Special Edition: I Have Better Things To Do

- All right, man, you and I are both gonna get right into it 'cause we are on a bit of a time budget, both of us, but we're gonna get it done 'cause we are dedicated to this show. So yeah, so here we go. We're really into it. (upbeat music) - This is a special edition of EMS 2020, in which we will take scenarios that are provided by the Master of Eormatics 100 patients, scenario books, and its add-ons. These scenarios are gonna provide the cake while we add some frosting. The protocols we used to navigate these scenarios may not be your protocols. As such, this podcast does not replace information or direction from your medical director agency or any certifying or licensing body, any state or really anyone at all. We're just two random guys who found love the internet. On EMS 2020. - Hey, everybody, welcome to another Master of EMS 2020. Yeah, so like we kinda say in the awkward disclaimer that is a part of these specialitions, their Spencer is gonna get a scenario today. It's gonna be a hard one, buddy. It's gonna suck. - Oh, good. - Sorry, kinda stuff, really. And you can go to our Instagram at EMS 2020 show and rate him zero being, he totally screws it up. Like this patient dies as a direct result of either his care, his terrible jokes or his looks. - Or I hate Dutch brothers in Arizona, ST, I see fuckers out there. - Yeah, yeah, exactly. That's another good reason to give him zero. Also, you give him a one. A one is where he does exactly what he's supposed to do. The classic example we give is he recognizes chest pain as a stemmy, does 12 leads, transmits, boom, gets through the hospital, hits, you know, all the appropriate interventions. A two is a one performance plus a little extra. So let's say he, let's go back to that stemmy call. And he does the whole stemmy thing and also decides to do serial 12 leads because as we know from our very own wonderful Spencer Oliver that a 12 lead is just a single frame in a motion picture. And you need as many frames as you can get, or I don't need them, but they help. Okay, they're extra. Another way to get a two would be to do a one job in an environment that makes that difficult like if there's crowd control, if it's in some austereal locations like on an airplane where your buddy just turns around and Satan says, you're turned to the emergency, when they ask if there's any emergency personnel on board. We'll kind of monster with you such a thing. Story. I don't know. Some animal, but anyway, so with that, Spencer, are you ready? No, but here I am. So let's make it happen. But here you are on our set of time budget or our crap time budget. All right, so Spencer, you are a paramedic. And your partner today is gonna depend on the dice roll. Oh, that's everything. We use dice. So yeah, what the dice basically, it's the luck value. So anything I decide, I can make it dependent on what he rolls on a 20-sided dice and I can make the values mean whatever I want them to mean at any time. And he can do things to mitigate, you know, like I'll say it's an intubation and we're gonna roll to see how well it goes. If he prepared himself and pre-actionate is patient and resuscitated before he intubated, then yeah, things might go better. But if he doesn't, things might go worse. And so today his partner is gonna be determined by the dice roll. Now I'll tell you this. We use the, I like to divide it up into quarters sometimes, like we both like to do that. So let's say, you know, Spencer, if you get that one to four or one to five rather, that's gonna net you a supervisor as a partner. Oh no. The angriest, grumpiest supervisor that is just, it's one of those who has a job just because they're loyal and that's it. Right, you know, it's like, oh my God, retire already. That's gonna be your partner. Hell yeah. Okay. If you get a six to a 10, you're gonna get a green EMT, okay? All right. If you get a, let's do an 11 to a 15. I got you. A brain, a brain prose. If you get an 11 to a 15, then you're gonna get a green, they're gonna get an experienced EMT. All right. Anything above that, you'll get an experienced paramedic partner. Let's do it. Okay, are you ready? Yes. All right, look at the dice roll. It is a three. Oh man. So you're gonna get that loyal, but they are a paramedic. They are a paramedic. Okay. They can be that. Yeah. It just doesn't matter. And you know it. All right. So what it is is you come into that morning, you're on your way into work. The one good thing that you did have going for you is that you stopped off at your favorite coffee store and got your favorite cup of coffee to start with. I will give you that. Okay. However, you go in there and you notice that your partner that you're used to isn't there 'cause normally they have the rig checked out. Supervisor comes out and says, "Hey, Steve, right?" Yep. Yeah, you've been working here like what? Six, seven years, right? Anyway, Steve Oliver or Oliver Steve, whatever your name is, Steven. Your partner called out six. Susan's not gonna make it. So you're gonna work with me today. Yeah. All right, I'm gonna text Susan and go like WTF and just that's it. Yeah. All right, let's see what Susan's text is. Yeah, please. You got a one. Just in what it means is a little notification that says red shows up and then no response. That's it. Yep, yep, absolutely. All right, well, thank you, Susan. All right, go on, sorry. Your Supervisor comes back and says, "The one good thing you're gonna get out of the day is that he gave himself one of the longer cabs so you don't have to be in a short cab ambulance at least today of all the ambulance. This tracks." You're getting the nicer out of the room. Yeah, this tracks. But that's it. You guys proceed to start to walk out to your rig and the Supervisor says, "And I wanna make note, you have not checked the rig out. Obviously you just rolled in and you don't know if anybody else has yet either." And Supervisor comes out and says, "Hey, we gotta go on the air. Low levels." Okay, let's just make sure that we have all the equipment that we need to at least run on call. It's good, man. It just came back, Ray Mund had it. He brought it in. He's a good dude. It just came back. VSC checked out. It's fine. We gotta get on the air, man. I feel like this is a trap, but here we go. All right, you know what? I'm in a fucking mood. Let's fucking burn this place down. Let's go. Yeah, let's go. Let's go. All right, cool. All right, so you hop in. I'm so excited. Hey, can you drive? I got some stuff. Can you drive? I got some stuff. I gotta work on. Absolutely, I can drive. He needs to pull out his phone and play what appears to be Candy Crush on your way to post. On your way to post? You get a sign. You're on levels. We're not on a call. Yeah. Yeah, cause you're low levels, right? So this badge comes on. They said, hey, you're gonna head out to a post seven, which you recognize as a post that's busy, but not busy for any other reason than that is in the middle of a town that has a high concentration of retirement facilities. Okay. Yeah. And you're starting your seven