(electronic music) - Medics 43, District 1, Engine 51, response, Cardiacal rap. (upbeat music) (engine revving) (screaming) - Hello everybody, welcome again to another edition of the MCHD Paramedic Podcast. My name is Dr. Casey Patrick, and we have a couple special guests joining us today. And at the time of recording, it's that transition from, I don't know if we really have four seasons here in the Houston area, but it's going from the cooler season to the oven. It's probably already progressed to the surface of the sun in Phoenix, where Dr. Jeff Comp and Dr. Jerry Snow are joining us from Adam Phoenix. And Jerry is a long time guest of the podcast from the talk side. Reading through one of my journal feeds, and I see a really awesome paper, looking at cold water, immersion, and heatstroke management from Phoenix. And then I see Dr. Snow's name as one of the authors, and he was kind enough to invite Dr. Jeff Comp, the lead author from this study. And so before we get into discussion about your work, y'all, tell the listeners a little bit about yourself, your roles, and really the manuscript, how you landed here, discussing pre-hospital cold water, immersion, and heatstroke management. - Thank you so much for having us in the first place. My name's Jeff. I'm an ER doc down Phoenix. I'm also one of the APDs for one of our EM residencies, Crater and Phoenix, Arizona, or Maricopa County for those of us who have been around for a while. And my background's in wilderness and environmental medicine. And I kind of fell into this when we started looking at our NED management of heatstroke, right around 2021, our hospital started with a cold water immersion, only protocol for heatstroke. After frankly, a resident QI project, who said, "Hey, we should be managing this better because our patients just really aren't doing well." And then frankly, through a really fortunate couple of meetings with Jerry and some other key hospital stakeholders as well as Phoenix Fire, we all just said, "Hey, we're working on the same kind of thing. "How can we really help each other?" And that's where this all kind of came about. And our study is just a description of the process and how we're taking care of these patients here in Phoenix. - What was your role, Dr. Snow? How did you get involved? - Well, since I've been out here case, I've been doing mostly medical toxicology, but also still working with the emergency department. I had seen some statistics where half of all heatstroke deaths in any given year in this country, half of my current Arizona. So I really felt like Phoenix should be kind of leading the way Arizona as a region should be leading the way. And when you look at this literature, it's pretty minimal. There's just not a lot out there looking specifically at this topic, especially in the pre-hospital setting. So I had, out of interest, in my own tree in these patients, because we see a lot of patients, a lot of these patients that we'll talk about in this paper, a good amount of them have problems with substance use. And we know the use of substances, alcohol, opioids, et cetera, stimulants contribute to people's risk of developing heatstroke. And I admit some of these patients, these people will do a lot of stimulants or opioids or do other things to impair their judgment. They're out here in these 110, 1500, 120 degree weather during the summer. And I end up having to admit them to the hospital with severe complications from the heatstroke and substance use. So that's where cold water immersion became more interesting to me. And then about three years ago, when I learned that I was really surprised to learn that there were a lot of places in the hospital. And nobody outside the hospital was really doing much as far as cold water immersion. And so I started looking at that literature more closely and put together a talk for some of the local EMS agencies, which then led us all to collaborating with the ins fire and many of the other systems here in the valley, looking at this more closely and then getting the implement into which, Jeff and them had already been working on it on the hospital side of things, even a couple years before I gave that talk to EMS. But EMS really took it and ran with it. They were very invested in bringing this to the pre-hospital setting and seeing what the impact they could have for these patients. Because it's a huge burden. I mean, we're talking hundreds of patients a year here. Yeah, so we've got emergency medicine, residency training, sort of the academic side, represented Dr. Comp. Jerry, you've got the talk side with some EMS outreach and education in there. Our listeners are mainly EMS pre-hospital folks. We've got EMTs, paramedics, locally, regionally. We've got a little bit of a little bit of this. Talk a little bit about the protocol specifically. How did it work? How did you protocolize this for Phoenix Fire and the other services that were involved? And what did that education look like? What did you learn as you rolled that out? Because oftentimes, doing this in the hospital setting and then taking it out to an ambulance or a fire truck and making that happen in the field, literally