Systemic Failure

What I always like is every now and again I'll do like a YouTube video Or I'll do uh something on here and someone be like, dude, your I guess his editor or whoever that is is crazy. I'm like, it's me. Like it's so if there's an edit that makes fun of me, it's me making fun of me. Like that's like in the YouTube videos, uh Yeah, I that's just me self deprecating. But so at our base, uh one day we brought in me, one of the nurses, and one of the pilots. Uh we're

less mature probably than the rest of our base. And we decided like, guys, we gotta bring in Nerf guns and have a nerf fight in the base. And so we did. And we're kinda like this is either gonna irritate people'cause you're gonna be finding nerf darts everywhere forever.

Uh truth. Or or it'll be great. And it ended up kicking off a nerf culture of people smuggling nerf guns in and then surprising each other and shooting each other with Nerf guns. And so Oh nice. It's a nonstop thing. So yesterday, after we ran one hell of a call, uh We get up in the morning and immediately start shooting nerf guns at each other, right? And so at one point uh As you do. Yeah. And so at one point the pilot he's in the pilot's room, he is out of ammo.

And I'm like, Wait, wait, wait, stop, stop, stop, stop. I'm like, I'm I got an idea And so I run and I grab a he's got two rounds left. I rub I rub. I run and I grab a tin can. uh popcan and I put it on my head. I'm like, you gotta shoot it off. And this the range is well beyond a reasonable nerf gun range. Like it's just stupid. And I'm like, yeah,'cause I'm not worried he's gonna hit me in the eye'cause I'm like, this thing's not gonna come anywhere near. He's like, all right.

He has two darts left, right? He fires one dart, misses completely. The next dart. Uh because you could watch Nerf darts will make decisions in flight, kinda go left, right, left, right. And the next dart it kinda ducks left, ducks right, and then nails the can. Dead center. If you have seen the movie Apollo thirteen, when they finally save the astronauts at the very end, and like it was that level of energy in the room. Like we went

And then the oncoming crew comes. Do I tell them about the innovation? I mean eventually, yeah, but the first thing I tell them about is that effing nerf shot. Yeah. That was it. I'm just envisioning I I wasn't expecting it to go that way. I was expecting uh the pilot to, you know, be down to his last two shots, fires one, misses, and then you're like, Listen, I can shoot you. Or you can do it yourself. Yeah. And then he just turns the nerf gun on himself and yeah. Yeah.

Wow. Uh I've been watching some dark TV. Boy, apparently no no, he d he just William tailed the popcorn off my head and that's what happened. So and it w it went great. But on that dark note, let's uh let's start the show.

This podcast is hosted by Chris Fingston and Spencer Oliver. They are both experienced paramedics. They've done everything from 911 ground Volunteer fire department work and are both Medics. This podcast reviews scenarios based on real calls run by real out-of-hospital companies. Details are changed to protect the privacy of those involved and to present educational opportunities to the This podcast is CMS twenty twenty. Hey everybody, welcome to another episode of EMS uh twenty twenty.

Uh, on this podcast we uh you know, we talk about calls that actually happened uh pre-hospital. Calls that you guys send us, by the way. And if you want your call to be on this show, then head on over to our social media. We are at EMS twenty twenty show on Instagram and EMS twenty slash twenty on Facebook. On Facebook there's a pinned post. On Instagram we have our description and uh our bio rather and in the bio

There is a beacons page and there you will find a link to a form where you can submit your call. Uh go ahead and fill out that form and if we like your call we'll get a hold of you. And uh yeah, that's what we're gonna be talking about today. But before we go too much farther, uh we have to talk about an upcoming uh I don't know if I can call it un upcoming or the upcoming, but either way.

There is an upcoming conference called the uh Fast 24 conference. It's uh by Flight Bridge Ed. And if you want to learn more about it on the interwebs, go to flightbridgeed.com/slash fast twenty-four. Uh, but basically, this is a conference that's going on from June 10th to the twelfth.

2024 in Wilmington, North Carolina, and you need to find a way uh to get there. Because look, like online education has been absolutely fantastic these days. I mean evidence of that is flightbridge uh ed dot com and their online courses. Um, however, uh there is nothing quite like being able to attend a conference and not only be involved in some of the discussions about critical care transport and pre-hospital transport and pre-hospital care in general.

But also to sign up for the pre-convention stuff where you get to uh take courses that are actually taught by people you've definitely heard of, such as, oh, I don't know, Jeff Murphy from Master Euromatics, which we've all heard of Master Euromatics, uh, go ahead and check out. uh flightbridgeed.com slash fast twenty-four and uh get signed up. And here's here's the absolutely the greatest part about all of this. I'm gonna be there.

