot of work for somebody in the back country that isn't a bad way that needs to be ventilated. Now, you can make the argument that it's a ventilator is going to make the world easier when it comes to breathing for them while in motion, and you're right. But I've not worked-- I've been doing this a while, and I've not worked a whole lot of people that need me to breathe for them that I'm worried about extricating. If it's to the point where we have to breathe for them, we're working them there to try to stabilize. We are not ventilating while in motion. Yeah, and you've heard us wax poetic on that very dilemma many times, so we're not going to get too deep into that. All right, so airway control. Obviously in your backpack, you should have your standard BLS MPOPs, and you could toss your superglotics into this. Yeah, me and Mike have gone on back and forth several times on what exactly we want airway wise in our packs, basically all the time. We've been like, yeah, maybe we'll carry superglotic now. Yes, no. And really, it comes down to that whole moving them piece, so it is what it is. So up and it from there, it's your truck UTV. That's where you might have your full intubation supplies for RSI or however you do it. Again, your SGAs could be there, your CRIP kit, et cetera. And then lastly, your AMBO, just the rest of your stuff tied back in with your airway control, which really is going to be more sedatives. So if you've had somebody from the truck UTV bring in your advanced airway kit, and you've decided to go with surgical CRIP, which isn't as big a deal. But if you've decided to RSI your patient, lay them out intubate. And you have a multi-hour extrication going on. You're going to need somebody to get in that ambulance and bring you a boatload more drugs to keep them down. This is one of the reasons that the military has gone away from intubations, because of the prolonged field care scenario. There's only so much ketamine and Versaed that I can carry realistically in the field to keep somebody down after I've paralyzed them and intubated them. So that needs to be a consideration for you that if you're like, oh yeah, we're going to RSI this guy in the field, that's great. Do you have enough sedatives to keep them down for the duration of your extraction? And that might be an hour. That might be five hours. It might be way longer. But do you have the ability to do that just basic patient care? So that is what it is. Sedation, analgesia, in your pack, really, you should basically have all your drugs, right? OTCs, opioids, ketamine, Versaed, whatever it is you're using. All of that should be in your pack, right? At least a fair selection should be with you. Some minimums to take care of your standard injuries and concerns that you're going to have by end your needs for these meds. If you need more, then people can bring them down to you from the truck or the ammo. But really, your meds basically just need to be with you in your pack. And if you need additional meds, then you have them requested and have them brought to you if necessary. I think I've only had to worry about this once before twice. Once with me, specifically, with one of my patients and one was just another patient I was helping with. And it was a prolonged carryout. And the patient had a very negative reaction to the ketamine. So I was heading to switch over and use fentanyl. - By very, I was there. It was bad. It did not go well. - Yeah, she did not like ketamine. She had a very negative reaction with it. So we decided that we were not going to give her any more ketamine. And he had to go over to fentanyl. And I used a lot of fentanyl to keep her as comfortable as possible for, and this was multi-hour duration. So anyway, enough of war stories right now. So that's really about it, right? So just truck UTV slash AMG illness might just be a resupply of that with other providers. Because remember, most of these are going to be a controlled substance. And so they've got to be with somebody else who is allowed to have them. And actually we'll have them with them. Number six, your physical examined diagnostics in your pack. And so remember, this is going to be separate than your patient monitoring standard stuff. You could add your analysis test strips if you're looking to get some very basic information on your patient. Is this going to tell you all the good detailed stuff you get off of an eye stat or something? Absolutely not. Could this give you a-- oh, they might actually have some blood in their urine. They might have increased pHs, decreased pHs, et cetera. Yes, they could. How accurate the test strips are and all this other stuff. That's to be debated. It's a different thing. But this is an option for you to carry in your pack. Should you want to be able to do at least something beyond blood sugar. I personally never put it to use. I bought some just to experiment and play with. And then I haven't had a patient in the back country that was had any need for me to have them pee into a bottle and test their urine. So-- I mean, I'm happy to help you next time we're together. If you just want to pee into a