or figuratively, can be two very different things. So talk about that a little bit. You guys can share that answer. Jeff, if you don't mind, I'll just jump in. Please. There were a couple stations, especially near some of the larger homeless shelters that were doing the version, maybe not full-on co-water immersion be close. And they were using a carry-on. They're like that tarp with the handles. Here locally, they call it a carry-on with other providers. But something you'd use to move a patient, maybe, to get them to a cart. And what they were doing is a lot of these shelters have like the industrial-sized ice machines. So they knew if they got to run, the patient was hyperthermic. They could go inside, get tons of ice and water. They would use the carry-on. They would kind of make it a homeless, like a hammock or a banana. They would velcro the ends of it and just dump ice on the patient. So they were doing that. That wasn't method. They-- not broadly, but a couple stations around the area were kind of doing. And they had seen good success with that. I mean, when I did some of the continuing education talking about co-water immersion, I had done what a lot of providers had done historically, which is just a body back, which now most people like to refer to as a cooling bag. But that was more self-containing, because as we can comment on, it's messing. And I think everybody who's ever treated these patients if you don't have something that's self-contained, there's water and fluids and feces and just everything spilling out all over the place. And that was the one downside of the carry-on that it did have kind of open ends. But they were dropping people's temperature by many degrees in like a 10 or 15 minute transport. So I think they were sharing their experiences. I was doing some of the education very early on and proposing like a body bag. I think providers out in the field could kind of see how that could all be tied together. Yeah, I think that we really focus on the in hospital component of it. And in case you bring up a really good point, there's a big difference in what we do in the ED versus what happens pre-hospital. And I mean, I had to give all of the kudos to Phoenix Fire and Phoenix Fire leadership for allowing this operational success to happen through education, through training, through drilling, through practice, through lots of communication with all of our members. I mean, it took a whole year to really get everyone trained up and get everyone ready to go. And last year was the first year that they did whole system. Everyone had to buy in and everyone said, we're going to do this together. And it just, it worked so well because of the time that they spent beforehand. And that's the big thing that I think is really important is designing the protocol is one thing. But you can write down, here's what you can do and what you should do, spending the time like they did and being intentional in how we're going to train and how we're going to really own this as a department was one of the key components of success for it. So what were your, let's get specific for a second. What were your cut off? So did you have, you know, temperature, mental status, I mean, I think some of these are probably obvious to some listeners out there, but just for sort of full disclosure, what was the qualifying bars that your heat stroke patients had to reach? So in heat stroke in Arizona and with anyone, we're always trained to think about the worst, but hope for the best, right? So we have to think about what could be going on with the patients and then we work in from there. So for us, we were really sensitive, meaning we wanted to catch as many people as possible. So our criteria was, ultra mental status with a temperature greater than 40 degrees Celsius. That's it. Straight forward. That's it. And we realize that we're going to catch some people that may not have heat stroke, right? I mean, the things that can cause elevated temperature with confusion, there's a lot. Lots of body systems can be involved. But if you're in Phoenix, in July, at 1 o'clock, and you have an elevated temperature and you have ultra mental status, there's, and you're found outside, or you're like, there's some sort of environmental exposure concern, there's likely a component of a heat related issue where illness. Now, there could be other things layered on top of that, but that's something that we can be working on in the ED. If we can start the cooling before the patient gets to the ED, then we can kind of diagnose and start therapy at the same time. So the idea was start cooling on seeing immediately, really try not to delay transport as best as possible, continue that cold water emerging during the transports. And then as soon as they get to us, let us know what's going on and what else they're concerned about. Whether other is their other concomitant trauma, or there are other things that we should also be looking at too, along with a heat stroke. Yeah, I mean, so for MCHD listeners out there, it's that time of year. And that protocol sounds very familiar to the one that you know.