Yeah. I'm not teaching or anything. Um but you know, or speaking. But you know, uh but I I will be there He'll be standing outside wishing he could be in with a cardboard side. No, I've actually been invited to be there uh as a uh as a special appearance. uh along with the guys from Master Euromatics and the EMS Avengers well will be there. Uh Spencer won't be'cause he sucks. And uh yeah. But other than that, yeah. So go ahead, check out uh fast uh flight bridge flightbridge uh ed dot com.

slash fast twenty four. Get signed up. I will see you guys there. Uh if you go to one conference this year, go to that one. It will be worth it. Uh so with that, um boop boop boop boop boop boop boop. Spence, what you got?

Uh well I don't have a nerf war. That uh Yeah. All right everyone turn it on kinda sad. Turn it off. The only thing I've ever done was we built a large blanket fort that we named Fort Kickass. with yeah, hand drawings in our base. Nice. Yep. Uh no ground paramedics allowed. Sorry. I'm kidding. I'm kidding. Oh god. Um yeah. I can I can I can hear the keyboards typing away for their comments and emails now.

Hey. Uh no no one was allowed. Uh people who think TXA does not help clotting are not allowed. But uh Nerf guns would have made it that much better. Yeah. Alright, well uh with that said note, let's talk about uh this call because it's Whew, it's a call. Um without giving anything away. Start drinking now. All right. Uh I do have a beer, so Excellent. Uh let's talk about the perspective of who gave us this call. Uh this call came from Tem

Tem is an EMT of about one year experience at the time that uh this call occurred. Uh they are nearing the end of their own paramedic program and are in the um Oh uh the part of their internship where, you know, the person's like, hey man, you got this. I'm gonna stand back and you tell me what to do. That part of it. Uh they are currently on this call working as an EMT. Uh important to this call, they do have an IV endorsement, so they are permitted to start IVs.

They are working with a paramedic that I'm calling sis. S Y S. Gotcha. So we have Tem and Sis. Yes. Are you sure we don't have Sis and Tem? No, it's Tem and Sis. Okay. I know what I said. Gotcha. Fair enough. Yeah. Fuck me. And we will unfortunately need to talk about uh sis. Uh because it is pertinent to this call. Um so

Here's the deal. Sis is a new medic with less than six months experience in that role. Uh, but they do have several years experience as an EMT working in the service that they are working in for on this call. Uh, Tem and Sis have been uh working together for about a month after Sis and a previous partner had a uh what's described as a personality conflict. Okay. Yeah. Um so Tem says that Sis seemed like a nice enough partner, but they were con concerned about the pairing. Um

Sis has a reputation within the service for being a provider who makes questionable treatment decisions. Um I was given some examples, but I won't go over them uh because it's It's not really important and you know, it's it's basically through the scope of one person or stories. Right. But essentially What I could decipher from this, uh from these uh examples was that these are categories of a paramedic uh both failing to recognize the severity of uh of uh conditions.

um and failing to treat those conditions. Uh or I guess overreading some time like what would be a more benign condition and pushing for treatments that don't really fit into a treatment box. Gotcha. Um So that is it. Now Yeah.

And and maybe some PIC stuff there as well. But you know, here's the thing. This all could just be like that juicy in-house shit talking that uh happens at some agencies. Um but It's not because when they were put on a car uh together, a supervisor for the service does tell Tem, like, Hey, you need to watch this guy and keep an eye on their clinical decision making. Okay. Um, so by the way, uh I want you to remember this supervisor.

Because they will come into this later. Okay. So uh Chris, I I would like to I would like your thoughts on this because Yeah I think it's hard. You know, it's um it is hard because I don't I don't like the poisoning of the well uh from a supervisor being like, hey, you better watch out for this person. Because, you know, like you said, this could just be some juicy in-house shit talking, and there's been a lot of situations where

where it is. One of the things that we're really good at in this profession is uh recognizing when we don't think someone's a good provider and making sure everybody else knows. You know, like uh we tend to kind of lament that. Um And there there's a lot of subconscious drivers for that, you know, because I don't think it's necessarily that people make stuff up. I mean, some people do make stuff up out of whole cloth and they're they suck.

But I think a lot of people, um, it gets easy to do.'Cause one, unfortunately, there's a part of our brain that juicy gossip just gets tickled. You know, just it gets tickled by ju by juicy gossip. There's just that part of the brain, you know. And so there's there's that. The other thing is that When you're working with somebody

you know, and you're working on the same patient and things go wrong, you wanna be able to distance yourself from the wrong thing sometimes. So it also becomes good to you know, th th there's a subconscious reason to blame the other person. Um and it can be and also I've noticed a lot of times like there'll be people where it's like once trust is broken, people tend to

find problems even when there aren't. You know what I mean? Like Sure. Yeah. The that they're they're looking for it. They've they've kind of been uh Exactly. Whereas like anchored to it. Yeah. Like whereas you know, someone who's trusted if there's a call that goes bad, you tend to assume like, ah, it's probably

It's probably just like no one could have done that call. Then you have the person where it's like, yeah, they made some mistakes early on, maybe their personality isn't the best, and we tend to just be like, oh well that call went bad obviously because of them. And then maybe we fill in the gaps with fictions here and there. So yeah. Yeah. I mean, this is a hard one and I don't like labeling people as bad clinicians.