o'clock at 7 p.m. night shift start. Oh. Yeah. All right. Some p.m. Also happens to be the time where there's a lot of shift change at these facilities. I just want to make sure that like I do the like, you know, like, is I'm turning, I look back just to make sure that there's a stretcher. Cause that, that may or may not have been a thing. I think if you get above a five, you get a stretcher and you got a 10. There you go. All right. Yeah. Yeah. You have a stretcher that's made. Actually, hang on. We're going to do another mystery rule that will come to play later. And I'm just going to tell you, you're going to want to get above a 10 for this one. Hmm. Hmm. Okay. It'll be in play later. All right. It's not that wild. But anyway, all right. So you guys are headed down the post. You almost get the postman dispatch comes on and says unit six units. I did the dice. Unit six code three to honey basket nursing facility for a sick person address is 1112 47th avenue. Yeah. It's going to be ambulance only. Okay. And you recognize it. It's about eight minutes away. You light them up and your supervisor's partner goes, you know where it is right? You've been there before. I guess I do a history check. Let's see. Let's do this. Do I know this one? You got to get above a 10. All right. Do you have been there before? You got a 12. Okay. Yeah. No, I like the back of my hand. Fuck is that on the back of my head? Anyway. All right. So you go lights and sirens. You arrive. This is ambulance only. Now I want to make you kind of a little bit more aware of your agency as you drive in. You are a private ambulance company. If that wasn't obvious. And you have ALS fire, which could be anywhere from one. to a full four paramedics. - Wow. - On the ambulance. Typically, you can expect one paramedic and three basics with a, sorry, not ambulance, but with a fire department. It is fairly busy evening. You do know that from the ramblings of your supervisor. So your fire response may be modified, 'cause sometimes even when the fire systems gets busy, if you request fire, you may get like a brush rig with two people on it, those kind of things, or a medic unit that they have, those kind of things. So there's a number of things that could happen, but we will see. All right, so. - So on the way here, I'm sure I would have gotten more dispatch notes other than code three, sick person. There would have been some kind of feedback, I assume. - All right, your read back is you are responding to an 87, your old, 70, sorry, 77, your old female patient. Patient is just listed as sick. They're gonna be in room, apartment number 26A. That's the information you have. - Oh, and the caller is not with the patient. That's the other info you have. - All right. Okay. Gotcha. - All right, you walk through the front door and you have somebody sitting at the desk. They are expecting you, and they're even holding a packet as you walk in, but they're not getting up from the desk. - All right. - Oh, and what do you wanna bring in with you? I should start there. - So we'll bring in all the stuff. Stretcher, first in kits, and oxygen tank, and yeah, 'cause who knows what this is. Yeah. - Gotcha. Okay, so you have everything on there and you're putting it onto a stretcher. - Yes. - Okay, I like it. All right. And then you approach the front desk, you hands you your packet. - Awesome. All right, what's the name on the packet? - Isabelle Cumberland. - Okay. By the way, if there happens to be a real Isabelle Cumberland that I made up nursing home, I apologize. - Okay, I'm just imagining a bunch of old folks sitting around doing a puzzle listening to EMS 2020. She's like, what? It's not me. - All right, but yeah, it's Isabelle Cumberland. - Okay, cool. So I will look for signs that indicate which direction to go. Like, you know, is there a, hey, apartments one through 50 to the left, to the left? - No, unfortunately you have one sign that says, this way to the East Wing and other sign says that way to the West Wing. - Okay. So I'll ask the person, hey, I'm looking for apartment 26A, which direction do I need to go? - Oh yeah, 26A, so what you're gonna do, you're gonna go to the East Wing. You're gonna go down the hallway, take your second right. You're gonna take the elevators up to the second floor, take a left out of the elevators and you'll be there. - All right, East Wing, second right, up the elevators to the second floor, and then what was the next instruction? - I'd take a left out of the elevators and it'll be right there. - Okay. - We will do that. All right. - So you do that and you also notice that one thing is really nice about the facility is they have the apartment numbers, but they also have the names of the patients on the apartment numbers. - Perfect, so I'm gonna make sure they match. - And they do. - Yay. All right, so we'll knock on the door. - Okay, knock on the door and it opens up and it inspired this patch earlier, telling you that the caller was not with the patient, which may be true, there is at least somebody with the patient. - I would assume so. - You have someone who answers. - Yeah. - But, - Well, there was a person with a packet, ready. - Yeah, that's true, that could have been the person who's supposed to be with the patient, you don't know. - Let's go. - Fair point, fair point. - All right, so, this person answers the door and says, "Hey guys, come on in." - Okay, like vampires, we enter. - We were invited in. - Okay. - You have to be invited in. - Yeah. - All right, so you enter the room and you come in, you feel like the room is a little bit warm, a little bit toasty, which may not be too abnormal considering, you know, it is a-- - 77-year-old. - Yep. - Yeah, right, they're always hot. And in the back, you see a lady who is sitting in her chair. She looks up and sees you coming in, doesn't really say anything and she just looks miserable. You know, that looked, that just like, yeah, looks miserable. Maybe a little bit pale, but just kind of like, stanchors kind of slumped over. Maybe you detect what might be, labored breathing, it's either labored breathing or just kind of maybe like that heavy breathing or like, I don't want to throw up breathing, but you're not really sure, but the breathing's a bit lair. - Okay. - Yeah, that's kind of what you see. - Okay, how big of a person are we dealing with height and weight? - She is five foot one, she's shorter, and I'm gonna say that she's about a hundred pounds. So let's do, that makes her 155 centimeters. 