EMSOTM 53 - It's cool, but do we need it?

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] And once again, Mike has brought us into an upward entry. Welcome back to another episode of EMS on the Mountain. As usual, you have the Bill and Ted at wilderness EMS. And I like that one. That's hilarious. I'm not going to make this bad man a robin or anything. We'll be the Bill and Ted of wilderness EMS. Because we are totally awesome dudes. We are totally awesome dudes. Bill S. Preston, S. Quarer. Polish it. So, today's episode was devolved by our friend Mike there. He has a selection of topics and ideas. And I am completely blinded to them because he wanted to get honest reaction. Just off the cuff. And I do want an honest reaction. Which I always give honest reactions, which is why we have some people that are grumpy with us, some people who are not. And two weeks ago, Mike and I made some really good friends. If you haven't read those comments, Mike, you should always pick out the ones that are about us. I adhere to the Joe Rogan model of commentary. Visivity. Don't listen to them. So, if you're telling me there's comments, I should go read. I'll go read them. All right. So, in the theme of, we're not good at making friends. Well, to be honest, there's been some discussions in the EMS world is of late about wanting to do more and wanting to have more advanced skill set and more capability and anything to a certain extent social media is getting in the way of this. I love the social media. So, I love everything about the social media. If I had to pick life with or without, that'd be a tough choice because personally, I hate a lot of online life in general. I think we've lost a lot of human contact. But on whole, it's probably a net positive. But part of that means that there's a whole bunch of keyboard warriors that think their rock stars add a thing because they took a class or they went and did an online tutorial on a thing. And then they feel like they can speak eloquently about a particular thing. What the hell am I talking about? I'm talking about a lot of the high speed low drag or high speed high drag advanced practice skills that you are seeing pop up all over the Instagrams and the Facebooks and the sets and the others. For those of you that know me personally know that this is a somewhat near and dear topic to my heart, but I started thinking about a number of these pieces of equipment or diagnostic tools and whether or not they were applicable to wilderness medicine. So I've got a list here. Sean, I'm going to talk about them sort of one by one. I do want to start off by saying, and I'm going to circle back to this at the end. Please keep in mind that the role of EMS, at least in my opinion, is to not fix things. Sometimes we feel like our job is to roll in and fix stuff and a lot of the conversations about alternate destinations and dispatched for care at home and leaving the patient there and billing for that and all those things are predicated on the paramedic is just as good as the doctor. I would argue that when we quote fix stuff when people quote get to better after contacting us that is largely related to the fact that it was relatively benign and easy thing to solve for. EMS, the concept of pre hospital medicine holistically, there are exceptions, it's largely to stay off death and intervene in the little things and make it easier on people, but it is not to quote fix them and move on. I want to explain that a little bit more in that we don't carry a bunch of diagnostic tooling that allows us to go in and remove a spleen or do surgery or fix this or that other problem. What we do is provide management of the situation and keep people from getting worse while we get them to a place that is more tooling and equipment to determine these things and fix them. Is that a fair statement, Sean? Absolutely, I think a lot of stuff going around, I think with the intubation side of things, the people want to do RSI change that to resuscitate sequence innovation. I think that sums up a lot of it. It's the temporizing measures, the stabilization of patients, the sequence. Obviously, they're not so sick that my belly hurts because I talk about it 3 am. Yes, if you're wondering, we do get those calls. I totally agree. Up the top of my head, how many things do we really fix? I think the only thing we truly fix pre hospital could be low blood sugar. That's still a temporizing thing because unless somebody's been on a starvation diet, which we're still not fixing that, they still need to go get proper medical care that's not just a paramedic and a truck. Getting somebody's blood sugar back up to a normal range so they can maintain and then sign the refusal. We didn't fix the problem because their problem is a diabetic problem. The problem is the use of insulin and their endocrine system. Again, it's still a temporizing measure. We fixed that one problem, but we didn't fix the problem. I think your spot on, right? We're not fixing anything pre hospital. That's why it's called pre hospital. Not hospital. With that said, I'm also going to stay flat out. I'm not opposed. I'm not for or against any of the things we're going to discuss here today. But I am for. I'm absolutely all in on the fact that if you're going to do more things, even if you're not going to do more things, I was a stupid statement. I'm going to retract that and say, even if you're not going to do more advanced things, as a pre hospital care provider, you are absolutely positively responsible to make sure that you are providing the best care possible for your patients. So for all of you keyboard warriors out there that are telling me, oh, we need to be able to do ultrasound. Oh, we need to be able to do. Paracardiocentesis. And the list goes on. Are you going to dedicate the time energy and effort to make sure that you're maintaining that skill set. A lot of these things are that we're going to talk about today are life saving interventions. I'm not completely convinced that they are going to be life saving interventions in the woods, but that's what we're going to talk about. But if you're not working on maintaining the skill set on how to perform the activities, like that's part of the downtime aspect of being a pre hospital provider. You're not going to put in the work. Don't advocate for the cool guy stuff. There, I'll say it is about as succinctly as anything I've ever said. If you're going to advocate to do the cool guy stuff, you got to make the time energy and dedicate the commit the, or you've got to commit the time to maintain the skill set and be able to do it right in those high acuity, low frequency events where these skill sets come into play. You're going to talk about the first one. You ready, Sean? Here comes the first one. Keep in mind we're talking about the wilderness here. Intubation. That makes you that's your cue. Should we be carrying around all the equipment necessary and performing intubation in a wilderness setting. I think we're going to caveat this with the lead in answer for probably everything you give me and it's the it depends. That's what I'm going to give you because context matters in this thing like in the wilderness. What are we calling the wilderness? There's something. Be in 50 miles deep somewhere is different than being a mile off a trailhead, right? That's a great easy area. Right. So all that being said, I do believe there's still a case where the ability to intubate and provide that definitive airway is certainly warranted. I think it's a skill that if your wilderness paramedic you should be up on your intubations. That was right, just because there is the need. Some people just need those definitive airways that a superglotic may not get it done with necessarily. I think a lot of time, superglotic will still probably suffice a good number of these settings. As all the studies have pointed out, pre-hospitaly, you're