But if someone is a bad bad bad clinician, then yeah, I mean you do have to keep an eye on it. So yeah, I mean Yeah, those are kind of my thoughts on it is I mean on one hand it's like, yeah, you know, you need to make your own judgment of people and try to ignore that ambulance rumor mill, but on the other side of things like

Sometimes it can be earned, you know? But uh but yeah. I don't like a supervisor telling somebody who is technically gonna be under the command of somebody else that, hey, you need to watch this person'cause'cause they they may not be good.

But I don't I don't care for that. That strikes me as very unprofessional and it's almost like the Civil R is being like, Hey, can you do my job really quick and just make sure this person's good? And like Yeah Why aren't you That's kinda where it rubs. Yeah. That that's kinda where it rubs the wrong way, is like I hey, you know

If there is a concern, I like I'm I'm torn between the is there value in being warned like, hey, you know, the this guy maybe has made some questionable decision makings, keep an eye on that. Like I there's a part of me that's like, I would like to know that. Um, but I don't think I would like to know that from my supervisor. I I feel like as a employee, uh being supervised, I'd I'd want my company to be able to

fix that before it became my problem. Well or you know, uh yeah. So and the thing is we don't have enough information, I'm sure, on this and and maybe we should probably just move on from it. But one other thing I would say is that um

The proper thing is if you have if you have a clinician that's not doing well, the proper thing to do is to be like, hey, you need to go back into a training session and uh of some kind. We need to increase your coaching, increase your training, because if someone's having some incidents, The best thing to do and what I have done as a supervisor is recommend, hey, this person needs an additional month with an FTO, with a trainer.

Yeah. And then when that person does well, what you do as a supervisor, especially if you know that that reputation is out there, what will happen eventually is you'll tell someone, Hey, you're working with so and so, and you'll say like, ah. What you do as a supervisor, once you put the person put that person back through through training and coaching, what you do is you champion them. You'd be like, hey, look.

They've actually gone back through a month of FTO. They did awesome. You know, I really think this is gonna be uh good for them. If it's not, you know, let me know and we can deal with it. But you know, I I th I think I I really if this person what what the employee needs to know is they need to know that if this person was actually bad, you as an organization wouldn't be putting him out there. Yeah. That's what they need to know.

Uh I agree. I think that I like that piece where it's, you know, hey, the the system recognizes and the system has ways of uh you know the the system that the employer uses has ways of you know correcting you know like hey hey'cause Some people just need more like they may not have gotten the exposure they needed to and then they go out and they get the hard calls right away and then yeah, they look like garbage because

that they never got any hard calls during their internship. Um I do like the I I I I I agree with your statement um with the poisoning of the well. I think that there's probably better ways that the supervisor could say, hey, yeah, you know, like keep an eye on this. Without saying that. Um and I I think the reason that we all like the juicy gossip is because there's sort of an we are included via exclusion of the other people. Yeah. We're in a club now.

Yeah, like, hey, you trusted me enough to be like, watch out for this guy. Yeah. You're one of mine. I'm why you know, like I think that's kind of the the ego gets fed that way. Not you know, um Uh our uh uh reviewer, external reviewer who has yet to appear on this podcast. uh probably because he hates us is uh he he said that you know a supervisor here is probably setting up a dangerous dynamic

Um, you know, rather than warning Tem that Sis is below average, it'd probably be more appropriate to approach it by talking to both parties. Uh hey, advising Tem like, hey, that Sis is a relatively new medic. Um, and I think that you as a medic student have a good opportunity to work with them as a team and make sure that you can make sure that they have a you have a good handle on any like of the critical BLS aspects of a call and you can offer valued valuable advice.

If something's getting missed. Oh, I think that's a good idea. That is sort of saying, like, yeah, hey, I am giving I'm empowering you uh as a phenomenal BLS provider and saying like he's new, he might miss some of those critical aspects because he's got a, you know, brand new toolbox that he's got to look at. Um And then likewise he could say that

You know, the conversation with uh sis, the paramedic. Hey, Tems is a strong EMT uh with some experience on some critical calls, and you should feel comfortable asking him his opinion uh if you get anything that you haven't dealt with yet. Uh, because you know, you b you both are going to work together very well. And then that sort of sets you up to cover those things without doing the like This guy's a piece of shit, watch out. Like so anyway. Uh

Let's talk about the system now. Uh so the service that Tem and Sis are working for is ninety nine Problems Ambulance Company. Um 99Ps is a private ambulance service with about 20 cars on over a 24-hour period. Okay. The cruiser medic EMT, with some EMTs able to get endorsements to perform IV starts. Like Tim. You like Tem, exactly. Uh the crews work twelve hour shifts and typically run five to eight calls uh in that period. Uh they do a fair amount of interfacility or uh stretcher transport.