45 kilos. - Nice. - Okay. So I am going to ask my partner to go over and get an initial set of vitals. I'm gonna talk to the person who invited us in and see if I can get kind of a quick rundown of what's going on. - Okay, so your partner kind of looks at you. You look back at your partner and you realize he's been on his phone texting on, well, looks like the supervisor phone and he goes, what's up? Would you be able to go grab vitals for me? I'm gonna talk to this person and see if I can get a rundown. - Yeah, sorry about that. I just got caught up with stuff. Yeah, I'll go get some vitals. - Excellent. - So he meanders over there. - Sweet. - Hey, man, I'm gonna check your vitals signs real quick. - I love it. - All right, so you start talking to the med aid. Her name is Reina. And she says, hey, I'm a seeker. - Okay. - And I was coming up here to help, just kind of check on her and give her medications and whatnot. She's actually been not feeling well for a couple days. We've got something going around the facility. We've had a few people with pneumonia or like flu-like symptoms. And so she had kind of started getting ill a couple days ago, went and saw the doc and they sent her back. I don't know if she got a flu test or what happened there. But they went ahead, they sent her back with an antibiotic and came up today, found her dinners here. It's just like cold. Like, you know, she just looks like she made food but then like didn't want to eat it. Yeah, and she just seems like just tired and just like does not seem well at all. And she looks pretty pale to me. So we call her doctor and her doctor said to call you guys. - Okay. Yeah. Gotcha. So Chris, I'm assuming here that this is not like a skilled nursing facility. This is like an assisted living kind of a place. - They have a skilled side. - Okay. But this is not the skilled side. - So she's able to make her normally able to make like her own food and whatnot. I'm going to ask this. I'm going to ask the CNA while I concurrently like start kind of digging through the paperwork about past medical problems. Just to make like what is baseline because you know, just because they live on assisted living side doesn't mean they're not like they don't have some amount of dementia. - Yeah. And one of the things that I will also add is this is one of those facilities that has an assisted living side that people frequently transfer from that side to the more skilled side. So or to where more assisted assistance is required. So anyway, that's a thing here. But anyway, what's your question? So basically like, hey, what's baseline for her in terms of like mental status as she have dementia? - Oh, yeah, I see what she's saying. No, like she's pretty with it. I mean, she gets a little confused here or there, but I don't think she has dementia. But you know, like yeah, she seems with it. She's normally able to answer questions about herself and all that stuff just why. - So does she make her own medical decisions? - She, her daughter makes a lot of them, but she also makes them. Her daughter's not a power of attorney, if that's perfect. - Gotcha. And does she have a post form or advanced directives? - Yeah, she does. - Okay, perfect. I'll snag those and take a look at that. - Perfect. And when you snag that, you also notice that there is a med list attached to it as well. - Yes, this is so great. - And an hour to use this. - All right. The trick here is to make sure they're up to date. 'Cause. - Yeah, yeah. That's very true. All right. And did you ask what was on the post form? Okay. You have DNR, but full treatment. - Okay. - So section A says DNR, so basically if you find her, if found without a pulse and not breathing, do not resuscitate, otherwise go the full gamut. - Let me take a glance at that med list. Okay. On the med list, you have a number of vitamins and like multivitamins and those kinds of things, but you have Sennah. - Okay. - You have Tylenol with, um, Cody minute. Okay. You have aspirin and you have a tenelol. Okay. Yeah. Uh, this, this makes sense. Uh, I don't see the antibiotic. So I take a look through the paperwork. Um, just to see if there's an up more up to date med list than the paperwork. Gotcha. You're not able to find any additional meds or the antibiotic in there. Okay. I'm going to ask the CNA. Hey, do you said that she was prescribed an antibiotic? Do you happen to have that antibiotic? Or do you know where that would be? I can look for it. Um, I'm not sure where it is. Uh, so her daily medication she keeps here, anything else would be kept in the nurse's station. It should be on the paperwork. Yeah, I don't see it in here. Um, oh, yeah, I don't know. Okay. Well, we'll figure that out. Yeah. All right. So, uh, at this point, I would probably check in with my partner because I had assumed that he would have a full set of vitals. Uh, all right. So you look over there and you see that your partner has the, uh, pulse oxon, uh, and the blood pressure cuff is over the top of the patient's sweater. Uh, and so you have a, uh, you have an S P O 2, uh, reading, uh, it looks like it looks like a pretty poor plethora and it says, uh, 84%. Uh, he sees you looking over. He says, hey, look, the plethora is really bad. I can't get it to read. I don't, I don't think it's actually 84% is probably bullshit. Uh, heart rate, uh, is coming on, coming off, coming on, coming off because, again, the plethora is pretty poor. Um, but it looks like when the plethora is briefly good, it looks to be about 112. Uh, and the blood pressure cuff says 172 over 155. Yeah. I like all those numbers. I mean, honestly, yeah. Um, yeah. Okay. So, uh, I would say, uh, okay, let's see if we can get a different pulse ox, like a, maybe a sticker on, um, if we have, you know, a, uh, ear probe, maybe a near probe would work better, uh, and then in terms of the blood pressure, I'm gonna say, hey, you know, ma'am, uh, uh, is it all my name Spencer or, excuse me, my name is Steve. Uh, uh, uh, and, uh, we're gonna have to take your jacket off so that we can check your blood pressure because the number that we're getting isn't, uh, isn't, I'm not wearing a jacket. I'm wearing a sweater. You know what? I'm so glad you corrected me. I make that mistake all the time. Uh, we'll take your sweater off. Yeah. You see Verizon partner goes, uh, it is just first in the job, ma'am, hey, this being annoying is fuck. I love it. I love it. Yeah. All right. He's being addicted to you because he didn't do the thing because you're trying to do the thing he should have done the first place. You know what? I'll take it. Just, yeah, you know what? As slow as we're getting the blood pressure, if that doesn't work, then I'd just say like, how about you just oscultate one or get one by palp? You know, that's fine. Um, I would go over to the patient's, uh, other side, uh, since he's working. So, oh, go on. Really? Do you want me to go ahead and try and take the sweater off? Uh, yeah. Okay. Sorry. I just, uh, I wasn't sure if you wanted me to do that if you wanted to try palp and are also tating. No, uh, or are you saying if taking the sweater off and then it still doesn't? Exactly. Okay. I'm an idiot. Yes. I understand. For a few days, I'm a guy. Yeah. Is idiot. All right. So what I would like to do is I would like to go kind of kneel on the other side and start having a conversation with Isabelle. Um, and, and, uh, while I'm doing that, I would like to try and feel for a radial pulse. Um, uh, uh, so let me get the radial pulse and then we'll have that conversation that I'm doing simultaneously. Yeah. Sure. So you had a radial pulse, uh, and it feels, it feels to be a slightly, slightly tacky. So the 112 kind of makes sense with