in the urban setting, right? So, not much is going to change wilderness-wise. I think, and this is, again, this is my personal opinion, and we've had this discussion before, if you're going to intubate, you need to be somewhere very close to the trailhead already, because the, or, let me caveat that one, you need to have compact portable ventilator because walking with the stokes and bagging someone and not dislodging tubes and everything else is great in a training environment with a mannequin and things like that, where you're really not sure because you don't have a real end title going on and you can't tell how I dislodged this tube because the basket took a little bit of a pitch. I held on when a different direction is the tube still in the right place. I don't know, but I'm squeezing the bag still and the training exercise goes on. And in reality, you might have totally now come out of the airway, or maybe you shoved it farther in and it's now a right mainstamp, who knows. And so walking and bagging or going up the side of a litter and bagging, somebody that's innovated, you and I both played around with these experimentally, in training environments, okay, if I'm with the basket and the patient, what's positioned is best for me to bag the patient while the litter is being raised or lowered and it's really not. Because you have several periods where essentially you're going to induce the apnea because you're not going to be able to bag like when you're making your edge transitions and so on. So unless you set up like the perfect setup with gantry cranes and shit, they can just swing you over smoothly without you having to do any work. Yeah, great. So I would put the caveat of yes, intubations for the will miss environment are a thing. But I also believe if you're going to be doing that, you do need to be working with transport ventilators. And this will go with superglotics, do you have, we'll put that in the advanced airway. You need to be having some sort of transport event, something's going to be able to breathe for you because you can't just walk right next to the patient their head and bag effectively as you move. And I think you also need to consider the amount of drugs you're going to need, particularly on the sedation piece, right? The paralysis piece, right? Cool. Most of those last quite a while, depending on what you're doing. But are you going to carry enough to keep your patient effectively sedated throughout all of that? So there's yep, you got to remember that piece too. So again, it's funny. It's going to vary. Oh, excuse me. That was a heck of a young. It's funny. You mentioned that because the next list was sedation. So I tend to agree with you on intubation. I'll give my thoughts on airway, advanced airway procedures here in a second. But I think you already answered it. I think you have to be able, you have to be prepared for and versed in extended sedation of a patient if you're going to go down the road of intubating somebody in the backcountry. This can't just be a, oh, only when they're unconscious. So, most of people, this is speaking from experience, unconscious people in the backcountry that are unconscious are either really messed up or they will become more conscious by the time you get them out of where they are. If somebody's been knocked out from a fall, you're usually with them long enough that they regain some level of consciousness unless they're bleeding into their head and working and dying. If you're with somebody for six, seven, eight, nine hours, it's just how things work unless you keep them down, they usually come up at some point, right? Yeah. And those that don't are on their way to permanent down this. They're on their way to downs forever, right? And now we're in that case, we're staving off the dying, not working on fixing the dying. So, I think I'm all for intubation. I think all of the exercises in paramedics shouldn't be intubating. I think we're being a little bit short-sighted in myopic in that. Kuru Chiu, again, the world's greatest, or the world's okay as paramedic. He's done a couple episodes on this recently. I think that numbers are skewed a little bit, but I think the end of the day, if you have to manage an airway, the only way to get her done in the backcountry is to intubate somebody. And that means that you have to be first in what a lot of what I'll call 911 systems are not really super, super strong in and that's keeping someone down once you've once you've intubated them. So, intubation comes directly with sedation in my mind and it also comes in my opinion. There's a whole level of how good are you at this and should you be doing it if you can't, but standing orders for Krakow Thyrotomy is a must in my opinion, because if you decide you're going to intubate somebody and something goes terribly wrong and now you're in a bad way. Now, there's actually agree with this, right? If you're going to take someone's airway, if you're going to arse somebody and then you have to correct them, you have failed so incredibly badly, because if you weren't confident that you could get the tube done. I shouldn't say incredibly badly. There's always the outliers, right? But it's a long conversation about so you decided to paralyze this person and then you couldn't get the airway and then you had to crack them. Why did you choose to paralyze them? Perhaps you should have used other measures to manage their way or position them better or prepare more effectively before you paralyze them. But a lot of severely injured falls and things. We're not in the business of paralyzing, which is in the business of trying to maintain life. And in that case, you absolutely positively need to be able to intubate them. Yeah. Because you brought it up in the world of this austere medicine piece, I personally, I don't know this would go against what a lot of people think. But if you're truly in a backcountry wilderness austere environment that's not, we'll say clinic based offshore oil platform where it could be. It's not always our days to help a copper can come get your patient, but you have a small clinic. In the woods, and if you need the advanced airway and you think you really need to go the advanced airway, I myself personally would advocate going right to cry. And there's a number of support that. But and that's part of that is my background. More advanced airway management from the people I did. And so I have a different outlook on that. And people ask me, but why? In some ways, it's more secure. Right, you stuff to obviously pay attention to your, where your tubes and everything else. But. Yeah. We're not going to get into all that. But anyway, so that's just a personal thought. You can do conscious crikes, right? Enough to get a mean down for a brief period. You do the cuts. You're bypassing all the things they're going to make people gag and vomit. Essentially, the whole reason we do the parallelization piece. So depending on your jurisdiction, the med you have available, that might be your only option for a legit definitive. Anyway, enough on that. Yeah, no, I agree. Okay. So you mentioned it briefly, mechanical ventilation. I go back and forth on this. Let's get your thoughts first. And then I'll tell you why I'm pro and con depending on the day of the week that I'm thinking about it. And if you are going to report to have advanced airway skills and do an advanced airway, whether that's super glad to hear and don't create dual innovation. I think you need to be having a transport vent like small compact transport fence. Pick your model. I don't really care as long as it does the job sufficiently for your needs. It includes battery life because again, we always talk many hours with some of these people. But I think some of the reality is on again, it varies. But if we've had to innovate, this is one of those patients that we're getting out as quickly as we absolutely can