here in the district and that is we don't do Celsius very well around here. So we went with 105 and That's perfect. That's perfect. We and nothing else. There was no other no other polyifiers I believe we could say the same thing in Houston this time of year if you're outside at one o'clock in the afternoon and your temperature is 106 and you're altered Heat stroke is on the differential with the top of differential now having a toxicologist onboard here is The other obvious piece is it's so many of these patients are not just an exertional heat stroke or a classic heat stroke and There's talks involved. There's infection involved. There's all the other things that happen They're super sick. Right Jerry? I mean these are sick patients Yeah, I mean the patients in the study were critically ill I mean we're talking a third of the patients had a temp of almost you know I think that the median was somewhere over 106 over 50% of the patients were intubated. This was no you know mild Heat stroke study. I mean these patients were sick and I can't remember off top of my head But an amazing amount of these patients started in the field with the GCS of three And a lot of those patients walked out of the hospital at 15 Yeah around 70% Yeah, just just shy of 25% so 23.5% came in with a GCS of three And then seeing that improvements throughout their care was was pretty dramatic. So It was retrospective you guys looked in the review mirror you rolled this protocol out and like you both said Being able to even structure an observational study requires some level of framework creation Right, we can't just do this in a willy nilly fashion even if we're doing a retrospective review or an observational study of this cohort. So You put into place the education you rolled out the protocol Servicewide and then you watched the patients come to the ED and and and documented your findings Looking in that review mirror We we just talked about one of the things that surprised me reading the study and that was They were really really sick patients they mirror the patients we've taken care of here in Montgomery County Not nearly the numbers, but ours are ours are just as sick these are not mild situations or or you know like uh, we're gonna come into the ED for a minute and get discharged in a couple hours These are not those patients. What else surprised you Jeff looking back on these patients? What did you learn? Just maybe that you wouldn't expect because you know you rolled it you rolled this out and then You know you never really know what you're gonna get what else surprised you You know, I think the one of the biggest things that surprised me was just the fact that We were able to do it. I mean, I'm gonna be honest like the the big goal of the first the goal of this first study You're absolutely right. This was retrospective, but this wasn't like really even a comparison I mean, I was just talking to a colleague before we talked about how hey We did something interesting and we wrote it down and we talked about how Different places can do this interesting thing and here were the outcomes and the outcomes are impressive But the outcomes really aren't compared against anything and that's the you know the the next big studies that that we're excited about But I think the thing that really surprised me was not surprised me Because I kind of knew this was going to happen But something that made me really proud to be able to go back to my EMS colleagues and say was you did a really good job So 70 72% of people had significant cooling before they got to the ED and what we know is that If you decrease the time that a person is subject to elevated temperatures, that's a direct correlation to mortality So if we can decrease the amount of time that the patient is at that team acts or the amount of time that they Are in that environment we're gonna have better outcomes and I think and this is interesting this is getting a little bit into the weeds I think that's 72 is probably a bit of an undershoot because of how we're taking temperatures I'm with the biggest challenges that we had was We're doing tempanic pre-hospital temperatures and we're doing core temperatures or rectal temperatures in the ED Which is a little bit challenging to do in the pre-hospital So I would suspect that the number of people that we got cooled is higher But based on how we obtained the temperatures the numbers just weren't as high But the thing that I really liked like I said, I'm gonna say again it was being able to go back To our partners at Phoenix Fire and say you guys are doing a really good job and here's the difference that you're making So I'll stay in the weeds for a second on this one I have another question I'm gonna ask but I don't want to lose this point We had the same problems comparing our temps We actually do take or we can take rectal temps in the field To Jerry's point earlier these are really messy patients. I'll let y'all Extrapolate what I mean by that. They can be really messy and that's okay because they're getting better Yeah, but one of the things that I found in and we've reviewed all these in my gummery county Is it so often the ED initial champ is taken from Change over in other words MCHD crew