that. Um, and you know, it's a pretty weak radial pulse. Like you had to sit there for a while. You're like, she has a watch on you, keep moving it around, you know, to try and feel it for a while. Yeah. It's weak enough to where you're like, is this my pulse or her pulse? Okay. Uh, so yeah, but it's a pretty weak pulse. All right, sweet. I'll underline week. All right. So the conversation that I have with her is, Hayes Bell, uh, again, my name's Steve. Hey, I heard from Reina that you haven't been feeling good for a couple of days that you went to the hospital and and got an antibiotic. Um, and I went to my doctor's office. You want to, yeah, you went to your doctor's office and got an antibiotic. Do you know what antibiotic they prescribed you? I don't know. Do you know where it was where we can just find the bottle? I, well, that, I don't keep it in my room. They bring it to, oh, they bring it to you. Okay. Okay. Did you start that like within like the last few days? Have you been on it for a day or two or has, I started the first day. Sorry, it's got catch right breath. I started it the first day. Oh, by the way, if it's not we're wearing masks by the way, I think a chunk for one day. Anyway, I started it the first day after my doctor's appointment. So, and then Reina interrupts. She goes, day before yesterday, I'm sorry. I don't know why we can't find it right now. I, but she started it. It'd be the day before yesterday because she went to the doctor's office three days ago. Okay. Gotcha. All right. Okay. So you've been taking it day. Did it help at all? No, I just been getting worse. Okay. Nothing's better. Okay. So I am going to put her on a couple liters of oxygen on a, well, do an entitled cannula and I'll bump it up to four. And I'm also going to listen to her lungs. You kind of have, you have bilateral crackles, kind of the rouse. Yeah. In each and all throughout. You do notice that it's a bit louder on the left side, but you have it on both sides. Okay. Just then you've noticed that her sweater is now off. The auto cuff is going and your supervisor partner has switched to one of the ear probes. It's an actual ear probe. It's not just like a finger normal stick probe taped on. It's actually clipped on. Okay. Sweet. And are we getting a reading with that? You are actually with a fairly decent pletht wave. And it comes back at 86% but climbing since you just started the oxygen. So 86, 87. Okay. We will keep an eye on that. Did the, with the blood pressure cycling, do we get a reading or is it still cycling? It's okay. So I'll take this up. It's a student thing where it's cycling and then taking like really slow and then like pumping up again. I hate that. Okay. So I'm going to take this opportunity to check in with Isabelle and see what her, what is bothering her the most right now? I just feel sick. You know, just like I feel like my lungs don't feel like they're getting any better, you know, like I feel like I'm just really just like I feel I feel lower than a bow-legged caterpillar. This is the greatest patient ever. Isabelle, I'm going to need you to marry me. Oh my. Yeah. Okay. Gotcha. Are you having any chest pain? No, not really chest pain. Just kind of my chest feels like full like I like my lungs just feel full. Yeah, I don't know. Like a tightness. I've been coughing a lot and whenever I cough it hurts my ribs. Okay. Gotcha. All right. So cough. I'll say chest tightness. And then you're short of breath. Are you nauseated? Yeah. Yeah. I just feel like I'm really having to work for it. Okay. Are you feeling nauseated? Not really. I mean, maybe I would be if I tried to eat, but I have no appetite. Okay. All right. And this is all just gotten progressively workers. There wasn't a point where you were like, oh, I'm much like suddenly short of breath or suddenly my chest feels really full. This is all just kind of gotten worse progressively. Yeah. Yeah. This has just been progressively over over the past few days. Okay. Okay. So there's a couple things that I would be thinking about here. So I mean, the most obvious one would be, it's probably pneumonia given that she has a history of getting, taking antibiotics and with her lung sounds. I'm going to ask her though, like, did they diagnose you with a pneumonia? I think they did. Yeah. Okay. Do you have any paperwork from the, from that hospital visit or the doctor visit? I don't know. dear, maybe I'm not sure. Ask Reina if anyone had it, they would have it. And I would turn back to Reina and say, Reina, do you know? She gives you that kind of look. Reina, it's totally understandable if you don't have it. Can you go check with like whoever's on duty and see if they have that and see if you can find out what Ainabotic that was? Yeah, yeah, sure. I will go see if there's anything at the nurse's station. I'll be right back. All right. So the other thing that I could be thinking about here that maybe like two things can be wrong at once is the with the chest tightness and the shortness of breath. There could be some kind of cardiac thing going on because your heart really doesn't like it when you're sick and stressed as well. And I'm worried what the blood pressure is going to come back as because it's been a while. Yeah. Did it give off? All right. Blood pressure comes back as 81 over question mark, question mark, question mark. Okay. I've had that before. It's not. I've heard of. Yeah. No, I believe the 81. I also believe that I don't know. It's not great. Could be. So at this point, we would just forego the auto cuff for the time being. And I would say, you know, hey, so Isabel, it sounds like, you know, my concern here is that this pneumonia has progressed to the point where you're really, really sick. And we need to take you to the hospital. And they need to give you IV antibiotics. They might need to support your breathing. And so what I would like to do right now is I would like to move you over to our stretcher. We're going to start a couple IV lines and start giving you some fluid because your blood pressure is pretty low. And we're going to need to get you going pretty quick here. Matt, hey, Steve, levels are kind of there still low. We got to. We got to go. All right. Yeah. We got to go in. So yeah, you know, you already, you just want to stand her up. And then I'll just get a gritty radio. Let's plop her back down on it. We may want to just kind of, we may want to carry her. I worry that she'll syncopate. Hey, man, can you stand? Are you going to stand? What's my supervisor's name? I never asked. Did we give him a name? No, we didn't give him a name. I don't think we did. It's, I want to make it like a super long one that he insists on like no shortcuts. I wasn't going to say a supervisor's name is Zach. Zach, right. Zach, right. Yeah. Yeah, because he'll call him. Zach, right. Zach, right. Zach, let's, let's make sure. Zach, right. No, no, no. Are you, are you Zach, toast intolerant? Then it gives you Zach, yeah, what did it? No, no, no, I totally called you by your, your name. So anyway, Zach, yeah, that's my name. Yeah, it's, am I saying it wrong? You said