And the crews on duty, uh, they rotate through who's up for 911. So if you just did a nine one one, Chances are uh you're gonna be assigned to inner facilities. uh following that for several rounds before you'd go back up for nine one one. That's an interesting depending. Huh. Yeah. Interesting. So this service does have stations that they can uh post at uh in various parts of their ambulance service area.

And the area that they serve is suburban slash small cities. Okay. Uh regarding hospitals. Uh Heavy sigh. Uh there are there are many, but there are two that come into play for this call. The closest hospital is a level three trauma center that is. Basically, it's not the trauma hospital. It's not set up to do high level traumas. It's set up to handle just like

regular ER stuff, uh, plus like cath lab things. Uh they're not there like this is not the hospital that's gonna be like, all right, crack the chest. Gotcha. Okay. Uh there is a trauma center uh that is equipped to take those patients. Uh, from the scene, the it's about like a twenty five to thirty minute drive. The closest hospital is about a ten minute drive. Uh those will be

important to this call. Also pertinent to this call, there is no protocol or policy at this service that mandates trauma patients be transported to the highest level trauma center. Uh, this is at best a soft expectation. You might be wondering why I'm telling you this, given that this was not a trauma call. Uh

Well, I don't know anything about this call. We we're still talking about the system. All right. So there is an ALS fire department and the paramedics for the fire department tend to participate in calls. Um their value kind of uh as participants depends on the provider, uh, but for the most part they're described as well, uh, like d decent providers.

Um this area does have a specific rule regarding who is PIC on calls. And essentially it is the minute the patient is on the ambulance stretcher is the minute that ninety-nine paramedics or 99 problems paramedics.

is in charge of the patient. That's all. All right. So uh here we are, the call. Uh so this call starts five and a half hours into an overnight twelve hour shift. Tem and sis are posted up at one of their stations and Uh they are currently one of two ambi Yop Sorry, th that that's pretty broad. Overnight basically just means it ends at sometime after midnight, right? So so what time is this during the day? Eleven. thirteen PM. All right. Eleven thirteen. Perfect. Yeah. And forty seven seconds.

And forty seven seconds. No, forty six. Come on, Jesus Chris. Uh so they are currently one of two ambulances available uh in their service area, while the other ambulance is uh posted at a station across town. Uh prior to now, they had run a few uh we'll call them ho-hum calls. Right. Uh uh, but really, you know, nothing of note. Um, so they do hear the fire department get dispatched out to a single vehicle rollover with ejection.

Uh, the roadway that this happened on is a residential road uh that they do know, recognize. It has a sharp turn. Uh the caller for this call was a passerby who's reporting that one of the passengers is under the vehicle uh and that there m possibly is a occupant entrapped inside the vehicle. Uh so in the system, fire gets dispatched sir first, then EMS, but uh before the ambulance even gets dispatched. the aforementioned supervisor, uh, who happens to be working

Uh requests that a second ambulance also be dispatched and adds themselves as a supervisor responding to the scene uh and that is a non-transporting uh asset. So uh supervisors responding solo. Uh the supervisor's name for the episode is Incident Commander, shortened to Ick. Oh God. That's not good. Uh oh man. All right. So yeah. Uh

We've got Tem, Sis, and Ick. Here we go. Uh the address uh for the call is about four minutes away from their station. Uh Sis does tell Tem as they go en route, lights and sirens, uh this one might actually be serious. No. Sounds good. Okay. Uh Tem is driving and they do discuss like trauma triage and uh prioritizing getting the more critical patient off the scene first with s uh sis.

Um uh and with the proximities of the hospitals to the scene that they're responding to, air medical is not a consideration because it's yeah. Yeah. All right, so Chris, what would your thoughts be as you're traveling to the scene? Uh we have an ALS fire department en route, as well as a supervisor and another ambulance. Uh and the other ambulance is probably like fifteen minutes away. Mm-hmm.

Um well I like a lot of things that they're actually talking about too. So one of the things I like to consider when we're going to the scene is I really start considering I start thinking about resources right off the bat, right? Because

If you need extra resources, getting them started sooner rather than later is good, especially when we're talking about trauma calls, because when it comes to trauma, especially when we're talking about the uh the potential for the potential need for, you know, the OR. Um, getting people off scene quickly is a priority.

You know, th this is one of the few scenes where we talk about, hey, load and go is a thing we want to do. So I kinda like what they're talking about, because even though we have a single vehicle rollover with injection, it kinda sounds like there may only be one patient. Who knows how many patients are in that vehicle?

And so they start talking about, hey, getting the most serio you know, like getting the most serious patient uh out of there first, those kind of things. So while I haven't heard anything specifically about requesting additional um resources. Uh it does seem like their mind is there, especially if they're also thinking about like, hey, is air medical something we want to do? Uh and it's not, because it's just it's not going to save them a lot of time, which is which is a good call.

