In The Wake of Stabby McStabberface

Yeah, so we were recently on the the right along podcast we were indeed. Yeah, so the right along podcast it's about a guy recently went through EMT school well so it's about two guys kind of in our age you know midlife will call it. Yeah, who at the behest of a paramedic friend. Go through EMT school. And what's what's beautiful about this whole thing is you can kind of like they start off. You know they record basically after every you know session in school and they're kind of like what is this even mean like what is who uses this medical terminology like really and over the course of their program. You they start to they start to kind of get it so it's really cool for people who are like I'm kind of EMS curious. You know coming from zero to EMT. Yeah, well and the thing I kind of like is it's kind of in vain with what we do in the sense of trying to kind of demystify the job itself. Yeah, and whereas we are more like hey we're going to demystify the field. Usually for for newer people in the industry but sometimes for more experienced people they're kind of demystifying school. No, that was cool. That was a fun project to be a part of their great guys. But yeah, it's the right along podcast. There was a lot of fun to be on there. iTunes Spotify, wherever you listen to wherever you listen to podcasts. They're on there and if they share some and if they share some social media, we'll be sure to put on our stuff as well. But yeah, thanks again to Mike and John to for having us on and it was a lot of fun. And we're sorry you couldn't be there. Oh, well, sorry Max anyway. I'd be add also quick shout out to Phil. Phil walked up to the hell pad every day. He saw me. He works in in my area and got a picture with him. It was great to hear of someone who's been listening to the show for a while. So anyway, yeah, shout out to Phil. It's great to meet you. And why are you not walking up to my hell pad? Well, he knows who carries the show. He did ask me if my lower back was okay. Because I can hear you verbally deadlifting Spencer each and every episode. So There's no response. Yeah, even said he goes, this is how I know you're so good at reviving people because somehow Spencer's not dead yet. So I'm such a dick. That's not true in the slightest. It's the best part. Yeah, it's not Spencer wants it to be true. So he could like not win this whole ship just sinks. He could just be like, was it me? It was him just ask him to get out. All right. Let's roll the intro. This podcast is hosted by Chris Vincen and Spencer Oliver. They are both experienced paramedics. They've done everything from 911 ground ambulance to volunteer fire department work and are both currently flight paramedics. This podcast review scenario is based on real calls run by real out of hospital conditions. Details are changed to protect the privacy of those involved and to present educational opportunities to the listener. This podcast is EMS 2020. Hey, everybody welcome to another episode of EMS 2020. On this podcast, we review real out of hospital calls and see what we can learn. Should we change what we're doing? Should they change what they're doing? And also we just have a good time and we make a lot of jokes, which is I think 90% of what we do. But with that, if you would like your call to appear on our show, check out ems2020.com. Scroll down a little bit. There's a button that says submit a call. That will submit a ticket if you will to us. We'll review it and if it fits with what we want to do, we'll give you a call. It's not really first come first serve. It's more what happens. So if your call has been sit there for a while and you're waiting to hear from us, don't worry. It may happen. It's just that's not really how we do things that necessarily. So also if you want to continue your education for listening to a podcast, you already love our podcast. Also in ems2020.com, you can sign up for the EMS 2020 continuing education for $39 a year. That's next to nothing. And already we have enough credits on there to make sure that you are 100% recertified as long as you have your other required cards like your AHA cards and those kind of things. But hopefully sometime very, very soon, if not already, our entire catalog will be on there. And this will be the way to listen to ems 2020. It absolutely directly supports the show. It's only $39 a year to make sure you never have to worry about continuing education again. And exclusive episodes are coming to that platform very soon as well. If not already by the time you're hearing this. So with that Spencer, what do you got? All right. I got a story and this is this is a good one. So if you came in here, you're like, I got nothing. It was your day. I'm like, fuck. All right. Bada Bada Bada Bada. Probably could you must to zero zero. But by all right. So this call this call is submitted to us by an EMT. I'm calling Ricky. Ricky has been an EMT for less than a year at the time of this call, but they are in medic school. So, yay. They don't have a partner for this particular call. In fact, they're not working an ambulance shift at all. They are working a standby event. You have your hand raised. Go ahead, sir. I do. It's just great for an audio format. Yeah. So when you say they've been in primary school, where they appear in school at the time of this call, are they in primary school now? They are in paramedics school at the time of this call. Okay. Got it. All right. There you go. So probably in paramedics now. Yeah. Yeah. All right. So Ricky works for the Sunnyvale ambulance at a Dartmouth County. This is a not real. None of these are real names just throwing that disclaimer out there. I'm going to beat Chris to the punch. Yep. Yeah. There you go. Dartmouth County sounds legit. It really right. And so the Sunnyvale ambulance. Yeah. All right. Yeah. This is a very large private ambulance service with a lot of ambulances, like a lot of ambulances. This is a mostly urban setting dynamic deployment model, medic, anti staffing with every kind of hospital in the area. Yada. Boring. Fuck all that because all we care about is the standby event that Ricky is working. Ricky is working. At a city approved mobile harm reduction center run by a nonprofit company. Basically, this service provides like needle exchanges, or no lock. Oh, got you. Like they do like wound care testing, social services, et cetera. Okay. Yeah. This service is mobile and that it has several places that it sets up shop on a very regular rotation. And today, it's at a community center near a park. I'm calling this the shit mobile standby because it is not a sought after standby event for any of the folks working at Sunnyvale. I want to use that as a title for the episode, but I can't. Like there's no way I could put that up for continue education and be like, yeah, who wants to click on shit mobile? I, I want everybody to wait right now. On our Facebook, it'd be like Chris, you're wrong. Maybe if you do like a S H asterisk tea, I don't know. I, I can try that. How about this? How about you guys vote by going to ebs20.com and let's see if you'll pay for it. You know, which that's the thing I want to point out. We don't charge you per CE. You get membership and once you have your membership, you have unlimited access to every single hour you could possibly walk on the actually that's a really good thing to clarify. Yeah. All right. But not for that us. Let's get back to the shit. No, be a standby again, mobile stand by not sought after by anyone. The standby is a 10 to 12 hour like event regularly staffed by a single EMT. If there's if there is a why can't they be married? It's funny. You should say that because I wrote it down by single EMT sort of like. I had to correct it. It's a speed. Go ahead. Go ahead. What great might stick alike. Beautiful. All right. With idiots get together. I think is more. I mean, that's probably more accurate, but here we are. Okay. Focus. Focus. All right. So singular EMT. If there is a need for an ambulance transport from this event, the EMT calls 911 and requests ambulance response and then the ambulance will arrive and transport the patient, leaving the EMT at the standby. Because this is a semi regular standby, there is a storage place, which has both ALS and BLS kits at this particular facility that they're at. They also have a monitor that the EMTs can access. This storage space is also where the EMTs can like stage for the day. There is a radio and a special catchphrase that the staff use to summon EMTs when necessary. What's the catchphrase? I didn't ask. It's probably something like why not I should have. I. Chris is giving me angry eyes right now. - Yeah. - Side up for the continuing education, just to show Spencer how much you dislike him, because I haven't figured out why that makes sense yet, but you should do it. (laughing) I don't know. It's the best I got. - Yeah. - A catchphrase though, like how cool is that? Like Falcon zero, come in. All right, let's just make up a catchphrase, right? We are, after all, we do disclaimer that we do change some of the details. - This will be one of the details we change. - I mean, how about. - EMT, response. - No, no, it's gotta be like, the Condor's Nest has been infiltrated, the Condor's Nest has been infiltrated. Something like that, okay. - Yeah. - No, I like that, the Condor's Nest has been infiltrated. - Okay, yeah. - I'm writing it down right now. - Yeah, Condor. Why am I writing this down? (laughing) - I don't know. I'm taking it all out of the dark. - All right, so here we go. Let's get to the call, unless you have any questions, aside from the like, how come you didn't get a catchphrase? - No. - All right, it's going to be a great day. This is Ricky's thoughts right here. It's gonna be a great day. Ricky had hope for the standby shift. It's low key, they could maybe study for medic school, and the company who is sponsoring these clinics had finally acknowledged a service wide concern about allowing folks with weapons onto the property and had just taken steps to defy this. Now, you might, you can't see it, but Chris's eyes just kind of went, huh? It might be surprising that they were, - Well, I have to try and get this up on you. It might be surprising that there would be pushback on weapons from the staff, but I get where the folks from this program are coming from because like lots of people, so you can care are homeless, and they don't want to put them in positions where like belongings that are essential for their security are just discarded, right? You know, it's like, hey, I don't need this knife here, but somewhere else I might need it for my own protection and to like protect my thing at cans. - Or like, I mean, a knife is a tool that has other uses as well, but is also a weapon, so that could be a problem. - Yep, yeah, I can see that. - But yeah, but I can see from the like EMS service perspective, and I mean, even like the staff at the facility's perspective, where you know, it's like, hey, well, there have not been any Sentinel events with this. This is a good setup for, yeah, - We're setting up one. - We're setting up to have one. So, but it's worth noting that there had not been any Sentinel events with all of that. Anyway, Ricky checks out their equipment for the day and on their pot plants. Those are plants in a pot, not pot plants, just clarifying. - Thank you, I have a clarification. - It's important. Not long after they get their checks done, they hear a kerfuffle occurring outside nearby like two-threat space that they're in. And their space is in a wheelchair accessible like basement room. Suddenly, the radio crackles, and instead of the usual, the condor's nest has been infiltrated. They hear holy fuck, he's getting stabbed. Just kind of rip over the radio. - Boom. - So. - I don't know what's that. The last time I did a bird