arrives. I'm changing my patient to you doctor snow my Vodelsons are this the temple is 105.7 and guess what gets entered in the hospital chart The first set of ED vitals is the last set of EMS vitals and you know it because the heart rate and the blood pressure and the sat and the restatory rate are all exactly the same and so there wasn't really a clear first ED temperature Which made our comparisons Difficult as well. So it looks like there's no change from Last EMS to first ER and it's just because a new one wasn't taken and so we tried to specifically address that case with with the data gathering as we When that was put together and I did not develop that Myself it was done by the Jeff and Cumbin fan expire, but when they Come up to us what we wanted to capture that initial temp specifically in ED So we would get the the temp from the EMS record But that first temp in the ED we made sure was a first temp in the ED as well And the beauty there the beauty there to to Jess original point was that All the systems work together and we have great hospital relationships here in Montgomery County And we're thankful for our ED partners and They're great, but we didn't really go that Extra step or at least that additional step to Take this protocol and say hey in the ED we would like you to handle The temperature this way and we would like to have a GCS on everyone We would like to time you know the temperature rate a drop There were some things that in our review that we didn't really have because we didn't you know plan that beforehand Um But all things to think about for folks who are going to go forward and try to you know take this to those next steps And we'll get to those but before we get to Designing the next study and how that would look. I got to ask you one thing How did y'all deal with ice where did you get your ice service wide That's a problem class that That's really a question and frankly because we dealt with that in the ED We knew that that was going to be a big limitation when we talked to our feeding supplier friends Because you know in the hospital we first started doing this that silly little ice machine that makes ice for a tiny styrofoam cup That was not that's not going to do it right so We actually worked with our food service With our food service groups to say hey like can you bring us these huge buckets? So we figured out in the ED so as soon as Phoenix Fire said hey like we're going to start doing this That was an initial question that they already started figuring out but we said ice is going to be an issue So the way that they have it now Uh, there are ice machines at the different uh the different fire stations They have coolers that are on the medics And a lot of us will have different strategies to help them out So like we we switch actually from big buckets to just ready ice bags Because there were multiple times when I'd have a crew come in dropping off patient with that was actively getting cooled and they would say hey doc we got someone else that we just got dispatched on So now I can give them a couple bags myself Um, so that was one way I heard some anecdotes of and I would of course never Never uh endorse this but there were some times where bags of ice were like liberated from a circle care or something And then they went back and and paid for them um after after the fact But that was something that we Um that was really intentional that and needed to be thought about because yeah It's a it's a melting resource as you're as you're working through the day Yeah, we had the exact same experience there wasn't a singular ride answer We had several Circle K bags of ice go to use and honestly our community was totally willing to help they're like yes sure You know, we'll deal with it. We we know who you are Uh Go for it. Um, so we had several gas station stops Uh, we had some fire apparatus in the county that would have some ice on there that we would start with uh, we used um A lot of random sort of ingenuity to to do the best we could because that's basically what we told folks like we don't We want you to cool on scene as soon as you can if you can't cool on scene and you know get to get to ice as soon as possible And even start with water if that's all you have um And and you know, so there was wild variability in our in our data set as far as exactly how much water and exactly how much Because it was pragmatic. I mean you have to exist in the real world Um, any thoughts there Jerry Yeah, I think it like Jeff alluded to I think some of the uh, precipit participating hospital systems Uh, would lean on food services that has like the industrial size ice machine I know specifically like the shelter is