bottle for you, buddy, I think you want to play with my pee. I got you. That sounded weird. Play with my urine. Yeah. All right. So we got that going. We're just going to stop there. Just going to move on from that one. That was awkward. That's how. And then we don't really add much to the truck UTV, which I guess in your truck UTV, you could add back in something like ultrasound and your point of care labs. If you so choose to, if you have that access. And then lastly, your ambulance. You might have your blood tubes and other stuff. A lot of ALS agencies will collect bloods and deliver them with the patient when they get to the ED. And this is something you're not going to collect hours ahead of time for obvious reasons. What's-- I may not be able to be that obvious. But yeah, folks-- I'd say if you were a long period of time is bad, that's not bad. Yeah, we'll start to coagulate. And by the time it gets to the lab, they'll be like, yeah, all your samples are fucking shit. Yeah, thanks for-- Thanks for doing that. Have a nice day. We're going to throw these away now. Yeah. It'll often do that when they were drawn in the ambulance 10 minutes from the hospital. Yeah, it's just going to say, I've often been told I don't want your samples after I had them. Yeah, because Mike ran with a place where they did the drulabs or tubes prior to getting to the hospital. And yeah, a lot of times they still are like, cool, these are old, we don't want them. Yeah. But that might be another thing. Maybe your service does or doesn't do it. Who knows? But it's in there. Yeah. It isn't there. All right. Number seven, going back over around to nursing and hygiene. So in your pack, this is stuff that's also-- I don't know. I would put this under just fundamentals of patient care too. But things like sterile curlics or sterile gauze, right? Things where you might need to be packing and taking care of wounds. Because remember, you've got to be there for an extended period of time. So if you have sterile dressings, you can use to help prevent infection or at least reduce the chances of by all means, please use it. You might have to be doing some dressing changes. Maybe you got your initial bleeding under control. You did your initial wound care. And then for whatever reason, you're going to have maybe a day or so with your patient. You're going to want to be able to change those out for new or clean sterile dressings if possible. Understand not everybody's able to use sterile anything in wilderness and austere environments. But if it's an option, by all means. After that, we're looking at litter padding and not just litter padding, but padding for the ground. I would just recently helping teach a EMS refresher course for an agency. And one of the people's like, yeah, make sure in your truck you've got your your phone pad for your patients. And I made the comment of, if you're your phone pads, not on your pack, you're an asshole. And I stand by that. Your phone pad in the truck is doing nobody any good. That needs to be in your pack going to see your patient so that you can put them on it. Even if you think it's an isolated, lower extremity injury, if they've been sitting on the ground for a while, they're going to start to get cold. All those big things of heat conduction and sets, right? So just think about that. And then things you may or may not need for some passive warming, additional insulating layers, the all impressive life saving should never leave home without at space blanket. Yeah, those are the best. I don't know if you can tell that is sarcasm while that piece of kit definitely has its uses just about the moon, dude, they used them on the moon. No, they did it space. They used a mile are, but they didn't use space blankets. Oh, all right. Well, I got lied to them. Of course you did. They had tang though. No, they did have tag. Heck yeah. That's right. Drink the astronauts. So passive warming stuff, this is best done with additional warming layers, have an extra hat, some sort of fleece or wool cap you can put on your patient. If you were so inclined to have an extra fleece jacket or some sort of, I always, I buy very cheap, almost disposable, I consider them disposable cheap fleece sleeping bags or sleeping bag liners. And you cut those up into one of those into at least two pretty compact and disposable Flesy blankets you can help. put around your patient and put a space blanket around that as a vapor barrier or something, it helps a little. But you should have these things with you. Obviously from the truck to the TV if they're not on the patient. Exactly. So stuff that's coming out of your truck or UTV, your padded litter, and Mike and I always like to really emphasize the padded part. Even if you have a patient who is relatively benign, an isolated low-extremity injury, but they're not going to be able to walk at all. So they've got to get put in a litter and carry it out. Using a full body vacuum split is the bomb because it just fills those voids. It makes it much more comfortable for your patient, etc. So if that's an option for you, we both strongly recommend use the option. Huge