sound, a bird experts flooded our inbox. The tummy was the wrong bird. So, yeah, I apologize. - I am gonna need those folks to weigh in right now on what a condor sounds like. - In fact, if you can send us a recording on our Instagram, if you're doing your best in pression, the best one will get, I'll put in the story. (laughing) - Not with your face or anything. I'll just put like a picture of a condor and you making the sound. - No, I will tell you what it is. - I wanna see your face doing it. All right. So anyway, holy fuck, he's getting stabbed, rips over the radio. So, Ricky grabs all their kits. They have an ALS kit, a BLS kit, a monitor. A D-tank, by the way, that's two D-tanks 'cause one of them is in a kit. And they grab their work phone and loaded to the brim, they rush out towards where they heard that commotion. As they head up the ramp towards the park, their pregame consisted of, oh fuck, oh fuck, oh fuck, oh fuck, oh fuck, which, a puppet. - Yeah, that's about acting. - Because this would be their first real trauma if this were happening. A staff member appears at their side, and asks, hey, are you calling 911? And Ricky realizing that their hands are completely full, like goes like, here, you call 911, you are. Like, you're gonna call. Unfortunately, the phone is password protected and there's a bit of a like, hey, what's the password moment? But by the way, most phones actually have a 911 bypass. Like, if you're calling 911 on a cell phone, and it's locked, they'll let you call 911, even though it's a locked phone. And then a lot of iPhones also have like, medical information for the owner on there too, which can be helpful. So, the more you know. Okay, so this staff member asks, hey, how many ambulances do we need? And Ricky says, let's start with one ambulance. So, thoughts so far, Chris. You say one ambulance. - One ambulance. - A ambulance? - Yep. - Like, D-U-M-B-U-L-A-N-C-E, yes. - The theme escapes you. (laughing) - It does, spare. It sure does. Yeah, so, not so far immediately is seen safety. We have someone who's screaming, I'm getting stabbed and we're like, run towards it. I'm like, why? Why would you want to run towards someone who's getting stabbed without any appropriate safety? So, yeah, I don't know. And then this person, I just want to make sure I might have missed it. It was a staff member that got their phone in them. - Yeah, staff member took the phone. - Okay, just want to make sure, it was like, hey, if you call them, no, here's the phone. So, it was like, where's the phone? - I don't know, who was that guy you gave it to? You know what? - Ah, shit. It was the staffer. - Hi, Carlton. - Anyway. - If you call them, you go ahead. - Oh, yeah. - Good. - He's just running around grabbing cell phones. Just like going up to people like, have you called that one? No, here can be a phone call. Goes to the next person. How about you? Did you see it? All right, give me a phone call. This like starts running away. No, seeing safety is actually my primary concern at this point. The only thing too is that one of the things that this call kind of seems to be set up for is kind of a panic induced start. You know what I mean? That's kind of what I worry about a little bit is that we seem to be starting from a place of panic as opposed to like a place of like calm dispatching. You know, we haven't waited for our code word. We're running into the scene of a stabbing with our adrenaline going and it gets really, really easy to get tunnel vision to put yourself in a dangerous situation kind of like they're doing, but just as easy as it is to run into this dangerous situation in a panic, if it's not dangerous, it's also easy to start missing other things 'cause you've already walked right past your own personal safety. What else are you going to walk past? Sure, sure, sure. You know, so those are kind of, my main concern is that there is a high level of chaos and panic going on and everything that can go with chaos and panic is on the table to be a disaster. And of course my starting main point of concern for any EMS 2020 episode is the fact that it is an EMS 2020 episode. That's usually, that's usually sign number one things have come wrong. Yeah. Is that you and I are talking about? And so here's from, here's this moment from like Ricky's perspective. They said, yeah, there was not a single thought about safety. All of that went out the window. I just heard, hey, a person's being stabbed and I went like, oh God, no. Like I have to respond. And there's a lot of, I think, and this is something worth talking about. There is a lot of pressure to respond. I mean, imagine if someone's like, hey, we need help here. And you're like, no, call the cops. Because there's going to, like there's an expectation from the public or maybe from the staff of what the appropriate response is. And you're kind of starting at like, hey, why aren't you helping him? Like as you're hiding from your bunker, you know, like, yeah, is that covered on? You're like, and I think there's also a factor that needs to go in here of like your personal morals and ethics that gets weighed in here. I think there's a way to thread this needle, but we can talk about it after. I just want to highlight in this moment, Ricky has abandoned all thoughts of scene state. It is as you have described it, the check engine light on the ambulance. It's yeah, exactly. The check engine light on the ambulance just gets ignored because it's always there. So let's revisit this later. And let's start talking about like, how do we meet the public's perception at the same time? Because the public's perception can matter and getting the public on your side can make scenes go smoother. The priority is to protect yourself. However, it is also important to make sure that we are meeting public standards as often as we can. Again, your own personal safety is above what the public expects. The clinical aptitude and your clinical capabilities is above what the public expects, but what the public expects is important, especially on scenes where you have a lot of people that can make your scenes so much harder when you have people screaming at you with what they think the expectation is, et cetera, et cetera. So those other two things, your own safety and the patient safety included can often fall victim to poor public relations in the moment, but I'll follow up that later on in the end. Yeah. Ricky arrives at the scene of the stabbing. It's about 50 feet away from the building in like in an outdoor area that's filled with lots of like clinic clients and their belongings. On the ground, there's a 40s male, 5 foot 10, 170 pounds, or a 178 centimeters and 77 kilograms, wearing a t-shirt, shorts, and flip-flops with blood present on their shirt. The patient who we're calling J-Rock is lying supine with a friend of his holding his head. And as you might imagine, there is a large crowd of folks who have gathered around J-Rock. So Ricky moves this beastie boys? No. Ricky moves them out of the way. It sets the kids down so that everything is accessible to them. J-Rock tells Ricky, I got stabbed. No, I'm saying. Okay. Yeah. I mean, I don't know if the note what I'm saying is necessary after I got stabbed, because that's a pretty straightforward. Right. I got stabbed. Not a lot of details needed. I guess where is important. What is excellent is I still do not think you know the source material, but this is one of the things that are like, hey man, you don't need to say no, I'm saying after everything you say. Oh, really? Oh, yeah. I still have no idea what the source material is. This one was by request. Actually, I had to watch a show. Oh, nice. Well, let's get to the assessment. All right. So obviously, it has speed, so I didn't miss it. All right. Get to the assessment. All right. But level of consciousness alerts for examination. There was blood on the shirt, but there's no massive like spurting wounds that they note. The airway is patent. The breathing is happening. Circulation, they're awake and their color is okay. Ricky uses trauma sheers to cut the patient's shirt and seeing a staff member come up to J-Rock side, he directs them to put the patient on the monitor. Ricky notes a stab wound on the left side of the chest just below the nipple area. It's bubbling blood from the wound. So Ricky wipes it down with a four by four grabs their chest seal from the ALS kit and places it on the patient's chest. Then they note another stab wound in the abdomen. So he grabs an ab pad from the trauma section of the BLS kit and places it over the wound. Unfortunately, they completely ruin all of the contents of that bag because they have bloody gloves doing it, which by the way, been there, done that on a left, like on a left stressful call. You know, like there's no excuse here. You're like, yeah, you're a lone EMT dealing with a massive trauma patient. What's my excuse? I was like, I wasn't big attention. That's my. Gotcha. So the person at the patient's head, a man will call Tyrone, works to assure him. If you don't mind if I pause for some thoughts, no, no, go ahead. Yeah. I like this so far. I mean, I think we had, we did an ABC. We found the life threat during the ABC and we addressed it with a with the chest seal. This is exactly the way it should be done. What I like about good BLS providers and sometimes even new reinexperienced BLS providers is they tend to follow the list and go right down it really well. And I love that. In fact, one of the things we talked about on the right along podcast, we had mentioned that there are certain things that right when you get out of school, there's a lot you still have to learn and you'll get better with over time. But there are certain things that you will never be as good as you are again as of that moment when you get right out of school. You know, and so I think sometimes just because you lack experience and you don't have any shortcuts, you tend to follow things a little bit more closely, you know. And so I like this question for you. Do you know where in the abdomen, the secondary wound was was at a higher low stab? I believe it was a high stab. Okay. So one of these to be careful with this high stabs is that the the line between abdomen and thorax is not as clean as a lot of people may think it is. And depending on whether a person was inhaling or exhaling in that knife went in, that could also be another place where a chest seal is. So be careful with your high abdominal stabs, especially if they tend to go up in stabbing, like especially if you have two people that are standing in someone stabbing kind of like in an upper cut motion like that and it goes up and in. You can have diaphachmatic rupture, other things that can impact the airway. I think at ABD Pat is totally fine. I would just say, you know, be, let's say this was an isolated abdominal stab. If it's an isolated high abdominal stab, be prepared for airway problems because or rather breathing problems because you can, again, you can damage diaphragm. You can get into that inner thoracic space with an abdominal puncture. Yeah. So also continued that those are my only touch. Depending on the left or right, and I don't think I recall I don't recall getting this information, which I and again, I should have gotten the condors nest was infiltrated and was in a left right or midline stabbing, but you've got important organs on the kind of the upper sides of your abdomen, the spleen and the liver. So the spleen can cause a significant amount of bleeding. And you know, they'll probably can't too. Yeah, whatever. All right. Yeah. Yeah. They both get. So continuing on, a person will call them ray, tells Ricky, I saw who stabbed him. It was Cyrus and he went that way. And this is about the point that Ricky Ryan realizes that they're like in a bit of an like an awkwardly situation. You know, by the