safely. This is someone where we can we can overnight with this one if we need to and we can try different methods in the morning like maybe aviation can come in the morning. Or we can assemble more people to make the carry out easier. Before the point where the patient's so bad that we've had to. Intubate or we've had to put in a king airway and everything to mangan airway and they're still down. Then those are people that need to be getting evacuated now. And that doesn't mean that it's only a couple hours because we've got a helicopter to come because it's still might not be an available option. So I think having a ventilator 100% 90% yes, it's mandatory. Can you manage without it? Yes, but as we've talked about. It's simply just not ideal. And then lastly, whatever you choose, you've got to be able to have the battery longevity to support the full mission with it. So that is what it is. Yeah, especially like you and I, unless we're going to get somewhere and then turn them over to a proper. PEMS unit local helicopter, you miss agency. If we fly with the other agency that picks us up, they don't have a ventilator on their helicopter. They're not. It's not a hemorrhoid. cellocopter. It's a helicopter that can be used for rescue operations. So you might need that vent work for hours on the ground and then transit time of flight, etc. So you got to be able to plan the whole mission with that. Yeah, I was actually going to bring that up at the end. So here's my take on ventilators. Twofold. One, I think that are an absolute necessity if you're going to be managing airways for an extended period of time and I define extended period of time in EMS on whole is more than like 20, 30 minutes. I don't think the data is clear yet, but I think my understanding of puzzle physiology and enough that I've read says that if you bag someone from more than about half an hour, you're probably doing more harm than you think you are. I'm not going to say you're doing more harm than good because not bagging somebody that's not breathing obviously has a guaranteed end game. There's a guaranteed output there, but at the end of the day, we're not very good as humans to paying attention to the nuance of a human that's in a bad way, more so than a ventilator. And this I'm not going to spend a lot of time talking about different vent modes and whatnot, but I've been doing this a long time. I've been involved in bagging quite a few people and I don't think anybody notices whether they're bagging over attempted breaths or overinflating or over bagging. There's so much education that goes into teaching folks how to not overinflate lungs and don't squeeze the bag too hard and two fingers and all these things, right? Some systems have gone to pediatric bag valve mass, which I actually at first was like, that's a good idea. And then I read more about it now. It's like, that's a horrible idea. Yeah, Sam. Yeah, not for yeah, anyway. But all of those things are all an attempt to do a better job at managing the airway of a patient that's in need of airway management using a manual bag valve mask. The better solution for more than what I'm calling half an hour is probably a mechanical ventilator, though there are complexities with those as well. What has me on the side of this worries me even if you're going to save, too, which I do not think is bare minimum in personally for the proper care that a patient should be receiving, I think. Some of them like an EMV or a Zoll X-Vent, a ruggedized device that actually has multiple parameters and settings for more lung protective strategies than what you get from a simple mechanical ventilator, though they're a little bit bigger and heavier is probably, you know, under the do-no harm do best for your patient thing. The did I say X-Vent? I think they're called Z-Vent's, right? Z-Vent's. Yeah, I'm not a similar with them. Yeah, I think it's called a Z-Vent. I'm familiar with the EMV Plus. Anyway, there's a bunch of benefits, but with the tool, there is a significant amount of complexity that comes with running a ventilator, like knowing how to properly manage a ventilator is not like a, oh, I did this once in a class and then I'm going to go do it in nine months when this guy needs it. And the wilderness environment, truly austere or extended care wilderness environments, do not have the call volume that EMS transport and 911 systems in busy cities do, right? So being able to calculate ideal body weight and understand lung protective strategies and all the things and pip and peep and all the stuff that there's plenty of podcasts on how to do. You have to know this stuff at a level that you're not going to do more harm and that requires a significant investment in education. So I think they are a critical component for extended care, but it is also, if any particular system is going to invest in them, there is a significant amount of investment necessary to make sure that you maintain that skill. So I'm pro ventilator, but I'm also reservedly concerned because a lot of folks simply don't have the time or don't commit the time to the educational refreshing and staying on top of the science when it comes to running things like ventilators for an extended period of time. I agree with you 100% on that. And I would say all of your concerns are why the safety was built the way it is, right? It was built for that. Mungo think friend five foot eight hit that button and it just does it. And then you can take off 10% of the projected volume for that and everything else trying to work it, but I think what you need to also consider is if you're going to go down the road of having transport vents, whatever model you choose, you also have to have the requisite patient monitoring equipment to do the job correctly. This is not where you can just toss an Emma between whatever that event set and your airway is, right? You need legit airway monitoring. You should probably be getting some cardiac monitoring. So you can see spikes in heart rate and everything else that you're just not going to get using what we'll call traditional field or wilderness basic patient monitoring equipment. Like this is where the Athena that WVSM comes into play, right? Especially the new model that can do full cap no stuff, right? Like you need to be seeing these things. And it's best if you can put that on a screen like if you had an actual Zoll or Life Pack Monitor or you can start to see breath stacking and things like that on with your stuff, right? Because if your monitor isn't going to show you that your vent, then you need something else that's going to show you that so that you know that oh, they're overbreeding, they're underbreeding, they're I'm given still given too much volume or maybe I'm not given enough volume. So I think the requisite patient monitoring that we take to give you an oxygenation versus ventilation problem, right? Just breathing doesn't mean they're actually needing, right? So I'm getting at this. If you can't do the full ALS level patient monitoring, I think just tossing them on event, even a simple one, as high speed as you want. If you want to bring your Hamilton into the field, I don't know what the battery like, is for one not attached to a helicopter. Hey, good on you, but you need to be able to monitor your patient in its entirety, not just whatever venture you're using. It's like the safety is only going to give you some high pressure, low pressure alarms. It's really not going to give you much else. There's no display to show you if things are working the way you think they're working. You have to be able to truly observe and monitor your patient. And so I think that's that should be a caveat with throughout is, yeah, I'm all about it. We should absolutely have access to some sort of ruggedized transport vent for advanced airway use in our steering environments, but you do need to still be able to do full patient monitoring. If