fans. If not, do your best to pad your litter up as best you can, make a patient as comfortable as possible. They don't want their legs completely flat, makes their lower back uncomfortable, etc., etc. And with that, things to keep your patient warm, sleeping bags, additional layers to keep them dry, assuming it's not necessarily assuming, but in the plan that it will not always be dry and happy. So some ability to not just insulate, just live in bag, but keep that patient dry as well. And this is often usually associated with pretty cheap generic tarp of some sort that you wrapped your patient all up in once they're all bundled up. It helps keep some of that heat in and helps keep them dry. So do that. And then if you've got additional active warming things that you can use, there's a number of different products that are out there. Basically, all based off of chemical hand warmer type technology, we'll call it that most people are familiar with. But these things are usually about a torso length, about four foot long, two foot, maybe three foot wide, miniature blankets that are very similar to a space blanket. There's a different manufacturers that are out there. But basically you can activate all these little heat pads or packs on them. And they provide active warming to your patients. You can tuck those in there in the sleeping bag or just above the sleeping bag beneath this thing. You got to take into account, you don't want to put hot things directly on your patient's skin, etc. But some sort of active things are pretty baller though. Those things are great. Mike and I think we used up one year we used up all of the supply on a bunch of cold patients. Like we were not afraid to use them. It's like that's what they were there for. And we used them and we got the, but those aren't cheap. Why'd you use them all? And we had patients that needed them. So we used them. It was like the patient knows no bill until after they get out of the woods. All right. So it's kind of like one of those, oh, yeah, that's why we buy them. Yeah, that's why you buy them. So let's use them. Anyway, and lastly in your ambulance, you get them on the cot. They're generally pretty padded. It is what it is. Let's be honest. But you can get them elevate their head, turn on the heat, turn on the AC, whatever is appropriate. And you just make your patient comfortable. Do not, once you've had your patient all warmed up and bundled on your litter, toss them in the back of the ambulance, strip all that stuff off and leave them in the back of the cold box. Just you did a lot of work to get them warm, keep them warm. Don't forget to transition that and carry it over. I've seen that a number of times. Oh, we've got to get our sleeping bag and all of our organizational agency kit back and patients left in the back of an ambulance with a sheet. Now they're shivering and getting cold again. So please continue to look after your patients. Please look after your patients. Please. We really appreciate that. We're in monitor, right? Number eight, your telemedical consult, right? So with your pack or you should generally be your cell phone, some sort of portable radio. And I have on here like a call sheet, right? So some sort of, it doesn't necessarily have to be paper. It could be an app on your phone. It could just be a notes app on your phone. Somewhere where you're going to write down all of the information that you are expected to transmit to the physician on the other end. Yep. And I like to write things down that way you don't forget information. Maybe you forgot to state it in your initial call. And when they ask, okay, did you ever have to get a blood sugar on them? You can look at your sheet and go, oh, yes, I did. It was an 82 or snap. We did it. Sorry. So I just like to have those things down. I've got a couple of fill in the blank templates that I have that I've played with off and on. Some people just open up a notebook and just write stuff down and that works for them. So whatever works best for you, I would recommend you use something to that effect. So in your truck, you, you, what you got, please write stuff down. Just please write stuff down. You will forget, especially if you've been with them for a while. Right stuff. And not just vitals. You might want to have several sets of vitals written like their initial maybe one or two interims in their current. Just so the doctor might also hear what you're seeing as far as trends. And here's a big one. This is Mike and I've both done. If you've worked out, I want to give my patient, I want to give them a ketamine drip of this and stuff. Have all that written down so that you don't try to remember in your head as you're talking to a doctor asking him if it's okay and then him going, you don't sound like you know what you're doing, I'm going to say no. Yeah, this is the fastest path to being told no. It's sound like you're not confident. Yeah. So have that stuff written down. All right. Continuing on with the telemedical stuff. In your truck, you TV, you might have access to satellite phones, mobile radios, which would be your vehicle-based more