way, before anyone thinks Chris included that I'm having a stroke with dumbbells and awkwardly awkwardly situation, I'm using what's called rickiasms from the source material. These are malaprasms, which are the incorrect use of a word in a place of a similar sounding word and acorns. Trailer park boys. You got it. Trailer park boys. You got it. All right. Got you got to get corn. By the way, is a reinterpretation of a word or phrase, such as the example provided by us leagues of nerds.com where I found this definition. Like so, a bald face lie versus a bold face lie. When you think about it, both statements actually work. Bald is without cover. So it's an obvious lie. Whereas a bold face lie is bold, meaning highly visible. Anyway, uh, back, we're back to this awkwardly situation. So Ricky is realizing that he doesn't know where Cyrus the stabber guy is. And that may be like that. He may actually be in some amount of danger. So he tells the people standing around. Hey, look out for Cyrus mixed stabber face. Yeah. Um, he noticed that there was another stab wound now along J. Rock's tricep with adipose tissue showing. And he directs someone to hold like heavy pressure on that wound. Uh, so Ricky in the same moment also notices that the patient's not on the monitor yet. And looking over, they see a tearful staff member tell them, I don't know how. So Ricky directs them on how to place the three lead the god invasive blood pressure cuff and the pulsing similar to to help him out. So at this point, we have some vitals. Uh, for level of consciousness, now that the initial assessment and, you know, like a rapid trauma assessment ish. Um, and, uh, you know, that initial assessment or done. Uh, J. Rock is now a little more somalent. They are not responding to tyrone, uh, as they did before. Ricky recalls seeing an S. P. O. To a 40% with a good pletht wave. They don't recall seeing cyanosis, but the patient's complexion plus Ricky's adrenaline have like have made all space time and assessment pretty weird. That is one of the most understandable things that we've heard all called blood pressure. 70 over 40 and heart rate is 130. Hmm. That's not great. That it's not great. So Ricky grabs out a BBM and then entitles the O2 attachment. They connect the BBM to O2 and instruct Tyrone on how to use it. While he's doing this, he tells the staff member on the monitor to pull out the D fib pads. An OPA gets placed in J. Rock's mouth, but oddly enough, like this is a weird one. The OPA isn't large enough. It just sort of like falls into the patient's mouth, so it does get removed. Oh, but in doing so, we learn that the patient does not have a gag reflex. So Ricky removes it. The D fib pads get placed. And this call is about to get worse, but Chris, what do you suspect is happening here to this patient? They were stabbed. I mean, that's why it's what's happening is happening. Yeah. Oh, okay, blood loss. They have blood loss and you possibly also have hypoxia going on just purely from the fact that you have a stab wound in the chest. So you have two major problems going on here. Let's talk a little bit about a 40% SBO2. So you'll hear a lot of people that will tell you things like, "Well, below 70% or below 75%, the SBO2 monitor is really, truly inaccurate, even with a good pleththwave, just because of how it works, et cetera, et cetera." True, but doesn't matter because all you know is that they are significantly hypoxic. And that's really what matters here. So if someone's telling us like, "Well, that 40's probably not accurate. Shut the fuck up, they're significantly hypoxic. That's all we need to know." It's not going to be like, "Wait a second, it's 76%. Don't worry about it, guys." That's still significantly hypoxic, right? Nobody, it doesn't really matter. The interesting thing here that I actually kind of like because it leads at lens credibility to a point that I've made many times on this show. And that is that you can have, depending on the person and depending on what's going on with them, you know, what. If they have a pulse-like similar, it's getting a good pleththwave with a blood pressure of 70 over 40. That's fantastic because oftentimes you won't get that because the body is going to say, "It is time to clamp down and the tip of your finger is not the place I'm going to be directing blood to." Right? Right? So, but we've talked about this before where people will try and guess a blood pressure based on where they can feel a pulse. Now, a radial pulse may still be palpable even in someone's clamping down because that's an artery. It's just playing a bigger vessel. And we haven't given this patient any pressors or anything like that. So there's that. This just kind of goes to show it's really patient dependent on how, on where blood will flow when everything's clamping down because everyone's anatomy is different. And where blood moves is a matter of the physical space available for it to move to based on the size of your vascular. So this is really a good example of that. But when we start talking about the blood pressure, we have a low blood pressure company with a high heart rate. That's what we would expect to see in someone who's bleeding out there, significantly shock index positive. And so this person is very likely lacking volume. The only thing that's a little bit interesting, not even that interesting, we do have a really low diastolic number in this. And oftentimes when people are starting to clamp down, you start to see a closer gap between the systolic and the diastolic until they get to a point of decomposition, which kind of leads me to my next concern is is this person cresting the ridge to decompensation. So are we seeing a hypoxia, maybe not necessarily due to the stab wound in the chest because the patient was speaking in, I don't know if it was a full sentence or not earlier, they just said I got stabbed. But you know what I'm saying. Anyway, do know what you were saying. I'm going to have to say this whole episode. But you know, are they starting to crest that to where we're decompensating now to where we're just we're dying. So we're starting to see that the the the basic constriction isn't occurring. The hypoxia is happening because our respiratory rates going down. They say there's no gag reflex when they put in the OPA. So kind of one of two things is happening. We are either really cresting that decomposition bridge and we're down to the point that we're losing a gag reflex, which is a reflex. It's one of the lower order things that your brain pulls off. You know, I've seen some pretty dead mother fuckers gag at the insertion of an OPA. Not and I want to be clear. They're not dead. They're very, very close to dead. They're otherwise unconscious and then you drop an OPA and all of a sudden they go, yeah, like that. And this guy is doing nothing. Lease me to one of two things. Either he is cresting that competency or we didn't actually test this gag reflex as much as we think we did. Yeah. You could just be that we didn't hit the right spots. Maybe he doesn't have a gag reflex or a strong gag reflex. Some people just don't. But it is one of those things that where it's, I'm curious to see kind of where this is going to go because because they were so recently conscious. It's difficult to believe that even if we were to arrest right now, would we be so brain dead that are that we wouldn't even have a gag reflex or sorry, would we have such neurological damage that we wouldn't have a gag reflex in what seems to be just a handful of minutes from consciousness to one consciousness. Which makes me doubt, did we really test the gag reflex or does this patient really have a gag reflex to begin with? So I wouldn't hold much credence to this gag reflex telling us how far down this patient is. Yeah. But that's, I think it's kind of a, it doesn't. Yeah, I think it's the 40%. Of course. I think that reflex is the 40% Spo2 reading right now. What's really more telling is that they are not as responsive as they once were and they're clearly getting worse. My thought would be, hey, this is probably like maybe they're developing tension physiology given how, how, how quickly they're, yeah. Tactical cardio, hypotension. Yep. Yep. Absolutely tension physiology on the table. So I mean, if it were me and, you know, we were landing, the first thing I would do would be like, hey, let's needle this chest. And then, that didn't fix blood. Blood, blood, blood. Yep. Anyway, I'd probably be doing both at the same time to be honest with you. Or you're just that good. Yeah. No, no, no. Well, you have more than one person. Not here, Chris. Not here. Well, no, but you're saying if we landed, you know, we'd be like, hey, yeah, you start spiking the blood. I'm going to start getting this, getting the site prep for a, for a decompression. Do you fight with a crew? I just fly myself. Oh, you let me. You let it on scenes. You're like flying to hell. - You're doing CPR behind you. Keep going. Okay. Yeah. No. I saw it. - I saw it. - I'm a real hero. - You're a horror plan. - Fighter jet. - Alright. Move on. Let's go. - Alright. Okay. Well, I didn't say it was about to get worse. So, let's add that brick now. Mr. Leahy, who was the staff member who had radioed. Holy fuck. He's being stabbed. Now tells Ricky, or yells at Ricky, "Hey, what are we gonna do about this guy?" Ricky lo-sovere, several yards, meters, and sees Mr. Leahy, Mr. Leahy, near another person who has been stabbed. - Oh. - This is patient number two. - Randy. Randy is another male, who is currently the color of dead. They're about six foot two and 220 pounds. That's 188 centimeters and 100 kilograms. They are lying unresponsive with their eyes open. Ricky turns to the staff member, holding his phone. Make that two, Danielins, please. (laughing) - Alright. - Ricky, recalling the I.C. dead people episode of EMS 2020, decides that the best thing to do is to bring patient number two, Randy, over next to J-Rock. So they go over, grab Randy, drag him over to where their equipment is, and J-Rock is, and start. So the patient is not breathing. Okay. - So Ricky grabs out an I.Gel and another BVM. He tells the folks working on J-Rock, hey, you stay with that patient, and like he has the monitor staff go, he has the person on the monitor, cycle another blood pressure, as he places that I.Gel and begins cutting up Randy's shirt. He notices that there is a stab wound over directly over where the heart would be on the chest, and there's also one on the left arm. There was no bleeding from the wounds. He checks a pulse. He notes that there isn't one. So he instructs Mr. Lay, he to start CPR. And then after the first cycles, where he gives to breast via the BVM, he passes this task off to yet another bystander with instructions to continue with that 30 to 2 CPR algorithm. So those breasts are delivered via room air. There again, there is technically a second O2 bottle somewhere in the equipment, like with everything he grabbed, but he cannot find it in this moment. So room air it is. - Hey, all right. - Yeah, Randy looks over at the monitor, and thinking, excuse me, Ricky looks over at the monitor, thinking that Randy, the second patient, might need it more than J-Rock at this point, because Randy is a code, and J-Rock is only about to be a code. He sees that J-Rock is now posturing with his legs, sticking straight out. The BP on the monitor reads 50 over, and he couldn't remember. He was just like, I don't know, 50 over fuck. - Yeah, that's not that, right? - That is an accurate, yeah, yeah, yeah. So believing that Randy does need the monitor more, he takes it off J-Rock, places it on Randy, utilizing a second set of DFIB pads. On the monitor, the patient is in a PEA at a rate of 30, it's an organized narrow rhythm. Mr. Leahy is told to continue CPR. - Okay. What do you think? - So this is a difficult place to