that I mentioned earlier, they'll have an industrialization. So, you know, fires are very resourceful, so they could refill coolers, refill ice, you know, when they would go on certain runs or follow certain runs. And then I know specifically some of the hospitals I work at, they have access to a larger like an industrial ice machine that they can use for their patients, but also used to resupply pinksfire as well. But ice that here, it was the real limiting factor because they used to have, they've always had coolers on the trucks, but you're talking, you know, it's a 115, 120, you'd have ice in the morning, you'd have a slurry at noon, and then like, three or four in the afternoon, you'd have like tepid water. - Yeah, by room temperature. - It's something that has to be, yeah, it's something that was, you know, they had to logistically, I know, 'cause I would ask when I presented it or I came back the next year and like, hey, what do you guys see as the challenges? Like, what do you see as the issue, you know, that make this difficult or how can we lower the bar to make this as easy as possible for you guys? And through things like, you know, higher quality of coolers, more readily available ice, those are really, one of the several comments that came up multiple times. - So we've got hospital support, we've got community support, we've got, you know, sharing between these entities, we've got ice stationed at these hot spots, no pun intended, in the community where we know these patients are gonna occur. That all sounds like protocol learning, and that's the essence to me, at least to BNMS medical directors, figuring out how the protocols you ride or we ride ends up reaching the patient and how we adjust those because they never are set in stone. They're always a living, reading, edited document. So if you had to roll this protocol out now, what would you do differently? You know, beyond stressing some of these ice caveats, is there anything else in there that, you know, if you're a list, you got a listener out there who's like, I wanna do co-water immersion, like Phoenix Fire did, what can you tell them about road bumps? 'Cause I don't, you know, no protocol roll out as perfect. If somebody tells you it was, they didn't look closely enough, I believe. - What do you think? - I think the biggest thing in my mind is early training and meeting with the people that are actually gonna be doing it. When we were starting it up in the ED, we start every year with tech champions, with nursing champions, it's not just the people at the top that are just telling people what here's what you're gonna do. We had people at every level from incorporation, implementation, designing, planning that were coming together and saying, "Hey, here's something that I think is gonna be challenging "from my viewpoint here." And we brought those all in and Phoenix Fire did the same thing. They had people that were trainer specialists. They were training the people. They were showing them the outcomes. They were showing them early benefits and why this is gonna be helpful. And I think when you get that kind of a buy-in from the group in general, that's when you have a really successful plan. So the early and intentional planning is so important. Not just like you said, "Hey, we can write this on the down "and just like throw it on the wall, "I'll say, "Hey, guys, do this." But the early adoption and getting feedback that this is really working was really beneficial. And that was, frankly, one of the big reasons why we wanted to publish this was to be able to show our guys and to show everyone else, "Hey, we're trying to do this." Yeah, the study's not perfect, but we're just looking to show people that we're doing some interesting things and it seems to be helping people. - You know, I think it helped a lot too, Jeff, that people were very enthusiastic in the pre-hospital setting and in the hospital setting. You had people. It wasn't hard to find someone at any level who was excited to do this work. Where there was a physician, a medic in the field. Like you said, a tech or a nurse in the emergency department. People are genuinely, I feel like, invested in this. And I think that helped, you know, it be as effective and roll out as smoothly as it did. In a perfect world, I wish we had easy core temperature moderation, you know, measurement in the field. And it's just not as reliable. As everything is, I mean, what is it more challenging in the field than it is in a hospital room? And I've always admired that about, you know, the EMS providers are at the job that they have to do 'cause I've always acknowledged it's much tougher with fewer hands and fewer resources going down above the road. But figuring out the core temperature thing would be very helpful 'cause then we can get more accurate statistics too about just like how effective it is. One thing, you know, going back to when you said like looking back, I knew it would be effective. I knew it would cool effectively. I was amazed at just how effectively it could even be in just five or 10 minutes of transport. And some of these even shorter transport times, you know, you're talking about people that, again, GCS is three, maybe not intubated, but we'd literally, there were people that would sign out from the EDI. There were people that would come in with the GCS three in the field, maybe seven or eight but the time they're starting to wake up and then they're like, I wanna leave within a couple hours, like even other labs maybe aren't back yet. So that really surprised me just how effective somebody could go from like critically ill, clearly trending toward a bad outcome if