powerful radio, which might get you longer range and distance. And again, another type of call sheet, same call sheet, but there just might be more located with it. Because you might work somewhere where you really, even with portable radios, might not get very good service to you, get up to perhaps where you're staged, your trucks and UTVs, and then you get to them, and then you have much better communications abilities. So you might want to have that same sheet available if that's where your first call is going to come from. Or maybe you've responded in your truck, a UTV, maybe you're in one of those environments, you can get to your patient with an actual vehicle and you didn't really have to hike, but it'd be nice to have those same call sheets available, you didn't have to dig out of your pack. And of course, your ability to transmit EKG and vital science information. So most of us on the urban side, we hit transmit on your cardiac monitor of choice. It automatically uploads into an electronic EPCR system. A lot of places when I like for me, when I hit 12 lead on my monitor, it automatically uploads to my local cardiac center so that if I just get on the phone and say, hey, this is my unit, I just transmitted you a 12 lead, I need to consult with a physician, or hey, by the way, this is going to be a STEMI alert, whatever it is, they can see that 12 lead right there. So if you have the ability to upload these things, and this could be as simple as taking pictures of things on your phone and sending them via text or email from your phone so that a physician can get a picture of whatever the thing is and then take a look at what you've got as well. So it's not always the estimate. Do not overestimate taking a picture with your phone and texting it somewhere. There are a lot of places that can do that. We don't talk about it a lot, that there usually isn't a sign in your ambulance that's like text images of 12 lead to this number, but there's a lot of places where you can call the hospital and be like, hey, give me a number to text some stuff. Now usually hook it up. Yeah. All right. And then lastly, number nine, the package and prepare your patient for e-VAC, right? So in your pack, really, you're not going to have a whole lot. You might have a checklist of, hey, if I'm going to hoist or do this, this is the minimum stuff I need to request or have or do for the patient prior to the event, you might carry some additional, like two other nylon, some sort of webbing to assist with tying them into a litter, doing a hasty harness for them, whatever it might be. And the only other thing you may or may not have with you for your patient, mind you, this is for the patient, which could be for your use as well too, if you have a set for you, would be like some ear and eye protection, right? So if you're going to have a helicopter coming overhead, putting in some ear protection, some eye protection, if you could put that on your patient prior to them being hoisted and all that stuff whipping around, excellent, you should have it for yourself as well. So you're focusing on the evacuation and the event and not trying to keep your eyes closed so they don't get poked out with all the flying sticks. That's a really good point. I often am reticent to make sure I am also protected. I usually take my stuff off and hand it to the patient and that is how to do that. I'm a bad person. And that's usually what happens with this. So Mike and I both, I know we both have eye and ear protection in our packs with our kit. And like you said, a lot of times it ends up getting put on the patient because the stuff that was supposed to come with the litter for the patient may or may not have made it. Then you're like shoot as you're flying up in through the trees. This is probably better for you right now than me. Yep, I'll just hike my bike vocals up a little higher and I'll be all right. But yeah, it is what it is. I don't carry two sets. I don't carry a specific patient set. I usually have extra ear protection because Mike never remembers his. Yeah, because I'm a bad person and I'll say you're as human. Yeah, he's protecting his eyes, which is arguably probably more important because let's be honest. On the ground, it's not that loud. There's noise, but it's not as bad as if you're riding in the helicopter. I usually just wait until I get into the helicopter and then they me. I just bribed the cable like without it because you know what's hearing really. Yeah. Just relax you'll be all right. Yeah. Okay. And then step into it as they say. Yeah. And the stuff coming up your truck and UTV would be your your full extensive evac kits. Right. What are there? This is ropes and rigging stuff for technical rescue things, raises and lowers, helicopter operations, things, the litter, tie-in stuff for your patient, tag lines, harnesses, bridles, whatever it might be, right. Whatever you've got set up, that's where all that kit should be. And as it necessarily always going to come down trail, nope. Some of that stuff might go to a specific landing zone for a helicopter or things like that. So it might go to a different