be. I think I understand the spot that they're at. Now, one of the things that I really appreciate is I appreciate their NEMAS 2020 listener, and that they used the ICDED people episode to help. them through this. And I do like the organizational temps that are going on here. At this point though, it would be fair to start traveling down the MCI route just a little bit with this patient. So we have to remember that mass casualty incidences are not defined by the raw number of patients. It's that number of patients in relation to the resources available. And it's reasonably fair to say that the number of patients here and the severity of the patients is is more than the resources available can handle. So if we went down a triage route, this person, Randy, would be triaged as a black tag, in other words deceased, whereas J. J. Rock was the other one. Yeah, J. Rock is the first patient. Yeah, whereas J. Rock is a red. Dark red. Dark, dark. J. Rock's maroon. So yeah, it's yeah, but still. And so my problem is is that this other guy has a stab over the heart. We're in a slow PEA. And that person's chances are very, very low to none. The other guy also has very low chances, but they get even lower if you take the oxygen from them. So I can appreciate feeling like I do have enough resources to do this, but I don't know that you do. And I don't know that this doesn't enter the realm of MCI where we have to say like, Hey, this guy is not going to make it. This is a victim today. They're dead. It sucks. Well, they're both victims, but you know, this person's going to die. We need to take our available resources and focus it on the guy that's going to live, you know, or yeah, could live. So I'm curious to see what the rest of this call happens. How the rest of this call goes on. The other thing to consider though is you may, this may be something that doesn't become an MCI one more resource has come out. So I don't wonder if there's some thought to, you know, Hey, there's an ambulance just around the corner. If I work this guy a little bit longer, I will have the resources and they'll be more viable versus if I give up now, there's no chance, you know, and so which isn't the realm I would take, but I don't wonder if that's what's going into the decision making right now. I think a way to split this needle is to, you know, essentially do what like don't move. I think you keep the monitoring equipment with the patient who's maroon colored on the triage. And you can assign people, hey, I just do CPR until an ambulance shows up and we'll go from there. That's he's if he's dead, that's all that can happen and don't move the monitor over. Just keep keep the resources with the person who has the chance versus the person who technically is a black. But if you want to avoid the like, why aren't you helping him thing, then you can assign some civilians to help because there has been a lot of delegation here, which is incredible. Actually, so there's a commendable level of delegation going on here. I want to point that out. There's also some speed bumps that have happened and we've continued the call going. That's that's a later conversation, but there's some commendable moves being made here. I don't want to lose focus on that, but at the same time, I do think the I think you're right. I kind of like the direction you're going. I think the second guy, Randy, I think he is a controlling obvious bleeding of which there is none. And in this case, that's not bleeding controlled. Everybody that's bleeding is complete. So it's yeah, we're just we're out probably. So in that case, if we do need to do something, having bystanders CPR going on, especially when it's very obvious, you're the only uniformed EMT there, you know, I think that's a perfect opportunity. But anyway, let's continue on. We'll touch back on this later. Okay. Well, it's been about 10 minutes after the initial dispatch. And at this point, a swarm of tactical police descend upon the scene followed shortly by a storm of medics. Ricky, who is next, Randy, instructs the first driving medics, Julian Bubbles to go to treat J. Rock. That guy is almost dead. Or maybe he just died. There's a sucking chest wound on his chest. He's got an abdominal wound and arm wound. Last fight. I'll say Bp 50 over something. No airway adjuncts, BBM on flush. So Julian and Bubbles go see that patient. I love that by the way. Medics. Yeah. Medics. Lucy and Sarah arrive. This guy, Randy, has a heart rate of 30. No respirations. Lucy interrupts. He has a pulse. Why are we doing CPR? Ricky, who had just done a pulse course recently says, well, it's less than 60. So we have to do CPR. And Lucy says, no. Sarah, meanwhile, checks for a pulse and says, hey, there is no pulse. So CPR is continued. In retrospect, Ricky was identifying PEA at a rate of 30. But under the significant cognitive load, unconsciously substituted a pediatric bradycardia rule from a recent pal's training, resulting in a confabulated explanation for ongoing CPR. By the way, we had talked about confabulation on our last episode. And this is a great example of that happening here. It's, yeah, it's, it's cool. Yeah. It's amazing what can come out of our mouths. Yeah. In the line of like, uh, Incourtness and Malapras, you know, what I mean? Like, uh, where we're substituting sounds and, and saying. Yeah. Yeah. Very true. Kind of fits. By the way, uh, this is, this was still a good, like, this was still a good move to happen with, like Lucy, you know, going like, wait, hold on. What do you think? Right. Because, yeah, it's closed loop communication. That whole thing of like, you have said something that seems off. I'm going to say it back to you and see if you hear what I hear. Kind of thing. Yeah. That's good. Yeah. All right. So, uh, Julian and Bubbles moved A Rock to the back of the ambulance and they start doing things presumably like a needle decompression because it's labor intensive. No one is getting up front to start the transport. Uh, so a supervisor is around Ricky, ask a supervisor, uh, hey, can you drive the crew so that they can start transporting? Um, and that's what happens. But by the way, pro move Ricky, uh, there, yeah, delegating that like, hey, supervisor. Yeah. Thank you. And they're good to be like, no worries unless they're seeing an arrangement to do, but it kind of sounds like I mean, yeah, I mean, every, every, every patient's got it got a responder at this point. So, yeah, uh, Randy, so uh, Randy gets loaded up by Lucy and Sarah and they quickly depart the scene. This is when Ricky over here, someone asks, so what about the third guy? What? Third guy? Oh my goodness. So I see a lot of dead people. It does turn out that Cyrus the stabber had attacked another person with a different weapon this time at an adjacent address. Uh, there was already an ambulance assigned to that patient. So there was no, okay. All right. Wait. What? I like how that came exactly after like, well, every patient has a medic at this point that you're like, number three. And I'm like, oh god, what I, what I, this is sort of thinking like, is this guy making patients? Because we don't know where Cyrus is still. Are we making more patients as the call is going on? Yes, that is, that is, that is precisely what happened here. Oh, got you. Okay. Perfect. Yeah. Okay. So generating calls left and right. Unfortunately, while the patient care part of this whole call is over, this situation was ongoing. Uh, Ricky had to wait around to give statements to detectives. Then they had to go back to headquarters to write up IRs for each patient, which they said was the worst part of this entire call. Uh, paperwork always is is yeah. Uh, like right when you're like, okay, oh my god, this is over. Someone's like, here, I want you to relive this all. Uh, yeah, can write this out, please. And, you know, be as detailed as you can. And you're like, I just know, I don't want to go to the color. I just want to go to the corner with a color. I'm going to throw all the reds out of the coloring box. But I yeah, yeah, yeah, exactly. Yep. Okay. So unfortunately, both patients that Ricky encountered did ultimately die from their injuries. The third person did live. So that is the call. Wow. So let me summarize this. Uh, so we're eventually at, uh, at, uh, we're at a stand by. It's supposed to be an easy stand by where we can get some studying done, but that doesn't fucking happen. And instead of hearing the condorsness has been infiltrated, we end up hearing over the radio, holy fuck, he's getting stabbed, which by the way, that's not a super helpful thing. I like how they tune up very clear. It's summoning. Yeah. You know, wait, it does relate that there's danger. Uh, then we throw safety to the wind and we arrive and we find, uh, we bring all of our stuff. So that was good. Uh, and we find that there's one page down who's been stabbed multiple times. They start rendering aid. Ricky does. And they start using bystanders and other non medical staff as assistants, promu, by the way. Uh, but nobody knows, uh, where the stabber is, uh, that Cyrus mixed stabber face, by the way. Sorry. Cyrus mixed stabber face. Sorry. Nobody knows where Cyrus mixed stabber face is. So, but then they discover, hey, by this guy So, discovered that patient and that patient has been stabbed right over where the heart should be and they are essentially a PEA at a rate of 30 with no diagonal respirations. So, more bystanders are utilized and another ambulance is added because they already had an ambulance. First guy, now they have a second ambulance come on in. One thing that I do love is that because Ricky is an EMS 2020 listener, they then drag the other patient to the same area and they start managing both patients at the same time. So they do that. Then all of a sudden a whole bunch of cops come in the area. We have a whole bunch of medics that come in the area. We're actually able to start assigning appropriate clinical teams to each person. Ricky once again decides that, "Hey, I'm going to start delegating and I'm going to delegate to my supervisor to see if they can drive so that we can stay in the back and keep working on the patient." Ultimately, nobody survives this. Well, okay, the two patients don't survive. Everyone else lives. But everyone else who was on scene will be survived. Unfortunately, the supervisor having not driven an ambulance in a while crashes and everyone. That's probably why the first person is a normal fire. Jesus Christ. Yeah. Wow. Somebody is playing with all the dark crayons. Jesus. Hey, before we get into the review portion of this, I think I want to say something here. I think it's important to preface this next section. Ricky found himself in a very dynamic mass casualty and something which there really is no training on at least in my EMT program. I have even never met a. What did my experience? No one ever gave me a handle on MCI as a low EMT basic with minimal experience course. I've never had it. I've never had it. I'm going to say. I'm sorry. Continue with what you were saying because I actually have praise for Ricky. Keep going. Okay. I do want to say, whatever we have to say, he responded heroically to a situation that was incredibly stressful and he had no other medical personnel to assist him. I think while we offer up considerations, I think we have to remember that this was happening in a situation that would be. It's stressful as. That is the weak-soss word for what this was. But regardless, it would be just a horrible situation for any single provider to have to show up on. Well, we may have considerations on how this could go better. Should somebody find themselves in a situation like this? Please don't. I hope you never have to. But I don't want that at all to take away from what essentially was an incredible job that Ricky did. So, I just want to make sure to say