they don't get treated and then walking out of the hospital. - We had those left AMA blew me away. - Absolutely. - Or admitted to observation and don't make it, doesn't stay the whole first night. Absolutely. - We had just amazing questions, same questions about accuracy of temp and how accurate are rectal, and we even had some rectal temps, but you know, some of the questions were rate of temperature drop and is there danger there? And there's some old school thinking there that I don't know that I exactly, but I don't wanna get off into the weeds here 'cause I'm by no means a heat stroke expert, but we did it in the same way that, you know, believe this is pragmatic and real and necessary. And the lesson for me at all this is this is a true time sensitive emergency on the order of, you know, stroke, stimme, trauma and those things we think about, and a flaxis. I believe heat strokes there. And the other piece when you think about an immersion bag and some ice recognizing a temperature and ultra mental status, this is not just a paramedic skill or a physician skill. This is an EMT skill as well, you know? So for the fire setting, and depending on how your systems tiered and what your, you know, ratio is of paramedics to EMTs and AMTs, this is across the board. Like this is not a diagnostic dilemma when it comes to needing, you know, EKG interpretation skills or advanced imaging or some, you know, lab work or an airway management. Like a lot of these, you know, were managed BLS and did great. So it's not a big expense, right? We're not talking about a large purchase from a, you know, a videoal or in scope or, you know, an iStat device or you've got to hire staff to manage this. It's really, you know, the education up front, the buy-in, some bags and discussion on where you're going to get the ice from. And, and the things we do in EMTs, that's pretty minor. - Yeah, and when we, if you, I know this is like newer literature that's coming out than I'm really excited about it. And I'm glad other folks are working on this too. It's not new, even in the pre-hospital setting, you can go back decades, right? If you'll remember back, Dr. Brian Sloan was at IU and at the mini marathon every year. If it was a hot year, they were, they were co-water immersing people in like the toddler tubs. People would cross the finish line, collapse. They'd go into one of them tubs, they'd get a rectal temp and some of those people never went to the hospital. You know, and they were heat stroke patients that would get back to it, you know, they'd be GCS of, you know, five or six, be very, very ill and end up going home. And that was 20 years ago. - And you know, Keese, the other benefit of this is, yeah, it's fairly low, it's fairly low cost. And like there's, there's not a lot, a lot of risk. I mean, you can, yeah, you can make someone super cold. But if you're at a larger city with shorter transport times, you're probably not gonna get someone to a critical hypothermia from a cold water immersion. And we're not asking someone to give a different medication. This is not a new procedure. This is not a new medication or something that has a risk or a harm. This is just cooling someone down. So even if you miss the diagnosis, and you, it's not heat stroke and it's sepsis, you're not gonna harm the patients by trying to treat the heat stroke if that is a component of what's going on. - I would agree 100%. I love that take and for the listeners out there around the fence. And, you know, in heat stroke prone areas, that's a really great point to take back if you're gonna educate, you know, your clinical department, your medical direction. It's always the double edged sort of any new protocol and any new matting, any new procedure is how badly wrong can this go? That's the thought that goes to my brain when I go to sleep a lot of nights when we're prepping protocol changes. And this one, you know, I didn't see one. It makes me really feel, feel vindicated whatever the word is, you guys don't feel it either and you've done this dozens more times than we have here in Montgomery County. The real deal and the real evidence from this, and I believe we'll see it, I think somebody will be able to put it together. I'm not sure who or when, hopefully y'all, maybe, you know, the Holy Grail here will be able to have two comparator groups, right? Y'all, do you know what I mean?
a descriptive study of your protocol and did not compare it to whatever we decide standard care would be in that situation. And I'm not really sure how you get to Equal Boys there. I don't want to get too far off in the weeds. But something prospective with a comparator seems to be the obvious next step here. Y'all are much more in the academic world than I am. Did you see that coming down the pike? What would that look like? Are y'all working on that? Let me hear your thoughts on that because I honestly don't know the answer. You're absolutely right. When you think about hierarchy of evidence, that's it. We need to be able to compare different groups. Some people that are getting cold water emergency, and some people that aren't. It's challenging to do, especially when it comes to