Um so no, so far I'm I'm I'm tracking I'm I'm picking up what they're putting down and I kind of have the same thoughts. What kind of resources am I gonna need? This is serious. Um let's kind of talk through more of our scene logistics. Yeah, and those kind of things. So Yeah. I kinda have the same thoughts that they do so far. Yeah. Yeah, I think the supervisor uh on at this point was you know, right on the money. It's like, Hey, there's two patients, one's probably very critical.

Yeah, so there's one who Oh, okay, yeah. So my whole my whole diatribe about about where I said I think there's one patient, but maybe there's more. I'm gonna change that to say, Hey, there's definitely more than one patient. So I'm glad they're thinking about resources. Alright. Yeah. No, there's one person one person under the vehicle and one person possibly entrapped inside. Uh so the supervisor adding a second ambulance.

is a good call in this uh in this moment. So uh Sis and Tem's ambulance fall in behind the Code 3 fire engine and they arrive on scene uh altogether in short order. Uh the dis the scene is described as a two-lane residential road with a car, uh a uh 90s problem Mustang, uh that happens to be resting on its side on top of a crushed wooden fence just off the side of the road.

Gotcha. From the appearance, it looked like the car failed to make a turn in time and uh crashed into the fencing, landing, I guess. Sideways. Now is this like a cedar fence? Is this painted pine? What kind of wood are we talking about? No, I I totally thought about that and I was like cedar maybe, but it might be a little too soft. I don't know. I thought cedar was a harder wood. I thought cedar was a soft wood.

Mm, I think cedar. To the Google machine. We need to know this before we get it. Like pine, poplar, those are all uh pine, that's what I was thinking. Yeah. Cedar, yeah, cedar's hardwood. It's porous. Okay. Um yeah, cedar's definitely hardwood. Okay. Yep. Would it be good to have a fence made out of porous wood? If you seal it, it's fine. All right. Yeah. Yeah, I mean just it's gonna take more sealant'cause it's more porous. But yeah, you can do it totally.

Yeah. All right. Yeah. Cedar's beautiful. That's the thing. That's why they're that that's why people have like cedar cedar shakes on their roof. I'm gonna go with not cedar because given that people know this turn, uh I'm betting that the homeowner has probably had to deal with this fence a few fucking times. Yeah. And at this point they're just like, I don't know, what's the cheapest, ugliest wood?

Uh, probably gonna be what they call uh uh uh SPF. SPF stands for uh spruce, pine, uh or fir. In other words These are just all the cheap softwoods and they'll write SPF'cause like I don't know, we didn't mark which one it was, but uh there you go. Okay. And that's what it is. Yeah. It's an F uh S P F fence. Okay. There you go. All right. Uh yeah. So uh it look again like the car failed to make the turn, uh, and is crashed into this fencing, now resting on its side.

Uh from the road, the crew can see the underside of the car. Uh the side of the road is described as flat. The weather, by the way, is dry and the temperature is about a cool forty to fifty degrees Fahrenheit, or for our Celsius people, four point four four four four four four four four four degrees Celsius to ten degrees Celsius. So yeah. Perfect. All right. Uh, there are a sea of police cars uh on scene as well. And uh Tem does tell Sis as they park.

Like their rig is uh they're like, hey, uh I've parked it in a way that this is easy to get to the trauma hospital uh if we need to. Um we don't know if Sis hears that.

Because they don't respond. So Okay. Yep. That was uh Perfect. Uh so Tem and Sis grab their stretcher and their jump bag. Uh their jump bag has their airway, IV IO, meds, and bandaging, as well as their monitor, and they head over to where the police tell them that the patient is. Uh patient as in singular, by the way. Uh police tell them that there is only one patient, and he is trapped under the vehicle.

Uh thankfully, by the way, no other occupants are present for this call. Uh they did look uh and see no one else in the car. So, um, let's talk about the patient. The sole patient uh for this scene presents lying supine on the ground, partially under their uh car. Uh the car is covering everything distal to uh the patient's pelvis, uh, but the patient's abdomen, chest, upper extremities, and head are accessible. Okay.

Uh Tem jumps uh down to the patient's side and starts an assessment. Uh the patient is estimated to be in their mid-twenties, they're about 5'9 and 150 pounds, or 1.75 meters and 68 kilograms. They are wearing a hoodie that is tied down tightly, which will have to be cut through. Okay. Alright, so here we go for their primary assessment. GCS. The patient is a three on the GCS scale. They are not responsive.

Uh regarding exanguination, there is no obvious bleeding that is visualized outside of the body. Okay. And uh airway. Their airway appears to be patent. Uh there's no strider, grunting, snoring, or gurgling heard uh for breathing. The patient is breathing agonally at about four a minute.