that. That's important to mention. We just have to understand what the nature of our show is. It's always defined what's the best possible outcome. That kind of stuff. And I kind of think this was the best possible outcome. But we will mention some things that maybe could have been done differently. I will also say, I don't think there was any decision that could have been made on this call to save anybody's life at this point. Unfortunately, this is one of those scenarios where in spite of your best efforts, you're not going to win on a lot of these. With that, let's kind of go straight into the call discussion. If that works for you, Spence. Yeah, absolutely. So let's kind of start with system problems, or at least let's look at the system. So this is a pretty standard. There's a lot of standbys that are set up like this. This is pretty standard to have a single EMT. And one of the primary goals when you're a single EMT on these standbys is to find a partner. I'm just kidding. It's two. No, they're single EMT tech. Anyway, so all the single EMTs, all the single EMTs put your hands up. Anyway, so, right. So one of the main things that you were there to do is to treat life threats and triage. That's really what you're looking to do. Because at the end of the day, you're not transporting anybody because you are but one EMT. So you have to call those resources in. And so what's kind of cool about this is on one hand, I guess not maybe not cool actually about this and that can be deceptive is on one hand, they always sound, it always sounds like an easy stand by right? Well, they just want one EMT. What is it? I'm just going to watch like some kids lemonade stand that needs an EMT on standby. Sure. But on the other hand, if something does happen, it's just you. That's it. And so what you really need to be ready for is you need to be ready to be a strong EMT. There's no place to hide when you're by yourself. Yeah. Yeah, it's true. And you can't hide. And so you really need to be good at your initial assessment, treating life threats and calling for resources when they're needed. And I really think that was done. That was done here. Other than that, this is a pretty typical system. There's nothing wild about this at all. It is sort of ironic that the people typically EMTs with not as much experience, it's like you're new to the company. They're like, "Hey, go work this standby by yourself." And that's where you may need to shine. Whereas the people who would actually do better who have experience, they're not doing these. So, which seems kind of counterintuitive in some way. But yeah, having that second person or another person or people is incredibly powerful into helping. Yeah. It's a situation. It's misplaced risk management is what I would say. That is. Yeah. But the goal there is, say, let's put our new EMTs in a low pressure environment where we don't. What managers see? What managers see? We see call volume. That's the number. That's how we judge what's a hard standby versus an easy standby. So, we're like, "Well, we're always transporting out of these football games or out of these rock concerts or these motorcycle races." Yeah. We're always transferring out, "Let's not put a new person there." Or, "Let's not put a single person there." Oh, but we. Everything on this. This is Bob's Breeze's Band-Aid. That's all that ever happens at this moment. We transported once last year. Let's put them there. So, there's no malice involved. No. In fact, it's actually a company trying to do the right thing. They're going to be like, "Hey, you're not experienced. Let's not put you in a situation where it's bad." But the problem is, is what's never visible in. I wouldn't say never visible. What's frequently invisible from a statistical standpoint when you're managing stuff is things like that, the clinical what-ifs, how bad could it go wrong? Because let's say the one transport we had last year was a gunshot to the head or something like that. Well, in the paper, it looks like, "Oh, we did this. We did this standby 27 times in one year and we had one transport. That's an easy standby." But we don't think about it. But didn't show up in that immediate statistic was, "Yeah, but it was a critical thing." Unless you're looking at a lot of people don't look. Yeah. There are. That might be a system pothole right there is that we're taking someone inexperienced and putting them in a place to where, if something were to actually happen. If they were actually to be utilized for the exact reason they're there, it's a problem because they're by themselves. Yeah. And we're baking on nothing happening. Yeah. And so, what I would say, my advice and demand management, is you're not actually putting them in a good situation if it being a good situation relies on not providing care. That's not a good situation to be in. Now, if you have standbyes where it's like, "Hey, it's a more mundane event like it's a marathon." We're going to have a couple people here that are probably going to need water. Maybe we'll have a transport with dehydration, but it's going to have several EMTs. That's a great spot for a new person. We generally know what to expect. You have more people there. It is still going to be a lower call volume or at least lower acuity kind of situation. That would be a good thing. But isolating an EMT by themselves or a paramedic by themselves as they are getting into this COVID practice is probably not a good idea because it really hinges again on them not having to do anything. And this is a standby that does typically involve like summoning an ambulance. There's a couple, there'll be a couple calls out of these events per day. And usually they're, "Okay, I don't want to say they're low acuity, but they're not this." You know what I mean? Yeah, they're not. "Oh, hey, we had to give Narcan to this guy." "Oh, this guy might be septic or something along those lines." Those are typically where it's still kind of like, "Wow, I got to do something." But you're really just kind of holding on. You're starting the care thing that the ambulance is going to show up and continue. You're not typically doing life saving interventions. So yeah. But I do want to say as a system bonus, these support from all of the folks at this place was amazing. Very cool. And the staff. frequently checked on them, Ricky got time off of work. And essentially when it came back, they're like, "Hey man, you third ride as long as you have to, to feel comfortable, getting back in the saddle." And that's really, that goes a long way to helping people, 'cause this is a critical stress event. And I'm sure there were nightmares. (laughing) Yeah, we do, like, involve, yeah. Yeah, well, the other guy I also wanna point out is having mental health friendly policies, almost every time they're done and they're executed, they, they, they, they result in, in actually people calling out sick less. There is a, as many agencies will do, whenever you have a policy that gives people time off, they worry about abuse of the policy. I'm not gonna pretend that that's not an unrealistic concern because policies do get abused. People are people and you do have employees out there that will do those things. What you have to understand though is that that is way fewer people than you may think. And so one of the things that our agency that you and I used to work at, Groud agency, they did really well is they had their stressful call policy, which was essentially like, "Hey, if you had a stressful call in the middle of your day, you got to take that time, you could say, "Stresswell call policy, I'm going home." And we paid you to the end of your shift and you came back when you were ready. And that was what was important is, it allowed people to make a mental health decision, not a financial decision. What it also allowed us to do is there were some people who did start using it a little bit more, but we were able to identify people where it's like, "Are you okay?" And then you start being able to, 'cause mental health should be treated like an OJI. And I know there's probably some managers and others out there that are like, "Oh, don't say that." But because OJIs costs a lot of money, not just the OJ, the self-based insurance rates go up. So, but helps to identify people that may have a mental health injury, if you will, that's more chronic, that has become chronic, because they're calling out, 'cause the problem is when you hide that, when people aren't able to do that because of their financial situation, like I can't take the time off, then you end up people going deeper and deeper and deeper into these mental health issues. And it's not just gonna mess them up for doing that with one stuff, it could mess them up for the rest of their life in any other category. And so, by enabling people to, and it's the same with just culture, right? It's actually all the same vein of why, with just culture you start from a non-punitive perspective, because it makes people more open to self-report. Well, this is the same thing. People are more likely to talk about how they're feeling and what's going on. If there's no detriment or financial problem with doing that. And so, people have the ability to leave work without taking a financial hit. You're gonna find out more about your work environment and about that employee, and you don't have to let it get to the point of burnout to where they quit, and now you have to train a new person, because we all know, and what's been shown time and time again, is that having an experienced, well-trained person quit is so, so, so expensive to replace. Even though you get to pay the new people less, because it's 10 year and that kind of stuff, there's a lot of expense that goes with losing that person. And there is an emotional and morale toll on your agency when you lose those people. So, anyway, I'll get off my soapbox about that, but having mental health supporting policies that allow your employees to make mental health decisions without having a huge financial impact are imperative to the healthier company. And in the long run, it is something that's going to, if all we look at is money, and that should not be the only measure, but oftentimes it does become a major concern. If all we look at is money, it's still probably going to save you money in the long run. It's hard to chase it. It's a hard investment to track, right? 'Cause you can buy an ambulance for X number of dollars, and then you can watch how many transports that ambulance does and say that investment made this much a turn. It's hard to do that for a policy like this, but just believe me, you also have less, less of a hard time hiring people. So, anyways, yeah, that's, it's one of those like, hey, how do you show that you prevented something? Like how do you show that you prevented a disgruntled paramedic who's burned out from dropping a patient because they were careless, 'cause they're tired and exhausted. And then they see every time they blink is the horrors and bodies surrounding them and knives in the back. Hey, but yes, exactly. Exactly. All right, moving on. All right. But let's start talking about what I think is, okay, let's kind of briefly talk about the assessments that kind of stuff. I don't think that's gonna be the focus of our discussion on this call, really. I think it's important to me, the big discussion is the delegation, right? Yeah, so I think we need to talk about the safety aspect. Because I think there is definitely something here. You brought it up in the pregame. You said, hey, there's a couple things that I'm worried about. Scene safety being the first one because there is a stabby McStabberface out there. Yeah. Up. And then there's sort of this panic induced start. That's not a real name for anyone listening. Stabby McStabberface. (laughing) Yeah. Sometimes our name sound real. We just make the most of it. (laughing) Not yet, but there's a child about to be born. And he's gonna be at EMS 2020. That's right. 