you're not, yeah, better than not having one, but at the end of the day, are you still doing the right things? Are you not causing that more harm thing? Yeah, I'm with you. All right, ultrasound. Should we have it? Is it a tool that we should be keeping in the toolbar? This is definitely another, it depends, right? So for what I will call short duration, we'll call it traditional 911 backcountry response, neat, but is it necessary? And I'm going to say no, because if you're doing a good patient assessment, even with basic vital science collection tools, right? Blood pressure, pulse, stethoscope, doing a fast exam, if my patient took a fall and they're complaining of abdominal pain, and I'm in the backcountry, my assumption is it's internal bleeding until a surgeon tells me otherwise. Now, if I'm working McMurdo station in the Arctic, and do I call the C-130 into evacuate this guy or not? Absolutely, using ultrasound to go, oh yeah, that's free fluid. We should definitely get them out. This is bad. So is there a need? Yes, case dependent, right? So should I carry an ultrasound in my backpack just to do a fast on some of it that took a tumble, and I'm going to evacuate them to a hospital anyway? Is it going to give me info? Certainly. Is it going to change anything I do for them pre-hospitalia? No. Other than ask for help quicker, but either the helicopter's coming or the carry out crew is coming or it's not, or it's going to be delayed, whatever it is. The time frame is the time frame. I think the biggest difference in the austere environment is because we have that extended patient time, almost irregardless of the situation. It's not as big a deal. It doesn't really delay evacuation or transport, like often does in the urban setting, where people sit on scene for next or 10 or 15 minutes playing with their ultrasound. When they could have been damn, you're pulling into a trauma center at that point. Yeah, I mean, are there other good use cases for it? I would think like hypothermia is this dead or hypothermia? I can look at the chest. Do I actually have cardiac motion and movement? Yep, heart's actually moving. Not dead, just severely hypothermic. Let's do stuff. That could absolutely be useful. Of course, the usual check-and-diameter of optic nerves to see if there's intercerable swelling and things like that. Yeah, but if they took a fall and they are unresponsive and they are still unresponsive by the time I get there. There's something going on in the brain that they need to go see a doctor about, right? It's cool. Is there brain swelling? I'm going to assume yes because they're completely unresponsive still or whatever the case may be. And again, this goes to your work and ever space camp, right? Is this some cerebral edema due to altitude stuff? Yep. I don't see anything else crazy can you hang out here and be better? Sure we can monitor it. But for average we'll call it again the 911 style of wilderness EMS response. I think with very limited use case it would be handy otherwise. I think it's just one more thing you're going to carry just to play with. And again, ultrasound is one of those tools that's been shown that you need a lot of sets of reps on to state efficient. It's not something you can just pull out twice a year and go. I don't even know what I'm looking at here. Is that the liver or is that not the liver? Is that fluid? I don't remember what that should look like inside their kind of thing. So if you're not good at ultrasound and the tripertation, that's a tool best left behind. So here's my take. I generally agree with everything you said. This falls directly into the ventilator category of are you spending enough time doing maintenance training and education. This is a sort of thing where you got to get out and loop up and ultrasound people at least a couple times a month to maintain proficiency. Because part of at least in my limited experience part of being good at viewing ultrasound is knowing what looks off and you have to see enough people to know what looks normal to then start identifying what looks not normal. Right? Yeah. I think it's got I'm 50. I'm on the fence on whether fast, e-fast exams in the backcountry or necessary. I think this couples with the next thing I'm going to mention, which is blood and access to whole blood administration. I do not think you should be pushing a whole blood on people without like clear traumatic injury unless you can get some differential diagnosis because there are some complications with pushing blood on people and things that come with it. But so if you have whole blood, maybe ultrasound is the thing you also need to maintain having whole blood is administering blood is pretty easy maintaining the program is harder. Yeah. That said, I think the place where ultrasound is somewhat interesting to me in a more wilderness environment is respiratory distress, right? Getting to a definitive answer around how urgent is this person is that an asthmatic attack is this is that that do we have fluid in the lungs. But again, that's getting more into the austere environment as opposed to backcountry medicine problem. Then the other one for me and this is so corner case from nuance, it's probably not even worth discussing. But I see a lot of use for ultrasound prehospital in termination resuscitation efforts. Oh, yeah. I don't want to do a bunch of things to someone or to someone's loved one when they had an inadvertent cardiac event on the trail. I don't want to crack ribs and call in all the resources and all the things if I can get there in a timely manner and determine that it's probably not something we are going to be chasing. Well, I would say it's actually more important because we're 90% of the time for talking actual backcountry. We're not going to get there in a timely manner. And there's already been 30 plus minutes of what we'll even assume it was good by standard CPR. We get there, check pulse, no pulse. You have a monitor, you don't have a monitor. Slap that thing on, zero cardiac activity, we're done. If folks appreciate your efforts, we're done or you see something you're like shit because again, you're probably not going to have a life pack or result with you to like actually look at it. Even for lead feedback. You're not even going to really be able to play the P.E.A. game, right? So is there cardiac activity or is there not? If there's not, that makes it very easy to then terminate the resuscitation. Especially when you call met control because of a backcountry thing because they're going to what rhythms have you seen. It's a row we have no monitor. But I have this focus device and I'm zero cardiac activity. Then they're like, oh, right then. Go ahead and call it time. Whatever. Yeah. Okay. So let's move on to blood administration. Is that something that we should have prehospitali or excuse me back. Yeah, say prehospital. Absolutely. I'm a fan. So backcountry. Yes. Again caveats with that. So you get someplace, somebody's got your assessment and whatever you find on your thing. And yes, this supports hypolimia. They need blood products. And given that they might be still an hour plus assuming that you have a helicopter that can hoist or something that's going to come. Getting them the blood products could literally mean the difference between life and death. Yep. So is being able to even just to maybe three units of blood. Yes. But I have to look at that kind of as a programmatic whole. Is it worth. If you were, we'll say an independent wilderness EMS agency and you're not based out of an urban system that already has a blood. Program should. A national park, for example, have a blood program. You'd have to really look at the use case of how many times a year would we legit use this? Because a lot of the patients we have that blood would be useful. This primarily where you and I are at, there's not some external traumatic injury where we can put