outcomes in pre-hospital interventions, because so much stuff can happen in a hospital as well, that determine outcomes that determine next steps. So what we're doing now is we're looking at smaller studies because like Jerry was saying, there's a lot of literature out there on from the sports, from the military aspects of exertional hypothermia, but we're not taking care of elite athletes that are found down in the middle of phoenix, like downtown phoenix at one of the afternoon. So we're really, we're in this really interesting part or area of research where no one's really talked about this. So we are now trying to lay the groundwork of like, well what are the questions? What are the easy questions that we can ask? What are some early ones that we're looking at? So questions like, hey, is there a difference to getting the person to target temperature first with pre-hospital cold water immersion with not? I think that's going to be the next big thing that we're looking at. And outcome study, that's going to be, that's the best thing. We need to have a huge organization with a lot of people that are really looking at that, because that is exactly that's the data that we need. And right now what we're working on is telling people this is what we've been doing and it it seems to work, but I don't really find that I have much legs to stand on from from that aspect until we get one of these big ones. We said that's often a core of any EMS or pre-hospital study is how quick matters. Does it matter? Tom zero? Is it matter? If you've got a 15 minute or 20 minute transport time and we start this in the ED and you know, my gut is yes, it matters. Earlier the better for this one. But I don't know that we 100% know that yet. What are your thoughts on what next steps might look like, Jerry? Yeah, I mean, I think ultimately I there's a lot of a lot of different you know entities out there not not doing this and and there's actually there's people not necessarily doing core immersion even in the hospital as well. So I think finding a comparison group wouldn't be that difficult. I'm optimistic that as this literature rolls out, though in places like Arizona and other very hot places throughout the south especially or in places where there's like heat weight because I mean there's been years where we played there's a lot of deserts in Chicago or New York. So I mean year to year sometimes heatwaves are going to come through and affect any of these different regions of the US. But I think for now, you know, especially in the pre-hospital setting, it's not as widespread. I think it will be in the in the upcoming years. But I think having that study looking at even a variety of different ways of cooling and looking at just not, you know, the impact of how rapid something cools those studies have kind of been done. We kind of know that co-wire immersion cools people faster than any other modality. When we look at that, I just really want to see like when we look at mortality, we look at end organ dysfunction, we look at neurological outcomes. That's what I'd be most interested in seeing. And I think going forward ultimately, that's where we need to be. Yeah, I'll put in stratification of these patients and just trying to group the types and the potential pathology behind the heat stroke itself. I mean, you know, definition of heat stroke for me and for listeners out there, you know, the simple version is ultra mental status and you know, greater than 104 or greater than 105 depending on where you look. But that's kind of like saying trauma. Like is it blunt? Is it penetrating? Is it isolated head? Is it trauma to the box? Is it an open-butt pelvis? Is it a, you know, an explosive device with an with an extremity blown off? I mean, that's all trauma, but those are wildly varying in their in their outcomes and their course and their treatments. And I feel like heat stroke and co-water immersion is a little bit the same. I mean, is it you're never going to be able to, I mean, unless you're working in an Iron Man or which we have here coming up, which we may get to dunk some people. At least in main medical, they'll dunk some folks. Those are isolated exertional heat strokes like the athletic literature or if you're on a battleground and it's a military environment, you really know what you've got. But in the real world, do you have infection? Do you have substance? You know, do you have thyroid storm? Like insert all the things that it can be and so I believe that there may be more answers as to, you know, what happens to the folks who have a component of sepsis? Like is this harmful or is it not, you know, how much more helpful is it in someone with stimulants on board or is it less? And I think answering some of those questions and trying to stratify the patients would be interesting to me. I don't know if it's going to show a difference or not, but at least takes my brain back to like all these folks lumped in this bucket aren't exactly the same and they've arrived at that 106 altered from different pathways. And I think cooling them is the right thing to do off the bat, but is it more right for one group and the other? I don't know that