Zach, yeah, Zach, Raya, no, I said Zach, Raya. You said Zach, Ria, I heard Zach, I, I, I, Steve, it's Steven. All right, whatever, whatever, we just, we got to get going. Okay. I'm gonna get the gurney ready. If you just want to help her stand up. She says you, you stand, right, ma'am? You're good. I mean, I could try. Hey, Zach, Raya, let's just let's just lift her over to the, Steven, let's just lift her over to the, the stretcher. All right. Hey, if you want to get out of here, let's do this the right way. No, it's, I get it. It's, it's fine. It's fine. All right. I'm gonna get the stretch ready. I'll get all the stuff off the stretcher. Okay, take me a second. Well, he's going to do that. I'm gonna go ahead and get her on the monitor because I realize that I've got a heart rate here, but I don't actually have a rhythm, right? Yeah. Well, the heart rate came from the pull socks with the bad plug way. Exactly. Okay. So, yeah, let's, let's try with that. It's just fine. Uh, possible cardiac na. What else? All right. So, uh, I'll put her on our three lead. Okay, perfect. We're on three lead. Uh, you see what appears to be a sinus attack at a rate of about 112 to 116, the occasional PVC floats by, but nothing crazy. Okay. Sweet. All right. Okay. Uh, so with the stretcher nearby, uh, by the way, like looking at the patient, how, how difficult an IV stick is this, is what I anticipate her being? Let's see. Uh, it's going to be, uh, we'll do the, we'll do the third thing again. Like we did last time. Okay. Uh, on the lower third, uh, we'll just do quarters. Lower bed. Yeah. You want higher is all you want. We'll figure it out after all. Okay. Uh, you got a seven. Okay. So I'm going to say you have, uh, veins are easily visible. Um, but they look kind of frail. You know, when they have that, that like, your veins are kind of bulgy, but you definitely don't work out kind of look like why are they like this? Yeah. Yeah. Yeah. Yeah. Okay. Sorry. I had to get my other whiteboard running out of room. Uh, all right. Sweet. So, uh, yeah, with the stretcher nearby, we're just going to gently kind of lift her, we'll go one on each side. She's a hundred pounds. We can do this. Uh, uh, uh, Zach Araya, you got this, buddy. We'll lift her over and set her gently down on the stretcher. Um, and then we, we can fasten all the belts and, uh, has her sat come up with the oxygen? I know it was climbing up. Uh, uh, 80, it's 88% at this point. Okay. Uh, I'm going to throw her on a non-rebrither mask. Um, and, uh, uh, we'll, we'll keep that going up. You want to sit out in the rig? No, let's sit out here because she's 88%. Um, and she's septic. And then we'll get moving. She's probably, she's probably always like that. She probably lives from the extensive med history that you got. Matt, do you feel sort of rough? And she reiterates, well, yes, that's what I've been telling this gentleman here. All right. There you go. This mask is really uncomfortable. Sorry. She gets that non-rebrither. She doesn't care. She's fine. Yeah. She smells like plastic. Oh, it's just turned on both of you. They just dunking on this motherfucker. Like even I'm doing it. I don't have to. It's just, yeah. Yeah. We're just both like fuck this guy anyway. So. All right. All right. So, okay. So, uh, we are, we're, we're going to head out to the, I'm going to give him this. We'll get out to the rig. Uh, but once we're in the rig, I'm going to say, I'm going to tell him, Hey, man, uh, so before we go, we need to get an IV, uh, her blood pressure is apparently 81 over. So you and I have both going to look for IV access. We'll get some fluids started. Uh, and I'm going to, uh, we'll see how the oxygen's doing and see how she's feeling. Uh, so. He says, look, uh, I'm not going to tell you no, I'm just going to throw this out there. Hospital is six, seven minutes away. So know it might, like you just want to try seven years, you just want to try on the way in, because we could just sit on scene and we could take seven minutes to not get one or we could try for the seven minutes from here to the scene. Okay. From here to the hospital. So, uh, and then if we don't get one, then at the seven minutes, we're at the hospital. I'm what I want to know, Chris, is, is the hospital that seven minutes away, even the right hospital for this patient? That's the question to ask. That was your dice roll earlier. Very well done. Well, I'll tell you what, Spencer, let me tell you about that hospital. And then you can tell me if you think it's the right one or not. Okay. Um, so, uh, it is a, it's not technically critical access, but it does not have, um, ICU services. There's no cath lab. There's no, um, yeah, they transfer a lot of stuff out. A big portion of your animals companies business is actually transferring people from that hospital to almost anywhere else. So your call, if the patient can go there or not, um, but okay, what, what is the closest facility with ICU services? It's going to be about 17 minutes, uh, without lights and sirens. Okay. Okay. Uh, so I'm going to tell, uh, uh, Zacharia, uh, Hey, man, Hey, Zachi. Yeah. Uh, yeah, we can't go to that one. Uh, they don't have ICU services. She's going to need it. Blood pressure is 80. Um, no, she needs an antibiotic, man. She needs fluids, antibiotic and fluids and a whole host of stuff. Uh, they've got that there. Yeah. But they, they're going to need to put her like she's going to go on pressers. They're going to need a nice. All right, man. So, all right, let's just go. Okay. Less than Rayna comes back in. All right. And she says, "Hey, I am so sorry about that earlier. Here's the box for the antibiotics. It's a five-day course of it looks like a zithromyocin." And here's her paperwork. I looked over on the way in and they did diagnose her with pneumonia. It looks like it was on the left side. Okay. Okay. All right. Hey, Rayna, thank you so much. Do you want to be my partner for the rest of the day? You'd have to kill your current partner. You would be more helpful. John! Okay. Cool. So, we will head out. This is where I will give my partner. I'll be like, "Hey, man, you're right. Let's head down to the rig and we'll do the IV stuff down there so that we can. " Hey, Steve. Yeah. I know I'm right, but yeah, let's just get going. Okay. Excellent. Okay. So, we head down to the ambulance. And then. As you're loading in. Okay. No, no, no. That's what I was waiting for. Okay. As you're loading into the ambulance, your supervisor's phone rings. Done, done, done, done, done. Yes. I'll take this real quick, man. Once you try the IV back there, I'll be right with you. Answer the phone and turns away from it. Perfect. Because, frankly, I don't want that guy. I don't want him here. Okay. Cool. So, I'm going to turn on lights. I'm going to get another set of vitals here. And I'm just going to osculate a blood pressure. And then set out my IV fluid, so LR, leader bag, the IV catheters, 18 through 22, because I'm not doing a 24 and I'm not doing above an 18. So, yeah. Another sick call. Are you serious? Anyways. So, sorry. You said it. So, you got a bunch