spot like you might have a carryout going one direction for a while. Then you know you get to this position and ropes will be needed. So ropes are might not come to you. You might go to a point where they've already gone ahead of you or gone to different route and you're just going to meet them there and then do a raise or a lower and keep going, etc. Right. And then those things at the ambulance, while you're at the ambulance, you've probably already made it to where you're going to go. Now you just got to drive to a hospital. So I'd say the packaging perverfer you back would be your seat belts and full tank of gas. And that's really about it folks. Like I said, I will post this document. It'll be a simple PDF. You're welcome to look at it. If you want to take it, use it for some food for thought. Maybe with your Sar group, your wilderness EMS agency, whatever it is you're doing, puts a thunders like, oh, maybe we should consider adding this to our kit. Maybe we're going, we've been going in the back country. Some very limited small stuff that maybe we should consider adding more things to our packs or maybe we've been carrying too much and we should take some of that out and it could be a follow-on item. Any number of ways to skin this cat. As they say, when you've seen one EMS agency, you've seen one EMS agency. Right. So there's a lot of ways to do this. Some groups needs will be different than other groups like me and Mike would prefer to have and take with us where we go is different than somebody working just 50 miles away. Might have a completely different need as far as the equipment they have and how they take it. You've heard us talk before. We prefer just because of where we operate and the way things fall out for us is we pretty much have to take a backpack and be prepared for pretty much all of the things. Now, that doesn't mean we're carrying harnesses and ropes with us everywhere we go. We have those kits packed staged ready first to add to our standard backpack but we don't have to have them with us everywhere we go. Just a lot of places only will go down trail with what we'll call an aid bag just with medical stuff. They don't need to worry about bringing additional warm gear for themselves, a lot of water, snacks, perhaps for an emergency overnight. They don't have to worry about that just because the way their responses work, it's not necessary. From Mike and I, we get stuck out a lot. For us, there's never a simple just one hour or less wilderness response. I'm looking forward to finding it. I haven't found it yet. And I got to be honest and I'll be selfish with this statement. If it's out there, I don't want to go to it because you clearly didn't need me. If it was 20 minutes for me to walk to you, 20 minutes for me to evaluate you and then walk back out 20 minutes, you clearly didn't need me. And if you did, you would look so true. You look so true. I do look good. Yeah. So again, different response models require different setups and loadouts. This is just a very simple look at what can be a very complex planning process for you. Like I said, I'll put it out there on the socials. You can make comments on it. You can just take it, modify it, do what you want with it. I don't care. I don't own it. I stole this from the military side. Not that they care either. I believe the term is requisitioned. The redistribution of government property. Yes. Right. Remember, yeah. In the government, there's only one thief. The rest of us are just trying to get our gear back. I heard that before. That's pretty good. Yeah. So that's right. There's only one thief. The rest was just trying to get our gear back. So this is the next. We're going to make this available on the interwebs. In the same way that Sean has requisitioned this fee, please feel free to steal it and making some of it. Yeah, if it's useful to you, good on you. Tell us if you want to change stuff. Tell us if you think we're we got it wrong. Add to it. It's fine. We can always. Yeah. By all means, dating versions, we're all about it. There's one thing that Mike and I are not afraid of, and that's learning something different or new or seeing a different way to do things that might be better than what we've got going on. Yep. I'm also super not scared of failing. I do that a lot. I just fear change. He does. It's cool though. It'll be okay. I'm a middle aged male. I'm setting my ways now. He definitely is setting his ways and he is definitely a middle aged man. With that, I'm going to hit the stop button because I don't think there's anything else to discuss on this topic. All right, then. Till the next one, folks. Bye. If you have any questions or comments or ideas for show topics, you can send us an email at the show at ems on the mountain dot com or here's some social media. We can be found on Facebook and Instagram at ems on the mountain, Twitter at ems o tm or you can engage with us in a whole community of wilderness emus professionals at locals dot com slash wilderness emus. Until the next episode, thanks for joining us and until we see you on the mountain, train hard, be safe and do good work.