a tourniquet on our pack wound and stop the bleeding problem. So that then when we give them the blood, it stays where it's supposed to be circulating within the vascular. Internally, I can't stop you. You're abdominal bleed. I can't stop you bleeding in your chest cavity. And if I'm dumping through units in and all I did was bloat your stomach with three more units of blood, I gave it a good value to effort, right? We tried. We did everything we possibly could, which should be done. But at the end of the day was the cost of that blood worth just dumping it in because we still had to sit on them for two more hours before we could get them. On a full evacuation pathway to a hospital in the Trotten Center, regardless of mode. So I think it's so you there's a lot of, I would say triaging that we need to be done by the providers on scene to determine if this person is a candidate for blood or not. I agree with that. Here's my take. I am pro pre hospital blood for a number of reasons. One, I believe I personally believe that we treat traumatic cardiac arrest completely wrong. We treat them like their heart stopped, but typically a traumatic event like the one you and I had not too long ago. Yeah. That was more like the preponderance of damage was not survivable. But assuming it had been, right, if there was a fluid leakage problem, fixing the fluid leakage has a much higher propensity of saving someone's life than filling him full of epi and telling the heart to beat when there's nothing moving. So when I think about it from we should be doing as much as we possibly can whenever we possibly can to save someone's life than absolutely like just on its face, like having a blood program sounds great. The problem is that administration of a blood program and the cycling of blood and the making sure you're not wasting is you really have two paths, right? You can start just paying for it. There are services out there that will ship to you blood for the purpose of administration to people that is an extremely high cost for most programs to maintain for the rare use cases. Blood's only good for about two weeks. Give or take, depending on where you're getting in, how fast, et cetera, et cetera. But it's not like you stick it in the freezer and you get to use it for four months from now. It's just not how it works. So at the current state of the science we're in right now, it's really hard for me to say we should absolutely have a pre-hospital blood program wherever possible for wilderness environments. It's expensive. It's about 500 give or take anywhere of $500 to $1,000 per unit of blood when administered. And if you don't have a way to cycle it back into the system and have it used, you're incurring a significant expense to have it sitting around to probably not be used. This is where a pre-hospital evacuation system makes a lot of sense. So here's where I landed when I was thinking about this my man. Where you and I play ball, I do not think we need a blood program. But I do think that given the opportunity and those of you that work with us and listen to this podcast, you're going to hear it and go, that sounds great. It's cute. I do not think we should be keeping blood on hand. It does not make sense for the rare use cases where we would need it. I do think higher level providers like ourselves should have the knowledge, capability and equipment to administer blood and we should ultimately work toward having a system where if for whatever [BLANK_AUDIO] and I cannot get a flight crew there. Or I have to transport them using some of the other air assets we have that are not, as you had mentioned earlier, critical care flight transport systems. They are just helicopters with the ability to pull people out of a bad way, but they don't have advanced care equipment on them. I would ultimately like to figure out a way to be able to acquire the resources and administer them, but not manage the system. I don't mind keeping bloodwormers on hand. I don't mind having Y tubing and filters and all the bips and bobs needed to administer blood. I think the cost of maintaining that equipment is relatively minor. You're going to throw away your tubing more often than you're not. But in the rare case where somebody does need it and it is life saving, if there's a methodology to get it to the scene so that it could be administered, awesome. The kicker is that those rare situations often don't include providers coming from other agencies that have the skill set of the ability to get to the patient and do the work. That's where we come into play. So for me, a wilderness environment with a blood system, absolutely, but I think it should be in a combination system where the blood would more often be used on the flight crew. But in the rare circumstances, we should have a protocol that says call for blood and that blood can be brought and we will have orders and procedures in place to administer the blood for those that need it to try to save their lives. That's where I ended it. Now, I would agree with that 100% like I said, should, yeah, like a dedicated wilderness EMS agency, which again, in the United States, really is the park service. Should you somebody have a blood program in and of itself, probably not, right? Should a smaller park have one, even less chance of it, right? You would really have to look at how many times in a given year with this be administered. And the answer for most of these places is going to be very seldom very seldom, right? Like you and I can think of, John, the years we've been doing this. I could have the good five times. Yeah, I think of the five times where I was seriously considered and probably moved toward blood administration had I had an available, right? Of those five times. Two of them lived three or two years, right? Yeah, it's once every two years. The majority of people that I would have considered it for have passed. I don't know that blood administration would have stopped them from dying, but it certainly would have given them a better chance at living, right? Yeah. Yeah. And that's why I'm like, oh, yeah, sure, if everybody could have access to a blood program. Yeah, sure, absolutely. Like one day when we can have the incredibly blood, awesome. Yeah, we can have dehydrated blood and we just reconstitute it and push it like cool, like where it can just sit on a shelf and it's relatively inexpensive. That'd be great. What are you envisioning? Like you mix it up in your knowledge and then put a special top on and hang it upside down. Absolutely. Just like miles back in the day. Like you can get your French press for your algae bottle. Similar, right? It's French pressing blood. Built in filter and everything. So you take out some of the everything. Some chunks, no class. So we're good. Good to go. Just like you have your any of the other dehydrated blood products that people have experimented with before, normally around plasma and platelets and stuff. But the other problem with that is once you've dehydrated a red blood cell and reconstituted it, it doesn't really come back to being a real red blood cell to transport oxygen. And that's why the big deal behind whole blood. So, yep. If we just want volume expanders, yeah, then we could just pick plasma or plasma platelets. Yeah. But we don't need the kicker is and I think medicine is going to go this direction. We don't need volume expanders. We need oxygen carrying capacity. And that's where all the studies have shown is like just giving someone plasma, yes, better than dumping leaders of normal saline and get to get on my soapbox again. Any of you assholes that are still out there dumping more than two leaders of normal saline and anybody is what's wrong with you. Trauma patients, there are some other whatever use cases, but like those days are over folks. Yeah. Yeah, like seriously, you could follow your local protocols. Yeah, if they're telling you to put