'Cause his parents are gonna be like, "It's where I got you, Dan!" (laughing) Oh my God, yeah. You know what? We need to start some like EMS 2021s. (laughing) Just stabby McStabberface. Whatever, keep going, keep going. We're good. Okay. Safety. Let's talk about safety. Yeah, so I think this is a really, this is a really difficult situation, right? Because I think there's sort of this false dichotomy that presents itself here where it's, hey, it's seen safety and that means that there's going to be a lot of people out there who aren't going to go, where are you? Why are you like, hey, why are you hiding? Like why aren't you, we're out here. Why are you? We're trying to help this guy. Why aren't you're the person who's supposed to help? And then also along that line, you might have your own like, I should be out there. I, why am I not going out there? Yeah. And there can be moral injury that comes from this sort of, like this thought process of either, I'm safe or I'm helping. I think there's probably a way to square this, where essentially your response is something along the lines of, hey, we, hmm. As I'm thinking about it, I'm like, exactly. It's tricky, it's tricky. So one of the things, so Q reviewed this call. And he said, you know, one of the things that he said is, hey, at the moment that you're kind of like, oh God, I'm in danger. I'm out here with this patient. Move them to safety. I'm in danger. Move them to safety. Move them behind closed doors, where the chance, knives are typically not going through, closed wooden doors. So you can relocate with this person to a spot that's safer. But in terms of the initial response, I don't know, man, this is tricky because I know that I would want to, that I would want, I would feel obligated myself to respond. Like, a person's problem is not sticking around. Like, sure. So, let me dig into that just a little bit. So moving to patient to a safer place, once you're there, I think that's an option, but the problem is you have to get there. You have to be unsafe to do that. You know, you have to cross that line. So it's a good resolution if you've already made a mistake of getting in there. So how do you square this? You know, boy, it's hard. The reality is that I don't know that there is, like many things in that's true in life. There isn't a black or white to this. There just isn't. What I would say is I would kind of say, kind of fall back to a method we've talked about on this podcast before and that is get the public in the same boat you are or get bystanders or loved ones in the same boat with you. And start working towards a common goal with them. And the common goal can be safety. And so if all of a sudden you're getting called, you're gonna have to use your loud voice in this. This is a command situation. There is no bold, clear concise is the only thing that's gonna work in this. Well, I hate speaking in absolute. So I wanna pull back the word only from that, but it is something that should work for this. And you gotta come out be like, hey guys, and yell out one like, hey, are any of you guys safe? Where is the, where is the stabber? Where's the guy with the knife? And say it out loud. Everyone here is at risk. No one here needs to get stabbed and all of a sudden, all of a sudden everyone's gonna be like, where is the, I think I started looking around. Now, I don't know, actually now that I'm saying this, like am I now inducing panic? You know, so you may. You may like, hey, like, but I don't know, I, it's hard. Like I think I would still say that. I'd be like, guys, where's the guy with the knife? Like everyone here is at risk until we find that guy. Where we know where he's at? Where is he? And then someone would be like, yeah, he ran off. He's, he's way down that direction. Great. Now we know there's at least a, like a distance between me and this dude with a knife, you know. If it was a gun, I would say fuck public's perspective stay inside. Yeah. because a gun has range. there's just that there's depending on the type of gun, there's infinitely more destruction capability with a gun than there is with a knife. I'm not saying people cannot kill a lot of people with a knife. Clearly, you can. Well, this guy only got two. There are incidents of mass stabbings out there where you've had victims into the teens and 20s, but significantly fewer than there are with guns that I'm not trying to get political. I'm just stating that. But if it's someone with a gun, I don't know, public perception, I'm not going to walk out there and get shot. I don't have a vest. I also don't have a gun if I'm at the stand by, like, you know, and it's not, it's just not feasible about there. That being said, chances are there's a bunch of bang-bang going on there. Nobody else will be out there either. So, yeah, everybody like, fuck that and move. But that being said, you know, we have someone who's been stabbed, the safety assertive is still there. I think if you get everyone in the same boat you are, get everyone thinking about their own safety and your safety, and then you can kind of go from there. I think that's a great approach. Yeah, it's a challenge. And I really want to hear from the audience on this one because I'll admit, it's questionable. And this is one where I think more ideas on it will be better. In fact, I want to hear from the audience and then maybe I'll put a, I think I'll do it. Yeah, I'm going to do an Instagram story with a poll with a question when we released this episode. I'm just going to say, hey, there's a spot in this. What would you guys do to ensure scene safety? Write your answers below. And then we can talk about it on the Instagram. Yeah, but can I hit it where we interviewed pilot down? Yeah, no, I think that's a great idea. Anyway, because I, yeah, I don't, it seems like there should be a way to square this. And it just, it seems the more I think about it, the more I'm like, even, you know, the thoughts that I had going into this, don't seem to, don't seem to hold. So the other thing that you brought up here, and I think this is again, just the highlight, you will not have the brain that you think you do in a panic and do situation. And I promise, I promise you, this is one of those regardless of who you are. You will not have the brain power that you think you do. You will overlook things. And we can kind of see that here in this sort of, the, like the assessment was not like a systematic approach assessment. It was a lot of, you know, you're, you're kind of, you're, you're falling back to heuristics, you know, it's like, well, he's talking, he's breathing, you know, we're not looking at rate in all of that. And maybe there's not really a place for that in this situation given that this became kind of an MCI. But I, again, I just think that when you, when you rush in, and I would be, I can't, I can't cast the stone again. I'm just saying this is an example of when, when you kind of, when you're forced to rush into something, you are, you are forced to rush in without forethought. And like Chris pointed out, this is that, that is sort of how you miss small things. Like, oh shit, where is the guy with the knife? So anyway. Yeah. I actually thought just to kind of actually go back as we're moving into arrival and, and, and, well, as we're moving into assessment, I actually didn't think their assessment was too bad. Let me scroll up to my notes really quick. At least there are initial assessment. I didn't think it was too bad. Let's see, what are they right down? What are they right down? Okay. They did do it. L. O. C. X A B C. And during that assessment, they identified what I did like is that, you know, they were able to cut the patient's shirt. Now, I know a lot of time people will say like, hey, during B, you should be cutting the shirt. Sometimes, and yes, ideally, but sometimes you got to go with like one supplies are there. I haven't known here that I just wrote down trauma shares and I were trauma shares not available immediately or was there something going on with trauma shares or am I just the news? He is, he is trauma shares. Okay. I don't know why I wrote that. But anyway, so, uh, graphs and trauma shares cuts, identifies a life threat and takes care of it immediately. That's kind of what you need to do. So I think that the initial assessment and treatments were absolutely fine. You know, your BLS level X A B C, you know, get after it and he's one person. And so he then does what I think is incredible. And kind of what kind of comes down to the the highlighted points here is that there was very, very strong delegation that was going on and delegation on this call is 100% required. And this is a call where your strongest skill is honestly going to be people skills. Because people we've talked about this on the show before the the Finkston Oliver leadership acceptance. I don't remember we call association association. It wasn't a curve. It was like chart. I think is what it was. The Finkston Oliver leadership association chart because there was no curve. It was for things that I made up. But anyway, well, amazing what it is is that when it's how ready a seed is to accept a leader and want a PIC. And when you have a high chaos, but no leadership or no direction, that's a scene that will look for any leader. And you get to be that guy because there is high chaos going on right now. And so the moment you start offering a path, people are going to boom, I'm going to do whatever this guy tells me to do because everybody wants to do something here. Right. Everybody wants you to do something. But everybody recognizes that something it needs to be done. And that's why that was done really, really well here is CMT goes out there and they immediately recognize I cannot do this alone. I need to start recruiting help and they immediately started recruiting help in any way that they could. And furthermore, the assignments they gave were appropriate to the people they gave them to. And I thought that was really good because it kind of shows that's the hardest part about delegation, especially in a situation like this. You really don't know what the other person knows. You know, these aren't other EMTs. They don't have a certification. You can necessarily go, someone comes up with a certification or a license. You'd be like, well, I know they should at least know this. You don't have that here. That's gone. And so what Ricky did really, really well was given that appropriate assignments. Second, what Ricky did really, really, really well, or at least what it appears that was done well is that Ricky followed up on the progress of those assignments. Let's take the person who was assigned the monitor. They had, and we talk about this, I talked about this in Nebraska, which a friend of ours by the way, I'm not going to say that. I talked about this in Nebraska. One of the difficult things to do or one of the parts being a PIC is make sure you're going back around to make sure the assignments you gave are being done or they don't have any hitches or you don't need to reassign people or add resources here and there. But this was done. And when we get back to that person who had the monitor and they're like, I don't know how to do it. They're like, okay, no problem. And they walked that person through and they fix that problem. That was really for someone who is new and without experience. This makes me wonder if they don't have other life experience prior to being any prior to being any MT. Or did you say they did? I didn't I didn't say one or another. Yeah. But it kind of feels like it a little bit, but maybe not. But either way, this is really well done in the sense that we recognized that an assignment we had given earlier needed to be revisited. Some help was