Circulation, there is a strong palpable radial pulse at about 100 beats per minute. So Chris, here we are. This is the patient that we have so far. We haven't cut and covered them, but we've gotten a quick uh Exanguination, airway, breathing, circulation, uh assessment. What are your thoughts? What are your priorities for this scene?

Well, okay. So clinically I I know a lot of people are probably like, Oh my god, they're breathing aggoli at four minute. We need to jump in and ventilate. Um Correct. First thing, scene safety. Uh cars were not designed to uh to rest on their tops uh or on their sides. They were designed to to rest uh on their on their tires. And th this car is not, correct? Yes. No, this car is resting on a SPF fence. Right. Well, right, but it's upside down.

Uh well it's uh I mean it's on its side, so two of four tires are on the ground. Oh. Well never mind then. Don't worry about it. This is safe. No, I'm just kidding. Uh but yeah. But you also have to you also have to watch out

gasoline could be leaking, there's chemicals, there's a lot of different things. So keep your head on a swivel, uh, and just uh you know, make sure you keep yourself safe. But when it comes to patient care, It says no uh you know we have no obvious bleeding visualized, but we have to remember half this patient is covered.

Yeah. Uh we can't see half this patient. So no obvious bleeding visualized, but that doesn't mean there isn't any uh obvious bleeding. But now here comes the second thing. Even if there was, what could you do about it anyway? Mm. You know? Like even if you could be like, Hey, there's a bunch I I think there's a bunch of blood creeping out from the car. If you can't get to the patient, you can't get to the patient.

Yeah. Transmission fluid's usually kinda red, so you know that's what it is. Yeah. Yeah. Yeah, maybe that's just what it is. Yeah. So yeah, then just get a refusal and go. But Um in the meantime, so we have a patient is uh, you know, breathing agon agonally at four a minute. This is the thing that needs to be corrected that you can do something about now.

Um, so what I would say is take your personnel, get somebody with a BVM, and start assisting breaths. And then we need to start figuring out our circulation status beyond, hey, I've got a palpable radio pole. Uh here. We need to figure it out beyond that. Um now, which is uh that's not bad at all. Getting a radial pulse and a hundred BPM, that's a good first move.

But let's start getting a blood pressure on this person. If we need lighting, let's get lighting and see if we can see a skin condition. But we need to really figure out, do we need to start loading this patient up uh with fluids? Because depending on the amount of compression going on on the uh lower half of the body, uh, you know, we may not need as much volume. And uh but uh anyway.

Uh so yeah, so we need to do a better assessment. Uh we do it d I don't want to say better to imply that what they've done is bad. It's not so far. This is a good initial I walked up assessment. But um yeah, we need to get get a handle on on the circulation. So we know the breathing's bad.

Immediately assign somebody to that, start working on circulation. Uh, I did like that they looked for exanguination first, uh, because remember in trauma it's X A B C. Any major bleeding. You stop now. Now a lot of people ask, like, well, what's the difference between cause a lot of people get confused? Like, oh, so now we're doing like CAB, circulationary breathing? No, not necessarily. Exanguination specifically refers to

massive hemorrhage that must be controlled. And the reason is, is because, you know, for a while we always focus on airway and breathing first because, well, hey, like it only takes a few minutes of hypoxia and you're done.

Well, if you have significant bleeding, it only takes a few minutes of bleeding out and you're done. And here's the nice thing about hypoxia. You can correct it. We can reoxygenate. Doesn't mean you won't have a lasting injury from that, but we can reoxygenate. If you're out of blood, I can't fix that. I mean we can scoop it up from the dirt and try and put it back in you. Put it back in. Yeah. Your body doesn't like that either. Yeah. Yeah. It's hard. So I don't like doing it.

It's sort of like when you mix diesel and gas. Yeah, exactly. Uh okay. But in all seriousness, you know, like if you're out of blood, you're done. That's it. The two units that flight probably carries is not gonna fix that. Yeah. Yeah. So yeah. So that's why we focus on exsanguination. Then we have the airway breathing. And now when we're talking about circulation, presuming that exsanguination is either not present or we fixed it, now we're talking about like, okay.

Do we have good radial pulses? Are are we able to start, you know, are are we good to start replacing that volume that's missing if it's there? Do we need to do other things to adjust circulation? So that's kind of the difference. We're kind of breaking up circulation into two spot in into two spots. And dealing with the most critical exanguination before we deal with anything else. Yeah.

Yeah, I I like your approach. Um, you know, you said uh by the way, correction half the body, uh According to the rule of nines. the legs and uh below would be eighteen, eighteen times two, right? So thirty six so thirty six percent of the body under the car. Uh no, you're forgetting the genitals. That's uh well wait. It depends on the genitals. I don't know if he's I don't know if the genitals are covered. Uh okay, but is this male or female?