four leaders in, then go for it. Anyway, beyond that, I think some of these people to get all poopood in the pre-hospital paramedic community, especially the social medial ones, about my god, we're giving pasta water and battery acid. It's a dude. If you watch an ED dump normal saline, like it's going out of style in a trauma patient before they get to blood, like we're a but a drop in the bucket, people stop. Yeah. Anyway, absolutely. Not that it's good for your patients. I'm just saying quit panicking. You're one bag of normal salines, not going to take them from a 7.35 down to a 6.0. Just get them. We're going to talk about that in a minute, but that ain't no normal saline. So blood, absolutely, but I think you're right. I think it's much better done in a coordinated partnership sort of agreement with local agencies that have blood programs like, hey, if we have this super trauma patient that I need blood, can I call on you and we can arrange some sort of link up and we can get your blood or your supervisor or whatever your provider can officially hook it to the bag and the line and go, whatever that is. But I think that is definitely the way to go for most wilderness EMS programs. So it sounds like we're blood administration, we're anti keeping it on hand. That's a partnership problem. For most US use cases, I think yes, correct. Because there are some parts here where wilderness EMS is taken care of by the local EMS teams, like the actual 911 ambulance curves, they just also do backcountry stuff. That's a different fair situation. So anyway, next. All right, here's one I stumbled across and then we'll get into some fun ones. I just want to know your opinion on this one. Paracardial synthesis. Dude, so this used to be like the dream gig, like a pyramid. Yeah, man. So yeah, but then we got ventilators and ultrasound. So it's not that cool. It's cool. Here's my concern. Is it something that could be potentially life saving again in that maybe traumatic arrest scenario? Possibly. But this goes back to your other argument about vents and everything else. This is a very high risk, very low use skill, right? Like, how do you, this is one you can't even hardly train for, right? The simulators for it would almost make it so canned because I go in the same holes everybody else's shoes, right? Let's look at the studies done on needle chest decompression and how people keep fucking that one up. And now we're going to go at the heart with a giant needle that sits between two lungs and everything else. Personally, if you work for an agency that you can do this and you use maybe ultrasound guided, which I would say would be almost the only way you should be doing this pre-hospital thing. Sure. That's cool. Could this be a life saving thing or at least a serious temporizing measure? Absolutely. But to just blanket make this a, this would just be a wilderness skill. I think it's pushing it just because there's so much you can mess up it. If they don't need it and you stab the heart, okay, that was a good idea. Doing a minor pneumothorax on someone isn't so much, it's not good, but usually it doesn't create a whole lot of harm on that patient. But accidentally inducing a hole in the heart when it didn't need to be there can be a big deal because it's a high pressure system. Stuff will squirt out that hole and it makes it harder for it to stop depending on where you mess that up. So yeah, I personally don't think there's enough need for it. I think that limited training time needs to be spent on other things. It's cool, it's neat. But if that's your problem, like you've had a good run. Yeah. If that's the only thing that's keeping you from preventing you from living, man, yeah, sorry. The COVID vaccine or just kidding. That was a joke for all you out there. I think part of this difficulty is going to be legit diagnosing it too. I agree. I guess people have a very hard time diagnosing no shit tension, no most, the only thing we decompress in that field, right? Listening for muffled heart tones. Holy crap, man. Is that muffled heart tones or is my stethoscope suck? How should it, how loud should this thing be right now? It's probably in that tone. That's the thing, muffled heart tones, plus if I have to look at where they parade in, is there, what other vital signs of my looking at that normally you would look at and go, this could be a pericardial tamponaut kind of situation. Holy crap, man. We're not, okay. 90% of us aren't bringing all that to the field in the wilderness, austere environment. So I just think that's a very high risk activity. Let's talk about decompression. Yes. I think you and I are both going to be in the, yeah, needle decompression is the thing that's absolutely necessary when it's necessary. It's just that you got to not suck at it and it turns out that you got to be really clear that you need it. And, yeah, again, that one's certainly skilled at every paramedic should be maintaining training. It's. I hate the training because it's usually so canned you have that one mannequin and it's got a thousand needle marks wherever everybody's done it most of them are wrong and when you get I should go in and put it in the right place because you actually know you're not being nowhere. Mythocovicular is That's why I do my friends Yeah, no Needle decompression sure 100% And this is one of those situations in the wilderness not stair environment Because it does take us longer to get to a patient you might actually start seeing the tension physiology Where most pre-hospital guys usually really don't The really don't Because the tension Physiology takes a while to build and present like you mean remember you got to collapse the entire long And then you got to build up enough pressure where we start moving things and causing that Yep, most of us don't see that pre-hospital even though we think we do it's like oh diminish long sound Let's go it's Diminished is not tension pathophys right it's diminished right Stop anyway So yeah, I personally think yes that's I think paramedics across the board that should just be standard of care again when necessary And I think okay, so let me ask you this I'm not I don't necessarily disagree with you, but given how long we're potentially with someone If we're thoracostean if we're Thoracostean of them if we're performing a thoracostomy Should be placing a tube Because the figure thoracostomy is just a whole correct I think this could go back to the it depends situation how long do I have them If it's just a couple hours six hours probably not Because you can keep opening You put your clues of on there and if you think that detention or the fluids building back up You open it back up squish your finger back in there and you cover back up Is that ideal no as there chance we're going to reintroduce more infection and everything else 100% I'm also doing field surgery on you in the middle of the woods here in a book But that's what I've said it's we didn't start out clean. I don't care how many alcohol wipes you use. It's gonna be a dirty procedure yep So it is what it is Infections of thing they're gonna get to hospital. You're gonna tell them what you did and they're gonna be like yeah they're getting antibiotics anyway Hopefully you didn't cause anything so bad that they're gonna die from that later, but If you did the right thing because you were supposed to and you saved the life for it then Having to get on some antibiotics because of an infections Not that huge a thing in my world So yes, should you be able to do it? Yes. Now if you're working one of those remote places where you've got them 18 hours a few days Yeah, I think the ability to put in a chest tube if necessary to continue to drain is important agreed But the only thing I'm gonna toss in with the caveat but that is Do you have the blood to support the blood that's being lost if we're putting in chest tubes simply for the fact that