needed at that station. And we did it. And it was awesome. And so I really, really appreciate that. What are your thoughts on the delegation? I think one so I yeah, 100% of everything you just said. I think the other part too is that when what I really appreciate is, you know, it's like we would find ourselves like I think it's easy to find yourself kind of confined to like, well, I don't have any other EMTs here. And so improvising and using the tool, the people who are available adapting to this situation as it evolves. And that is a that is an incredible skill set. And it served them well in this call, especially, but that will serve them well in all EMS calls because there are going to be things where, you know, it's like, Oh, I don't have, you know, it's like, well, I can't make I can't have this person ventilate because they don't have like an empty shirt. Like what am I, you know, how do I defend that? It's like, you defend it because this is now an MDI. Like and you're using the people who are available to do tasks that you cannot do by yourself. Because if you're like, well, I have to ventilate this person. That's what you're stuck doing. You can't do anything else. You might find yourself needing to put on a chest. Yes, you'll have to be like, shit, I can't. So yeah, I think going with the flow, the requesting requested ambulances, you know, like requesting resources. Yeah, I think there was there was so much here that it should be that that should be borrowed and used in in in other calls. There's a really cool skill set here. Agreed. Yeah, another point, but keep going. No, no, no, go ahead. One of the other things that was really appreciated was when we were doing the scene management bit at one point, we hit some speed bumps. So let's talk about not being able to find the O2, for example. Speed bumps are going to happen. And they're going to be speed bumps that later on you're going to go back, be like, man, you know, I made a mistake. I should I should not have lost that O2 bottle. You'll go back like what part of my process caused that O2 bottle to get lost. And that is a good thing to go over after the fact. But the reality remains bad. things are going to happen in the moment. What you can't do is get sucked in and magnetized to those bad things and be unable to move on. And what I really appreciate about Ricky in this case is Ricky saw like, I don't have the a two bottle. I can't find it. Let's move past. Because sooner or later you can sit there and be like, you know what? I can ventilate this person with with at least 21% oxygen, you know, because that's what's in the air. You know, so we can do that. And then maybe that bottle shows up later. But if I were if Ricky were to have sat there on that single decision and trying to fix that one problem. And here's the thing, it's actually a pretty big problem to be dead off with you. Not having oxygen for someone who really fucking needs it. Hypoxia is bad. Mk. So the fact that that problem existed and it is a big issue. But Ricky was able to be like, look, the only thing that makes this worse is not bagging them at all. Yeah. Yeah. And so Ricky's like, you know what? Push past. If it comes up later, it comes up later and they started to delegate resources. So that that was actually a really mass full job of seeing a speed bump, not getting hung up and continuing to make decisions. Yeah. No. So another thing here is because I'm thinking about this. I'm like, you know, I have been in the situation where, you know, it's like, oh, I got to check a blood sugar on somebody in a busy task saturated environment. And then I will put my hand will put the glue cometer somewhere. It won't fucking tell me where to put it. But it's not this is where this belongs. And then I'm looking around for it going like, what the fuck? I just had it. But I'm thinking here applying that sort of like pamphlets, like, yeah, it's probably right there, you know, like right in front of you. You just can't see it because this is a crazy situation. But one of the things that I think really stood out to me in this situation is, and I think this is really the path to take us. You know, you're he's walking up to this call going like, oh, fuck, oh, fuck, oh, fuck, oh, as he should. Yeah. But one of the things that I think really helped and you kind of see that he gets his feet up like feet under him pretty early on. And that is following at, you know, that forward momentum of going like, hey, all right, we let's start here. And then the things start kind of filling in right? Yeah. Like the pathway to take kind of appears before him. And, you know, maybe a skip step here or two. But for the most part, like that pathway is there and he's able to proceed through the call. And then, you know, it's like when you're not panicked, you're able to go like, yeah, that could, that could can bag. Like that's not hard. Like we can make him do that. Like, you've got this. You put the monitor on. I got other stuff to do while you're doing that. I'll push back the bagging actually is pretty hard. But not, not when you've got an eye gel in place, which they do. Very true. Yeah. And that's, that's a masterful delegation of resources. So I think this is a really, I have a lot of positive things to say. I also want to talk about, um, it may, maybe this will come off a little bit later. But when the other paramedics started coming in and that when, when the help arrived, when the, when the, when the Rebel Alliance left warp speed and showed up on the battlefield, he was able to, uh, Ricky was able to take somebody say, okay, there's a patient stab here, here and here of our science or this, this and that go for it. Phenomenal job. Phenomenal job because at this point, you are one person in the middle of a ton of chaos and to be able to give, and you're just looking at, okay, give some life threats. You know, don't sit there and be like, and their meds are, you know, like, don't. It's just, it's not, it's not germane to the situation that this victim, I'm not saying medications are not germane to stab to trauma patients. It's not what I'm saying. What I'm saying is in that moment, when you have resources flooding you're seeing, you need to get people to places. That is the way to do it. That handoff was solid. Um, let's skip. I want to talk a little bit more about MCI stuff, but I kind of want to skip into, normally we talk about handoff a little bit later, but I think now it's kind of an appropriate time just to keep it thematic. Um, when you think about the handoff, I, I, I thought the handoff was good. And I kind of wanted to think, uh, a little bit more about, I'm forgetting the name of the other response. Was it Lucy? Was it one that clarified, right? Yeah. Yeah. Yeah. What are your thoughts on that whole situation with? Cause we kind of briefly touched on it. But, um, where are you? So I, I could understand the confusion from Lucy's point. You know, if you show up and you're like, I feel that. Yeah. I'd be honest with you. Yeah. Like, and I, but you know, it's like, I think the other part of that is, you know, like for, for both sides, like, there's probably a way to do that where you're like, Hey, hold on. I just want to clarify versus like, uh, no, you know, like it kind of depends on the approach that Lucy took. It's absolutely fair for Lucy to go. I'm sorry. Hold on. What are you saying? Like that, that doesn't make sense. So he has a heart rate. Like, cause those are different treatment paths, right? Like you're not doing CPR for an adult with a heart rate of 30. Um, but I also understand from Ricky standpoint. It's like our brains do not function very well under an immense amount of stress and confabulation is a very human phenomenon, even if you're not, even if you're not missing some thigh. I mean, yeah. Uh, so, yeah. Um, and so confusing those things and substituting like, why hold on? Why is the reason that I'm doing this? Okay. Yeah. This is something I learned recently. Like maybe that's what it was. Uh, it totally makes sense here. So I think it was good for, uh, Lucy to clarify. I hope that she did it in a way that is kind and understanding given the situation. Um, and, uh, I, I think an ounce of understanding. What are your thoughts? I think, um, what you said, uh, yeah. What you said, the only comment I would have is when it comes to a kindness and understanding, uh, it, it's important. It really is. But there's two sides to kindness and understanding, right? And in fact, let's focus on the understanding part. Uh, you cannot be in this job. Bold, clear, concise communication is necessary and bold, clear, concise communication lacks personality sometimes. And because we are human, we will often hear something that's bold, clear, and concise and take it as frustration or anger because in any other situation, it would be. What I think is important in these situations is that what we really have to do is we have to one as people on scene, we have to be able to receive, you know, Hey man, that's incorrect. Uh, or, or, Hey, you're saying this or you're saying, Hey, someone should be able to say, Hey, we don't stop CPR for heart rate below 60 on patient, uh, or on an adult patient. And you should be able to be okay with that. Okay. Yeah. What needs to happen though and what's imperative with making sure you're okay with that is follow up that this is, this is how we need to behave on scene and the kindness and the carefulness can come afterwards when we regroup and figure out why things were said because that's going to do two things for you. It's going to have the other person know that you're not an idiot and you knew this patient wasn't an adult, not a baby. Uh, so that's going to help out because you're like, yeah, look, I meant to say this. I was really busy and I just said that because I recently took a pals class and I remember hearing the words leave my mouth and I wanted to grab them and bring them back. They were out there. By the way, that, I'm just saying that from experience because I've been here before. But, you know, and so you, you have to be able to, I hate being saying like, just be tough and accept verbal abuse from your partners on scene because that's not what I'm ever going to say. But you do have to be tough in the sense that if someone just says something bold, clear and concise, but like, Hey, this is what I'm seeing. This is wrong. I think we need to do this. It's not personal to you. Yeah. It's going on. Now there's a line. Like if someone says, Hey, fuck stick like that. Okay. Yeah. That's bad. That's bad. Yeah. But unless you're a fox stick in which case tape, no, I'm just kidding. Yeah. Yeah. So then that's kind of the way I look at it is I don't want people because what I hate on scene is if I'm making a mistake, somebody comes up and I actually hate this and like a lot of parts of my life. But someone kind of like, um, so the way I would do this is maybe this like just fucking tell me I don't want to see here in the wait three minutes for you to get an answer out of your fucking face and just tell me you think something's wrong. Tell me exactly what it is. Don't sit there and get too flowering fluffy. If the scene allows for it fine. If someone's dying, just talk. Yeah. Now I think you're right on the follow up. I also think, uh, and this is sort of a separate thing is there like, don't if if there is a confrontation, that's also good for the follow up moment. Um, there's a story. It's a very fun story. Oh man name Brady. Uh, there was an EMT who worked with a gentleman, uh, who was known to be very terse with their EMT partners. Um, and uh, in this situation, the EMT who did not enjoy this particular person, uh, found themselves in a situation where the paramedic, uh, asked them why they were doing something in front of the firefighters, the patient, and the patient's family and then