This is a male patient. Male patient. So there could be an extra one percent in there. Okay. You're right. And also just yeah. So uh I mean, yeah. Thirty six percent. Uh and thirty seven. You're right, like thirty seven. Okay. Uh But y if you can't like i if you think like, hey, that transmission fluid, that's weird, uh coming out of a nineties problem Mustang, uh Uh maybe you can throw a tourniquet up high on the leg. Uh in the meantime, if you're presuming.

I d I all I know is that the pelvis isn't visible, so I'm assuming that maybe there's a little wiggle room. But hey, you know what I mean? You know, I mean here's what I do. I mean, again, going back to that circulation, if you assess the circulation and you're like, hey, you know, this patient may be bleeding out and you have access to high legs, even if you can't see them, fuck it, throw two tourniquets on them.

Yeah. You know, throw a turn on each leg. Yeah. Um Yeah, so uh I think your idea of like hey, let's let's do this, let's Make sure, you know, like like focus on the ventilation after scene safety, uh, making sure that nothing's exanguinating, and then, you know, work on trying to, you know, make sure, hey, do we what are his vitals?

uh and whatnot. Do we need to do any other, you know, life uh life interventions prior to uh getting him out of there? But I think the focus really is like, hey, we're gonna do this stuff. Fire people, you work on getting him out of here and making sure that this doesn't collapse on him'cause boy, that would look dumb.

Or us. Um yeah. And and here's here's the other thing I I would caution. You may not have the appropriate PPE to be close to this patient. You know, think yeah. Think about that. If you don't have a helmet, maybe you shouldn't be I mean, I again I'm not on this scene, but

Think about that. Yeah, I wanna help, but you know, i uh are parts gonna fly, am I gonna get hit in the head, et cetera, et cetera. So if you don't have the appropriate PPE to be in the situation, then don't be in that situation. Yeah. We'll be over here. Uh let us know when the NOS explodes. Yeah. Exac exactly. All right. So uh Tem asks.

Right. All right, so Tem who's at the patient's side and has given us this uh lovely uh primary assessment, asks Sis, who's just behind him and apparently talking to the fire department crew, Hey, I need you to grab me a B VM. Uh Tem then works on exposing more of the patient. Uh they cut through the hoodie and discover that there's a large laceration, approximately since six inches or fifteen centimeters, uh on the patient's right anterior neck.

Uh the wound appears to be like subcutaneous layer of fat deep and is not currently bleeding. Uh so Sis has fetched the BVM and monitor, uh, but is now talking to Ick. The supervisor. And uh the fire department crew who have again just kind of all walked up. Um and so Tem says like they called out to Sis several times about the BVM before they finally came over and then set down the BVM and the monitor next to Tem.

So they're not so so t is Tem let me get Tem's the only person working on the patient at this point? At this point, yes. Tem is the only person working on the patient'cause their partner is talking to uh the providers behind them. Tem says to their partner like a few more times, like, Hey, no, you need to bag the patient. Uh,'cause they are again cutting and uh exposing the patient. Uh before sis finally complies and kind of realizes, like, oh

Yeah, I should be bagging this patient. Uh so they start to do that. However, at this point, Sis also realizes that uh they brought over the BVM, but they did not bring over any O2. Uh so they yell to the fire crew uh to grab their O two bottle off the stretcher, which is about ten feet away. Um fun fact that will not happen. Um Hey, did anyone think of just grabbing your kits and bringing all the kids to the patient? Did anyone consider that instead of just picking out bits and pieces?

Did anybody consider that? Uh yeah. Grab the same fucking kits every single time. So everything you need is there. So as you uncover your patients and you discover new things, you do not have to run back and forth to your fucking ambulance to go get them or rely on other people to run back and go get them. Yep.

All right. So'cause we how many times have we run into this on this damn show? I brought a handful of things that I thought I would need and it ended up being a problem. Yeah, exactly. And here's the thing, carrying it in ninety-nine times when you didn't need it.

is worth it to save you from that one time that you will. It is worth it. Well, hey, I mean half credit or thirty seven percent credit because they brought them on the stretcher uh and just left the stretcher and all that ten feet away. Uh so mm, no? All right. Fair enough. Nope. Okay. So I I do wanna comment because there are there are probably some people who are going like, what the fuck is wrong with Sith?

Um and I because like Sis is the paramedic and they are not participating or haven't yet so far. And I But nobody is. Sorry, go ahead. Well no Tem is. Tem is down there. Tem is, but the patient fighters aren't. Nobody else is. Nobody else and everybody else. So I want to I I want to I wanna address that because I think there's two possible interpretations that I can see from these actions.