we losing blood right Where do they keep developing tension right physiology Man if the lung's not fixing itself holy crap. That's about the only time that Keep in the air evacuated Yeah holy crap. So anyway Finger thores yeah, I I fully support that one chest tubes I would say that would be the specialist places that have folks for multi-day kind of things All right, I can get our board with that I stats put a care blood work Wait, let me guess it depends Again, like in that clinic setting Um, I guess it will platform at the Everest Base Camp chair 100% 911 again wilderness response What's an I stat gonna tell me that I can do anything about Yep your lactate's up Got it. I can't fix that for you It can confirm some Diagnosis I'm thinking about in my head But it it's really not gonna help me do much for you Yeah, I didn't agree Here's where I landed on this one It's cool. It's useful It is a diagnostic confirmation tool more than anything else it points you in a more specific direction Unless it's 48 hours plus the cost of these things and the maintenance of these things and the management of these things Doesn't buy us a whole hell of a lot unless we're an environment or managing someone's health for multiple days though their needs They come with tools that are if you aren't coming with the full complement of tools to go with them to start Managing things like lactate It's neat, but it's not necessary and I'd rather save that weight in my backpack for other things because to go back to my original statement we are in the business of staving off death. We are not in the business of fixing things and I stat more or less Feels like a diagnostic tool to get to the right thing to fix stuff not a stave off death stuff That's why I was gonna go with it. It's exactly that Okay, you're assidotic and I've got you for 12 or 18 hours How much of bicarbon my legit gonna give you that I think is gonna do anything and then have I started messing with your All the rest of your metabolic processes because I'm dumping bicarbon to you that If it stopped two amps ago and who carries that much It is it's such a temporizing measure, right? I think even pre-hospitalying the urban 911 systems Where it's oh, I think it might be assidotic. I gave them an amp of bicarbon. It's like drop in bucket. It's a Yep That's that's one of those drugs I wish which is pull out of the drug boxes for 99% of use cases I think there's some probably benefits of critical care transport stuff But for the rest of us it's like It's one of those I don't know they've been down for a while in a cardiac arrest which is just into bicarb Sure, when do you ever push bicarb, right? as Prophylactically if you have Cress syndrome stuff and you're about to release but then I don't get into all that but Yes, what's an i-stat gonna do treatment wise that's gonna help me Stabilize a patient to get them to definitive care, right? If it's not gonna give me enough information For me be able to treat something legitimately treat it In that stabilization role then it's just yeah added weight and space that I don't need Okay, I tend to agree At that point I think it's all you have to do is to even say again I said at that point before starting to do lab testing Your endips dicks might be more beneficial for the backcountry provider Do I see protein and blood in your ear? I do that's interesting Not much I can do about it, but I can identify it and I can give you fluids and help See if your kidneys are functioning At least I know that you're working on dying Yeah Okay, couple more Let's talk about this one hypertonics late saline/manitall Hmm, I think it should be available Simply because a lot of wilderness places find people who fall and have those head injuries and if they're presenting With we're starting to swell that brain up Cannot 3% For use of manitone or the combination of all the above help Again stabilize them while we get them transported to definitive care where they can get infresurgery and Maybe get some pressure relief etc Yeah, I don't see why not it's Our most of those bags gonna go out of date before they get used Yeah, probably the vast majority of them, but that in my opinion is a pretty low cost of benefit thing like having a few bags available Wouldn't hurt like they're going out for a fall patient grab a bag costs in your pack off you go And if you find you need it cool use that thing If you get there and you don't need it and you just give 250 ml of A normal saline ball is just to check fluid and stuff Just as good Relatively cheap like why would you not have it available? Here's the kicker for me I'm all in for having the medication It goes directly back to an education program that is absolutely necessary the one thing that never gets talked about a whole lot with things like manitall For hypertonics saline as you started a clock and We know with the end result of that cloud severe dehydration is ultimately just like where we're headed I'm not opposed to doing it But you have to understand and you have to have the knowledge base that If you're gonna do it you started a clock And I think as long as there's significant protocols in place to start all the other bits required to solve for that problem We're okay But I do know of a number of wilderness programs that are still in the band-aid and boo-boo Even with paramedics on staff right there in the band-aids and roof fixing mentality They are not in the critical care level mindset of understanding what they're doing in those situations I don't think it's the right thing to do Now I 100% this is definitely one of those I can only think of what two I can think of two patients One of which for sure and the other one I would have been like yeah, I don't know that you and I have treated in our 10 year doing this that would benefit. I can actually I can think of a couple more but on hold it's again a high-risk low-frequency event and it is pushing Manital or Hypertonic saline is not a net zero event right it does have repercussions if you're wrong. Oh yeah. So or if you don't even have to be wrong but you know there's all if you go too long thing where they're going to die anyway right but but I would say and this goes back very much to your education piece it is this is not one of those like with that last case we had with that fall victim right where 100% that patient could have used it long-term absolutely what it got in and had we had it yeah but it's one of those things of this is not you get on seeing go oh snap like this patient we need some Hypertonic for this right there already like we know this is a thing you can't just start giving it now and then your evacuation doesn't start for eight hours right you have to temporize what you can now and when you know you're getting closer to being able to get out you started administering that Hypertonic knowing that the evacuation is coming and they're going to get to the hospital probably that drip is still going so then it could be better managed and again did you sit with them for four hours before that happened at a certain point you're just going to have to use some solid provider judgment say shit we can start it now we can shut it off after a little bit full of some normal saline there's a lot of because the pathophage involved with putting Hypertonic into somebody because it's not just a brain that's being affected for my listening fans it's every cell in the body that's going to be impacted by this sudden increase in the sodium the whole water follow salt which means it's coming out of all yourselves across the board it's not just the brain that's being shrunk a little bit so you gotta think about that yeah I agree so I think I'll leave that in the we generally agree but it's got to come with the education you think yeah no it's one of those rare use case but it wouldn't be a bad thing to have a couple bags around I agree okay here's a couple more fun ones related