of IVs. Yeah. Okay. Perfect. You're lighting in the ambulance is adequate. It's good. There's no light bulbs burnt out or anything like that. What? Sounds like you're pretty well prepared. Yeah. Tell me about your actual IV start technique. What are you going to look for? Yeah. What was the blood pressure coming through that part? Blood pressure reading that I got prior to this, because I osculated one before getting out the IV stuff. Oh. Of course you did. I'm sorry about that. You osculated one and you got it at 77 over 56. Okay. 77, man. I'm good. That's pretty good. Yeah. That doesn't quite feel like a 78 number. I'll ball. Let's see. Okay. 78. If you asked your partner to do it, it was definitely going to be 120 over 8. I would know. Okay. Cool. So what I would do is I would get a constricting band around the patient's upper arm. We'll just kind of take a look and see what pops up. Hey. All right. You see your best site. You see a couple decent sites. It looks like your best one's going to be in AC, but you also see the intern vein pop up as well. Well, I'm going to try for the AC and given the role earlier, my evaluation earlier as a seven, I would probably go with a 20 gauge catheter because seems good enough. Good. All right. The vein appears to support. I mean, it looks like it would support a 20. Perfect. So what I would do is I'd let her know that we're going to do that. We're going to start an IV there. I've got all my vani guard stuff out to secure it. I've got a short line flushed and ready to attach to the IV catheter. We'll pull, we'll clean it with an alcohol prep. We'll pull traction to really kind of stabilize that vein and then we're going in. All right. So I was going to make it a six or lower and you would get it because the six is what you rolled for the IV check earlier. But with your extra steps and your preparedness, I'm going to save 10. Okay. If you get higher than the difficulty threshold is 10. Why am I so backwards? I was like, you said six or lower and I was like, yeah, that sounds successful. Yeah, no, no, no. What you have to do is you have to roll lower than a six. Does that make sense? So we're in vertical. Oh, okay, gotcha. Yeah. Yeah. So you have to roll lower than a six because a six was the difficulty level you got. But now you just have to roll lower than a 10. Yeah, you, okay, you threw me for a loop there. Lower would be better. Gotcha. I threw me for a loop when I was better. So lower than a 10. Yeah, well, I figured because I was kind of with that like that you hold. I like that. You know what I mean? Yeah. So here we go. You got eight nine. I did get it. Perfect. You get the line. Just then you hear the door shut. You're welcome. Not ready to go. Oh, this motherfucker. And then without waiting for a response, he puts it in drive. Okay. Yeah. I mean, all right, fine. I got the IV before we started moving. I'm going to connect it to that leader bag. And I'm going to, with an honorary breather, what's her, what are, what are, what are, what did her O2 sets come up to? About 92%. Okay. Uh, and three leads still the same. One 12, one 16. Yeah, that is not changed. Okay. You know, so you started to cough it really hard again. Okay. I'm going to grab out a, a, a, a, a MSS bag, because sometimes coughing leads to vomit and sometimes coughing leads to coughing stuff up that might be interesting to look at. So, uh, I'm going to ask her like, hey, have you been coughing up any like blood toned sputum? Any, you know, like anything colorful? Or has it just been, you know, clear? Well, today it's been a lot of coughing that just feels chunky, you know, like I feel like there's a lot of mucus, but I've not seen anything come up. But before today, there's a lot of stuff coming up. So I don't know if that's getting better or what that means. Okay. But yeah, but everything else about this feels worse. Um, well, I'm, well, I'm kind of at her side. I would also check for like her skin, uh, touger, you know, they, uh, like see how kind of dehydrated she is. Um, yeah, yeah, yeah, yeah. Kind of things, if a tense, uh, it tense so badly it could be sold at Bass Pro Shops. So it's pretty pretty. Yeah, Zachariah. Let's stop by a Cabela's. Sullivan. Sullivan's second. Yeah, dead. All right. Uh, okay. Oh boy. Come on, Spencer, focus. We're out of time with it. Okay. Yeah. So we're doing great, man. We're going to get the, we're going to get the fluid going in her. Um, I'm going to also, do we carry a Norpinephrine, uh, or, okay, perfect. Uh, so I'm going to, the, the pressures you have available to you is going to be Norpinephrine and Norpinephrine. That's pretty much what you carry. You don't carry any of the D words. You don't carry, uh, base of present. Okay. Perfect. Uh, so I would get a Norpinephrine infusion. If it's not mixed, I would mix one. Um, and do we carry an infusion pump or is this a like 60 drop set system? Oh, let's find out. Yeah. Get above a 10. 10's been central. Oh, you got 12 again. Wow. Uh, you think got nothing really good this entire time. Got a few bad ones where it didn't matter, but then you've just been hitting like that center run to the point that I'm going for. That's what I'm going for, baby. Just a nice, right. You know what? Right down the middle. Good enough. Uh, that's what it is. Yeah. So you, so you are indeed right down the middle at this point. Okay. And you've got, um, what do we? Yes. A pump. Okay. Yes. You have a pump. Okay. So, all right. Yeah. I want to get that programmed and it's not pre-programmed. Okay. That's fine. So you still have to do the M.L.s an hour. Okay. I can do the, uh, I can use the calc mode on it. Yeah. Yeah. Yeah. I mean, you saw it, but you have to punch in all the stuff. Yeah. So actually, no. It's some super obscure brand that they got off T-Moo. Hell yeah. And all it does is M.L.s an hour. You just, that's all you can punch in. You can't put in like your four milligrams and two, five, six, so I use the M.L.s an hour. Let me do some math. I know you're good at this part. Right? Sure. Did you do a class in Nebraska that was all about bed math? Uh, yeah. And in Oregon. Uh, and I teach it because I can't ever remember it. And so I hope that when I teach it, it sticks. Um, it's going a long way. You'll notice. The fridge. Tell us how much are you mixing into one? Okay, so it's four milligrams into 250 mills that makes six you don't carry a 250 mother fat. What do I carry? You have a 500 back. Okay. Do I have eight milligrams? You have two four milligrams vibes. Perfect. Let's do that eight milligrams in 500 mills that makes 16 micrograms per mill liter. So what I would plug in then to get a starting dose of four micrograms a minute would be 15 mills an hour. Okay, 15 hours for four micrograms. Yeah. Okay, perfect. You confident in that? Yeah. Probably. Okay, yeah. It's crazy. Alright, so yeah, because let's see, let's just do it real quick. I got a little bit of it. So 50 because you're at 16 mics, you're gonna be at 16 mics a minute. So 15 times 16 and then divide that by 60 and that's four. So nailed it. Yes. Okay. Good job. Alright, so