proceeded to slightly berate them for doing something that was, you know, wholly unnecessary. The EMT in this case, stopped doing the, you know, okay, fair enough. They got into ambulance, they took the patient, it was the EMT's patient, they took him to the hospital and after the call, the EMT approached the paramedic and said, essentially, I don't have a problem with you telling me, hey, something is unnecessary. The way that you said that in front of the patient, in front of the other responders, in front of the patient's family was belittling. Now, our company, you know, you're talking about trying to, you know, like, why are we doing this? It's unnecessary. If you're saying the company's, the company looks bad when we're doing unnecessary things or EMS looks bad when we're doing that, you look, you made us look like total assholes, the way that you approached that. Do not talk to me that way. And that happened after the call, which was the best place for that to happen. By the way, they got along great after that. So, is this you? Are you the EMT? No, no, no. All right. So I think, again, even, even in moments where you're like, whoa, somebody stepped on my toes, uh, following up and having, you know, and coming around after the fact, even in those situations is a phenomenal way to, to do that. So, um, yeah, really quickly to be a less part out of the way. This whole call was BLS do this. So, uh, let's talk about the MCI part of this. We did briefly touch on it. Um, I, and I'm curious to this came up in your discussion with, uh, the call giver, but the way I, the way to look at it, kind of going forward here is that it is a big question on whether or not this was an MCI because one of these we mentioned earlier, we've mentioned time and time again that many people know is that an MCI is dependent upon the resources you have available and one EMT, and this is not an insult. This is a fact. One EMT does not, it's not able to handle a whole lot of high patient, high critical patient volume. Uh, so, and that's, that's okay. You know, I would worry about the EMT that says they're fine with that, you know, we should all be crying a little bit, uh, you know, on this one. Um, yeah, this is a rough one. And so I, I do think, uh, had, had I been there with my literal, you know, you and I are both approaching about two decades of experience now, right? Yeah. I were really close. Yeah. No, no, like, like sooner or later, as someone who got a paramedic cert, uh, when, uh, who was born when we got our paramedic certs, we'll be able to buy alcohol. Yeah. They can already vote. Why are you hurting me? I don't know. I like it. I'm going to follow up after this episode. Yeah. And I will just tell you this because that's how I feel about you. Everything you said, everything you thought in your head's legit. Don't like you. I'm just kidding. I actually like you a lot. You're fine. Uh, but anyway, so, um, um, right. But when it comes to this whole, uh, MCI bit, you know, you have somebody who is going to be oh, task overwhelmed. And I think this is kind of the, the example of why we do triage and why the MCI is the way it is because at this point, and again, super easy for us after the fact is to hear and say this. But the second patient seemed very clearly dead. I mean, given the location of the stab wound, they're, they are coded at this point, the FPA, which, you know, P.A. and a trauma is, is a really nice way of saying I'm out of blood. Yeah. You know, um, I imagine just guessing, you know, the source of that blood is, is a hole in the heart somewhere and that car. The blood is still inside the body. It's just not an a usable spot inside the body. Yeah. Oh, yeah. Exactly. Yeah. Yeah. The blood doesn't left the body. It's just not where it should be. And so when we have someone where we're bleeding, it's not control, but bleeding is done. We're moving any amount of resources from the other person is not really going to help that person. And it's only going to be a detriment to you, a person that being said, that being said, I want to make it clear. I don't think the moving of any resource from patient number one over to patient number two was going to change patient number ones outcome. I want to make that light like super clear. And I think given the decisions in front of them, Ricky made the right ones in terms of a treatment or at least didn't make anything that was detrimental. Yeah. But I think if this was to be done again, I would say, and get Ricky, I hope not if you're listening. Ricky fit happens again. It's you. I know the comment denominator is you. You know what? Resign. No one would blame you. Nobody would blame you at all. Everyone would be like, yeah, fucking, I'm out too. That's that's absolutely fine. I'm going to make sure he's hand us the calls so we can get into the episode. Yeah, absolutely. Is there been anybody? Is anyone been a two time EMS 2020? I don't think we've ever doubled double. Yes. One person. One person has has been I've done I've taken multiple calls from, but they were really good calls. So no, got how many episodes do we have from this one person? Two. Two. Okay. Gotcha. Gotcha. Gotcha. I was thinking like we said multiple. I'm like, is there a lot? I mean, two is a multiple. Yeah. That's fair. That's fair. So anyway, but go ahead. No, so I did talk with Ricky about about this. And they said, you know, like their thought after the fact was like, I probably should have declared it and just put all put all the effort and resources into the into that first patient. But I didn't know how to tell like how to deal with telling people like this is the way it needed to go. There were lots of panicked people, you know, like, oh, we got to help him too. And so it seemed like, okay, you know, this person's what I think is at a BLS level. This is probably fine. You know, like there, there isn't a lot of things that he can do, like he cannot needle decompress the first patient. He can't administer fluids or blood product. There isn't a lot of treatment that that he can do at the level to manage that first patient. And so, you know, starting BLS care for a second patient, it seems fine in this situation. I would say that if you had limited like ALS resources, then the second patient is probably dead, right? Because you've got to, it's like, okay, that that person is deceased. And I think that's the, I think it's okay in this situation. You know, like if you find yourself with a second patient who's dead, you bold, clear concise, that person is dead. There is nothing that we can do for that person. You can check a pulse, open an airway, you know, or the 32 can do, you know, sir, can you hear me? Open their mouth. Are they breathing? If not, you know, they have a pulse now, they're dead. And then they're, and then you just make that, hey, there's nothing we can do for this person. Let's focus our energy on the person that we can't save. But I can understand, again, in this spot where you've never really been in a situation where you've had to tell people, I'm sorry, there's nothing we can do for this person. That would be a really hard thing to have to do, especially in a moment like this. So I think what they did here in this situation actually was probably fine, given that everything's being kept at a BLS level. And they had enough resources mostly to do that. I probably want to move the monitor, but yeah, that's yeah. Yeah. And you made a point here that sometimes it could be really hard to really determine if there's a pulse, especially if you're, you know, your own part is beating. Right. And they said that you, you know, you can use the stethoscope and listen for heart tones because if they're dead, they're probably will not be heart tones. And then you can, yeah. If you have caveat, if you have experience listening to heart tones and you are good at finding them, this is helpful. If you do not, do not try to figure out how to listen to heart tones when you're confirming if someone's dead or alive. It's a bad thing. Okay. Fair point. Yep. Are not. I think heart tones are useful, but we are bad at identifying lung sounds and we train to identify lung sounds. The problem with heart tones, not doesn't come from a clinical perspective, from a clinical perspective, it's actually fine actually. So that, well, it's not fine. It actually does have some issues. So heart tones can be present without a pulse. P.E.A. can make a heart tone. So if you have a heart that is moving, but for whatever reason, you lack volume to actually generate a pulse, a heart tone will tell you there's a pull or a heart tone will tell you the heart is moving. So you have to make that that differentiation there is that just because you have heart tones, just not mean your patient has a pulse. What it does mean, like Spencer says, if you do not have have heart tones, you're doing a lot of two things. You either don't know how to listen to heart tones or the patient's dead. - Yep. - And that is where my problem lies. It isn't clinically, clinically it's sound, operationally it isn't, because unless you train on listening to heart tones and you know exactly what you're listening for and you're listening in the right spot and you're good at it, what you're saying here, the only time heart tones has value, has actual value in a code is in their absence, right? Now guys, if I hear heart tones, it doesn't tell me anything. It just tells me the heart's moving. It doesn't tell me if there's a pulse or not. It doesn't tell me to stop or continue CPR. It's useless if you hear them. It's only useful if you don't. And that's what I don't like about heart tones in confirming codes is what you're saying is I have to be absolutely positive that the silence I'm hearing is because they are dead, dead, dead. And at that point, I'm gonna ask you another question. What is the difference between heart tones? - Heart tones. - Yes. - Heart tones. What is the difference between heart tones and anything you see on the ECG? - Dairy queen. - Dairy queen, exactly. So that is why I don't like heart tones is because heart tones as if you hear heart tones and you have PEA, then you have PEA. Just use the monitor. So that's my problem with heart tones is that there isn't anything we don't already have access to in the field that doesn't do the exact same thing as heart tones does. - Yeah. - So I've heard this, I've heard this argument before, it's out there, that's the reason I want to bring it up. With further record, cues of phenomenal clinician and if anybody was to have a set the scope and tone, there's no heart tones that I would trust, it's Q. So I don't, coming from Q? Yes, but I want Q to know that not everyone's as good as you are. And so we have other tools that are available that it's gonna give us the same information that's more accessible to more people if you're not Q. So that's my statement on heart tones. - It's a good statement. - It's kind of, it's like taking a temperature. - Mm. (laughing) - I just thought that's a talk with you, man. - By the way, I did do a deep dive into, I was like, okay, let's see, what is the sensitivity and specificity? So a temperature is highly specific, right? It's in the high 90s for at least an infectious process. - Sure. - The sensitivity is probably in like the 30s. - Yes. - Which is not great. - Yeah. Anyway, thanks for listening again to Blah. Thanks for listening to yet another episode of EMS 2020. If you're listening to this on our Can You Get Education Platform, get ready for the quiz. If not, check out our Can You Get Education Platform on emes20.com again, $39 a year, then never have to worry about your can you get education. Again, outside of, of course, you require certifications that are like for American Heart Association or whatever your agency tells you that you need. 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