almost exclusively to wilderness local anesthesia I'll lump these together local anesthesia and wound closure techniques and by the way just for clarity for for the three people listening local anesthesia in my mind includes things like your blocks oh you broke your leg but it's going to be along it extracation I'd really like to be able to make the leg pain not a thing without loading you up with sedatives or laying out a shed of metal yeah I think this is again for the austere clinic setting potential value for the wilderness we'll call it again 9-1-1-EMS response not so much both either neither I lumped them together and now I'm forcing you to talk about them separately because I am an asshole first one nerve blocks and local anesthesia I don't think necessary could it be handy sure if you got a doc on your team and he's very proficient and he wants to do it because he's gonna hide on your shattered your hand and he's gonna do something at your wrist to numb y'all up nice and happy cool for the rest of his paramedics holy crap what are you gonna be practicing that one like legitimately practicing not just watching videos on I just don't see that at the paramedic level personally again if you've got a physician and he's an ED physician or whatever and this is something he's very familiar with and he does fairly regularly and he's comfortable with it yeah sure roll on doc good on you I would this is one of those things that where I would not involve the paramedic personally it's not that it can't be taught it's not that they can't learn it again it's how often you really gonna do this because there's only so many places you can do nerve blocks and with local anesthesia again what do you what do you give it for I guess the only time I would envision myself doing that as a paramedic that's not in a clinical setting would be in the next part of that part two of wound closure if I'm gonna like doing it simply either sutures or staples yeah I would be nice if I could numb that particular area up to make it a little less uncomfortable right vice just giving you a global dose of fentanyl or something but for your normal 911 acute response will learn this thing I don't think we should be messing with wound closure especially if it's a fairly sizable thing that you something that warrants actual wound I wanted to weave through to get the glue out yeah I want to clean it as well as I can I want to banage it and keep it clean but if I close it if I haven't and if I don't have access to the antibiotics to give you to prevent the infection that could be coming with me closing all that crap in there even if I think I've squirted it out and I don't see chunks I can't physically see bacteria right I don't know what I've just closed into your system and then yeah it starts getting infected and weeping and then somebody else has got to go pull all that shit out clean it out again for the average wilderness responder doing the EMS rolled now I don't think wound closure should be a thing this is definitely more that austere clinic setting where they can go in do a better debris mentor clean out close it up and have access to some antibiotics to give you to help prevent that kind of infection occurring it's just my tape all right so it sounds like we're generally on the same page I went back and forth on this one I read about some places that do it overall if it's something your team is proficient in like who might have fight you but at the end of the day I don't I'm not in the business of closing up a lot of wounds I think if it's really bad and it needs some staples like I could see the argument for some local anesthesia to make it not suck but oh yeah 100 percent but in general not a thing I care about it's just another skill set to maintain I know how to bandage wounds I'm yeah pretty not sucky at it the only time I've ever used local anesthesia was literally to then go in with a scalpel and cut at a boil or some sort of other infected nodule on somebody and that's in my for my personal use right that's going to time I've done because anybody else it's developed even a pretty significant laceration out in the woods somewhere you clean it up as best you can in the woods manage it and if it's for multiple days you clean it and bandage it daily twice daily whatever you think you can you got the kit for and then you get evacuated and then proper clean out comes and then depending on the wound it now might not be eligible for stitches or staples so that is something you need to consider because as it begins to heal it doesn't want to come together and nice and clean anymore because of surface layers blah blah blah yep so that is a consideration you need to make but at the same time if it's healing right and everything's going good then you can just keep on that path they can get back and see a local doctor and get it cleaned out and same thing bandaged and get antibiotics to make sure it stays healthy and go on about their day but man once you close that up it's not that it's permanent but you've got to be ready for the consequences following that and you might not see those that might be something only your patient now has to deal with you're like I did staples in the field you feel really cool about it or I did feel suturing because when paramedics we generally don't suture people right even right those that work in EVs generally don't suture some dockets to come in and do that don't have some resident uh so as just my personal thing that for those is work the pre-hospital most EMS response I don't see there being a need for either but you work those osteoclinics or maybe you're on that very long month long expeditions then yeah perhaps both depending on the needs could be a time in a place there I agree yeah all right we've we've largely gotten through my list there's a couple more minor things like pumps and stuff but yeah those are usually like I like them you don't we've talked about this before well it's not that I don't I just there's not many medications I'm giving pre-hospital in the wilderness they require a pump that's fair long term sedation would be fantastic if I'm trying to keep somebody sedated int because we're bouncing around the trails and all the other stimulus by keeping that sedation constant whether that interval bolicing yeah 100% right aside from that pre-hospital in the woods it's not a whole lot that we really need you doing the rips on yeah let's hear I won't say there's not a use case but it's not that wouldn't that's a piece of equipment that wouldn't be high on my list of things to buy for a wilderness program I was gonna make a joke but I'm gonna hold that off. All right, we're gonna call this done. I do wanna mention a couple of administrative things and we probably should have mentioned this a big in the episode, maybe I'll toss something in at the beginning of the episode. Sean and I are gonna be at Fast 24 in North Carolina for anybody that wants to actually meet us in person. I don't know who would listen to this podcast and also go to Fast 24. But if you're one of the three people that listens and you're gonna be at Fast 24, so like one of you, you can send us an email at the [email protected] and we will try to find a time to link up and talk with an as medicine and meet you in person. So if you're going to Fast 24 and for whatever reason, you're dumb enough to wanna meet us, we will be there. So send us an email and we'll find our time to link up. Yeah, we've got stickers. We'll bring all kinds of cool stuff. All right, with that, I'm gonna hit the stop button. So now I'm stopping. If you have any questions or comments or ideas for show topics, you can send us an email at the [email protected] or here to sub 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/wildernessemess. - Until the next episode, thanks for joining us. And until we see you on the mountain, Train hard, be safe and do good work.