are you starting that or just prepping it right now? Let's I want to see how she responds to the fluids. Well, well, we're here. I would also with that ready, I would do a 12 lead just to make sure that we're not missing anything crazy. Yeah, 12 lead. So it's sinus attack. It appears to be a little bit low amplitude. Okay, I'm learning that it's sinus attack with the occasional PVC bop and by you don't have any ST elevation or superhold depression or depression. Okay, perfect. And then yeah, let's wait five minutes and cycle another blood pressure. And I want to see what they're all probably. I will cycle another blood pressure. I'll read, listen to long sounds and I'll see what our O2 sets are doing and go from there. Sure. Tell me a little bit more about your fluid bolus. How much? How fast? I so I'd aim for a 500 mill bolus to start with. Okay. And then just kind of see where she's at. Got you, got you. So we're trying to get 500 mills in before the next blood pressure. Ideally, but it's, you know, it's fluid dependent. So yeah, well, so I mean, you should be able to get that right. It doesn't seem too wild to me. Alright, so 500 mills goes in. Five minutes goes by. You check your blood pressure. And I'm going to say it's up to 84 over 61 on the auto cuff this time and actually worked. Okay. Okay. What's her O2 set? I'll do saturation's remained at 92%. Okay. Okay. I'm going to go ahead and start the, I'm going to start the leave of that. Her blood pressure barely went up with the 500. And so I'll get the, I'll keep the fluid going in because she'll still need fluid. But we'll, we'll start that to leave a fed as well. Okay. And lung sounds are in changing. Yes, about those. They haven't changed. I'll also check up blood sugar. Alright. Because she hasn't eaten in some amount of time. Perfect. Blood sugar comes to 84, which in millimoles is 4.6. Sweet. Okay. Sweet. So yeah, it'll be essentially just cycling blood pressures and seeing how she's responding to interventions. Hey, man, your hospital's down to. Okay. How far are you from the hospital? 10 minutes. Okay. So what is the name of this hospital? The name of all the doctors and all the nurses. How do you like it? Yeah. It is. St. Bartholomew's hospital. And if you call it St. Bartholomew, it's St. Bartholomew. Yeah. Yeah. I cannot spell Bartholomew by the way. It's just, that's your whole scenario. Okay. St. Bartholomew, this is Medics 6. Alright. Medics 6. Go ahead. Well, St. Bartholomew. This is Medics 6. We are in route to you. ETA 10 minutes. I've got a 77 year old female. She was diagnosed with pneumonia about three days ago, prescribed on antibiotics. She's been taking the antibiotics, but she has just gotten progressively worse. This is a sepsis alert. Patients last blood pressure was 84 over 61. She is 92 percent on a non-rebreeder. Heart rate is 112 to 116 sinus attack. We do have fluids going. We also have her on four micrograms a minute of leave a fed. And, yeah, we'll be there soon. Any questions? Are you aware we're on divert? No, there's no questions. I'm kidding. I've bad news. It's just super-finishable loses as shit. Next hospital's half an hour away. Alright. Perfect. I said, no questions. Okay. Alright. So, Spence, tell me your general strategy over the next 10 minutes. We're in a wrap. Okay. My general strategy would be, at least let's keep a balance of oxygenation and blood pressure. So, my big fear is that her oxygenation will decrease that fluid will, you know, third space into her lungs. And so I want her blood pressure high enough that I could put her on a CPAP if that happened. But essentially it's together blood pressure up and, yeah, support circulation and breathing. Okay. Alright. So, how would you keep her blood pressure? Tell me, how would you do, what are your tools your mechanism by which you keep her blood pressure? You said fluid and the leave a fed. So I could titrate the leave a fed up to eight micrograms a minute, 12, 16, 32 height. Go see, yeah. See, how super bowl. That's as close to home 10 pictures all over. Alright. Alright. Yeah. So, okay. Great. That's. I'm sorry. I'm boring you. No, no, no, no, you're all good. So, yeah. I mean, that, what? So, Spencer, tell me what's going on with this lady. I mean, you kind of just said it in your in your report, but yeah, she's in a, she's in septic shock. And she needs a nice you. Gotcha. Yeah. And she does. So let's kind of talk a little bit about like kind of what made her sort of obvious, obvious sepsis. And we're going to talk a little bit about history, which is kind of a big thing. So when it comes to clearing somebody's sepsis, it's not just that they have the vital signs of sepidcemia, which is going to be of septic shock, which is going to be hypotension, tachycardia, tichypnea, and a low end title value. Sometimes they can be altered as well. But you also want to find a mechanism through which they could have an infection. You know, in this case, hers is pretty clear. It's she was diagnosed with pneumonia a few days ago. She went with pneumonia. But there are some caveats. And we've done calls like this. I think I've done scenarios like this before where one of these we have to watch out for in these patients with this with these pneumonia kind of sounds is that they could also be pulmonary edema. It could be both of these things. And so that was what Spencer was doing. So the big issue you can kind of run into on these patients is that they are both on one hand, you need to give them fluid. But on the other hand, you don't want to give them so much fluid and have it wind up in their lungs. Should there be some sort of associated heart failure with this? Yep. You know, so you really kind of run the risk. And that's why making that line between heart failure and pneumonia is really is really important. And the past thing I've done a scenario where it ended up being heart failure. I don't know why I keep coming back to this bag all the time. But it's going to be really good at this call. But why does it get a temperature, man? It's on my it's on my to-do list. Extra points from me, actually. No, no, no, no. I think it's fine not getting a temperature in this case. That being said, I for all the ranting I do about temperatures, I'm not saying that they are unimportant. And I'll I'll take my claim that as as something to track the progression of this patient's infection, it's great. That's something the guy treatment, it's not, which is why for EMS, I should be clear about that for EMS. Because if they have all the signs of being septic, but they don't have a fever, you still treat them like they're septic, they do have a fever, you just say, okay, I guess I'm still treating them like they're septic. It's important for the ER to know, especially when you're going to be trending, the progress of somebody's infection, but as far as our treatment in the field, something you can say for later. So when we get it, one thing that you asked for indirectly and I failed to give it, so this is more on me than it is on you, you said you're going to put an entitlement as a cannula on and then