we know that yet. So wrapping up, I mean this is super interesting. It's the right time of year. Just I know how hard it is from personal experience to take something like this idea when yes, it's not all that expensive and no, it's not all that complex, but goodness, to get all those players and people in the room together and to agree on a protocol and to roll it out to educate, then to track the outcomes to synthesize it to say, hey, let's write this down and describe it. Like huge kudos to y'all for putting the team together that it took to do this because it may sound like, oh yeah, that's no, that's a massive earth moving undertaking that was it's really, I mean for someone like me that has a protocol that us like has this protocol and has supported it to have some more evidence saying, hey, we're doing this out there in the in the center of the earth where it's hotter than hot and we're seeing these outcomes. That helps us support what we're doing here. So any thoughts on where you see this going in the future, anything we've not talked about, I'll let Jeff and Jerry take us home and then I'll close us up. You know, the fact that we're all talking about this now is the first step. If we can have a bit of a shift in the paradigm to like, hey, start cooling when you find them and then make that a little bit more of the idea and and rather rather than the exception, that's that's why I love having these conversations because it does take a little bit of time to get everyone on board. It takes a little bit of time to get the process started, but as long as this is staying in in people's in people's minds as, oh, this is this is a true environmental public health emergency in some places of the world. That's like that's that's one of the the big key takeaways that I'd want people to have. Just keep this in mind. You know, next steps, I think obviously more MS agency is expanding. We both both Jerry and I work with different hospital systems, telling them like what what our processes are, help them out and saying, hey, you know, here's some of the the hiccups we had. We'd love it if you if you started the used ours as a start process and then then go for it. I mean at the end of the day, we're really trying to help people and yeah, the research is the research and that's important to have and you know sharing ideas is sharing ideas to make sure that we're taking care of patients the best is huge. That's number one. Jerry, what's your got? Yeah, I mean, I think ultimately your data collection needs to continue and we're going to we're going to keep working on this as a group with Phoenix Fire and the other hospitals and providers that we've been working with. I think we're going to continue to grow and expand it only get better data. We're going to be able to answer more of the questions that people are going to have. You know, it's going to take time as all these things do and we're able to eventually look at something prospective and do that comparative study. We can specifically add outcomes. I think you know, we'll be answering some more basic questions initially, but I think eventually we're going to be able to say like what you know, what should should not be the standard? Is there any difference between these different modalities as far as the outcomes? Because one thing I'm not trying to do is make anyone's job more difficult inside or outside the hospital. I want to do the you know, what's the most effective therapy for a given set of patients period regardless and if that requires a little bit more work than that's what we should be doing. But I don't want people having to do extra work, make develop other protocols, or do something that you know, we eventually can't demonstrate is the clear right choice when it comes to treatment of those patients. Well, for those of you all that are interested, we weigh too far along this podcast, but if you want to read more about Jeff and Jerry's experience with Phoenix Fire and Infinix with co-water immersion, we'll link the study in the show notes. It was in pre- hospital emergency care published online on March 13th. So we're within a month. Yeah, we're upfront on the cutting edge here.
at the MCHC paramedic podcast, fighting fire with ice, a multi-site collaboration to evaluate the impact of pre-hospital cold water immersion on heat stroke patients. I'll just close out. I think these are times sensitive patients to speak language that EMS is familiar with. And we get off scene 10 minutes for our trauma patients. We get that EKG as quickly as possible. And we think there's a stemmy. These patients need to go into those similar buckets, a similar mindset. We need to cool them as quickly as possible. At least that's what we believe right now. That's why this is always an imperfect science. But time is brain when it comes to stroke. I believe time is brain when it comes to heat stroke as well. So as always, we appreciate our special guest. Jeff, Jerry, thanks for joining me today. I know the listeners are going to get a lot out of this one. If you have ideas, questions, thoughts for future podcasts. Please email us
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