I just didn't give you the values and you never asked for Restory Rate or Entitle after that. - Oh yeah. - So, yeah, so, but in the real world, you would put that on and there they would be. And so when you do things like that, I try and give you those values. So I'm going to own that one because that'd be kind of like, like yeah, I would go ahead and put the blood pressure or the auto cuff on and hit the button and then me just being like, - But you never asked for the number. - Not saying anything. You didn't ask, you didn't tell me that your eyes looked at the monitor after it got done. - Yeah, that's bullshit. So that's on me. But the fact that you were looking for that side and those to Kipneya, guess what she would have come back as? - I'm going to say 26 for a rate and 26 for a number. Yeah, I'm going all 26. - Yeah. She would have been to Kipneykin hypocarving. That's what she would have been. - Yep. - So, yeah. - I believe when I walked in, you did say she was too Kipneyk and then I just kind of based my like, how bad it was on our conversation. - I said her breathing looked labored as well. - Oh, okay. - She came in. - Yeah. - That's what I said there. But either way, you did essentially ask for it. I was just digging in and give it to you. So there's that. - Thanks. - Chris, - I'll be you. (laughing) - Let's talk about your, let's kind of talk about some other things really quick too. So I did talk about, you know, making that differential between us this congestive heart failure or is this a pneumonia. And one of these that I do like to see in that case is specifically looking for PETal edema. - Oh yeah. - On like a head to toe. 'Cause that's gonna be a really good indicator of whether or not pulmonary edema is likely. And I don't know if I heard that when we were not doing that. - You did not. - 'Cause I did not. - Yeah. So that I would add in, the other thing that I did like that you did, but I would have enhanced it a little bit more, is you were looking for skin turgor, which is great. Because that's gonna kind of tell us like, okay, like are we dehydrated or not? In other words, do we have enough fluid on board? Another question would be like, hey, how has, you been going to the bathroom? Okay, how have you been peeing? And if she suddenly is like, I don't remember the last time I took a piss, then that's another indicator. Basically, you're kind of monitoring like you're in output. - Sure. - At that point. You're in that point is more closely monitored with a fully catheter in, but you're in output is a really, really good indicator of whether or not someone is adequately flutter-assuscitated. In this case, it's not that big of a deal because she hasn't had any IV fluids. So she's not flutter-assuscitated. I mean, unless she's just been down and gallons of water straight for a day, she's gonna be not flutter-assuscitated. So, but the skin turgor is another way to kind of take a look at that. I did like that you have 12 ECG, which is another, and I think like, hey, do we have a cardiac component in this? And in this case, we didn't. So we had a little bit of lower amplitude and we had some PVCs going by with which can both kind of be signs of hypoxia, hypoxia, not hypoxia. (laughing) Hypoxia is where it's very contradictory itself. (laughing) Yeah. And also, let's talk a little bit about your supervisor partner. That was kind of the biggest issue with this whole thing, but the problem is, is you handled it so well that it was hard to make much of an episode out of it. You weren't like me who just teed off at one point, but the problem is, even though I'm telling the story, I tried to make it a challenge for you, it started to become a challenge for me, like to the point that I started creating scenarios in which he did dumb stuff, just like I'm like, this character that I made in my head. So yeah, and the big thing about this is, that is kind of a real listening that can happen is that when you have people who are in the field who are essentially doing two jobs, whether it's a supervisor or even an FTO as DORs to write or as down charts, it's not necessarily something malicious towards you, necessarily, it's just that they, it can get really easy speaking from experience, to be in a different job where most of your job is managing these other priorities that when you get out into the field, those priorities are still, you know, like weighing on your mind, because at the end of the day, your boss isn't gonna ask you about your clinical treatment of anybody. They're gonna ask you about, did you accomplish your other priorities that day? So those are always first and foremost on your mind. You know, I mean, the guy that says, well, of course you do a good job clinically. It's like, yeah, but I'm human, and you're giving me two jobs to do. And so that can happen. And that's very much what this guy was. The entire time he was focused on his other job, and he really kind of left you alone and tried to push things clinically to go in that one direction. I do have a question for you, and that would be about the antibiotic. And this just a point of curiosity, you really seem to want to know exactly what that antibiotic was. What were you looking for with that information, that kind of stuff? - I think it can be helpful to be able to like say, like, hey, this is the specific antibiotic that she was on. I'm imagining a lot of them are, you know, like they're like, yeah, this is the antibiotic we prescribed when somebody comes in with pneumonia. But, you know, I don't know. Could be a weird one. Could be something where, you know, they're like, oh shit, they tried this one. Okay, that's weird. Let's do this other one. - Okay. - And I also wanted to, I was trying to get the timeline down of more than the med itself. I was really also trying to get the like, how long have you been taking it? Have you been taking it? Has it failed? And then I was just like, oh, I mean, it's no, like if they'd been like, hey man, we don't know, we can't find it. I would have been like, I mean, that's a little weird for the skilled nursing facility. But I would have just been like, okay, well, okay. - Gotcha. She was kind of giving you answers like, well, that's at the desk. - Yeah, that's her. - I don't know, man. - I don't know, go find it. - Gotcha. - It's fine. - She didn't want to leave though. She saw her shooting her partner. It's like, he gave me by himself. - Yeah. - Well, hey, I don't have much else to add to that. It was a pretty straightforward scenario today. But if you guys have lots to add, then check out our Instagram @EMS2020Show. On there, you'll see a post about Spencer's call today where you can rate him to his face. Zero if he did a terrible job. One, if he did, what he should have done. And two, if he did, even more than that. With that. But by, oh, and Master of Maddox, there was who's bought to do. - That's a show of the same way at this time. - Yeah. - But by, this has been a production of Long Posit Media, a division of Flight Bridge Ad, leading the way in pre-hospital critical care and emergency medicine education.