Um the first would be that Sis isn't recognizing the critical aspects of this call because one, they either don't have the educational uh or like knowledge foundation to recognize it, or two, they just don't care. Um But I think the other interpretation uh is and the the one that's most likely is this.

is that they are just plain overwhelmed at this point by the critical nature of this scene and this patient. The intensity of this call has overwhelmed their ability to think and plan clearly, and they are failing to act Because of this. Um the and I I there's a couple things that I think add to this. There's an unwritten rule or code uh or like culture in EMS which basically says like

Uh we responders don't get to be overwhelmed. We don't have the luxury of that. We are expected to think clearly and act in any crisis that we find ourselves in, and we have to perform. Um and if we're supposed to be in charge, we must be in charge, even if we are in a psychologically or physiological state which prevents us from doing that. Um

So well like we have a lot of training about how to work through those. Um that that's one of those I think that's just one of those educational pieces where there's a disconnect until you get enough of those calls where you have to work through it or where you get to see someone else walk through it. And I think th this is one of those moments where sis could have been like, Wow, Jesus, this is serious. Uh, you know, like Someone like we need a PIC. Um, you know, like hey

Supervisor help out, but like there isn't there just isn't any mechanism on the scene that really allows for that. Um and I I I think that that's kind of what's happening here is like the fact that they're like They're not moving towards the patient to start doing patient care that they're grabbing a B VM but failing to like Yeah. They're grabbing a B VM and a monitor. But not doing it, yeah. And then grabbing it to their partner. Yeah. Yeah, like here.

Does am I helping? Like th this is and like and failing to do the like oh if I'm grabbing a B VM they'll need oxygen. Yeah, like that That all just to me spells overwhelmed. I I don't know what the fire department is doing in this. Uh you know, t Tem's partner is you know, like Tem is noticing their partner because that's

That's who they work with. But the fire department might be doing things where they're like, Hey, let's figure out how we stabilize the car so that we can get this guy out or Yeah. Whatnot. But um Well yeah y here's kinda what I so how many how many fire apparatus do we have on scene?

Uh uh one, possibly two. Uh'cause there's the engine that responded. Maybe there's another one. I don't know. So we're not sure we're not sure how many we have at this point. We are not sure how many we have at this point. Yeah. So we have at least probably four? Uh What for firefighters? Yes. Yes. I I'm saying well I definitely know we have at least a uh

Yeah. We'll have at least four at this moment. Yeah. Four. Okay. At this moment I have at least four. Maybe eight. But let's say four. I have Tem, I have sis, I have a supervisor. So I have seven I have what? Ick is a supervisor. Ick is a supervisor. Oh yeah, yeah, yeah. I have uh I have Ick. All right. So I have seven people on scene. Yeah. Correct? One person is doing patient care. Yeah. This is not a problem with just SIS.

There is not enough on this scene to require six people to be ineffective. Not necessarily ineffective, but there's not enough things on the scene to require six people to do nothing while one person does patient care. This is not a sis problem. What sis's problem is is what sis appears to me to be avoidant at this point because I think you're right. I I actually really liked what you had to say about silently drowning in their own panic.

And what Sys appears to be doing is trying to find a place to be where they're not in the line of fire per se. In other words, where they're not to be relied upon. And we looked up and and we see, well, hey, here's these other responders. sitting around talking about other stuff, I'm gonna participate by being involved in this thing over here because it's less scary. And so I think we're being avoidant.

He's Kyle directing traffic. Like, don't worry guys, I got this. Hundred percent. That's exactly what it is. And so or or that's what it what it seems like to me. So I feel like Sis is being avoidant. The fire department uh the fire department and the supervisor is giving Sis plenty of places to be avoidant into, and nobody's really focusing on this patient aside from Tem. And so yeah, sis sis makes mistakes here. I mean

Yeah throwing it throwing a B VM at Tem and and not doing anything with it and bringing a monitor and not bringing their equipment over. And again, like I don't give a shit that the ambulance is only ten feet away. If you were in the back of the name, it's working on a patient, you want stuff where you can reach it, why does that change where suddenly you're out in the field? And so uh yeah, I'm I'm frustrated. This whole call i i is frustrating.

Everybody in this car right now is frustrating me a little bit, even Tem a little bit. And I'll I'll s say why in i i in a little bit. I I th I think Tem's the best of the group right now. But we also got the call from Tem. But uh I think uh th they're kind of the best of the group right now. Um but yeah, I'm not really satisfied with any of it. There's an immediate life threat that nobody but one person is is attending to. And uh and yeah. So anyway, that's

That's what I think I think Sis is being avoidant. I think everyone else is being equally avoidant. Um or at least or at least not focusing on the first thing. uh where they should.'Cause if you have another engine en route, uh I can almost guarantee you're gonna wait for them to move this massive car anyway. So why don't you stick some stick some firefighters on it? Why is no one looking at the at the patient but one person?

Yeah. So no. All right, so uh for perspective, uh th like this is just like within the first few moments of showing up. Um uh so like this isn't you know like'cause uh just f for placing where we're at in the story. Uh it's taken several times for Sis to finally kind of cue into the fact that they need to provide positive pressure ventilation. And then

Even once they do that, they're like, no, no, no, you have to be the one to do it, because I'm still doing an assessment on the patient. Uh so Sis is now at the point where they are starting to provide positive pressure uh ventilations to the patient. Uh Tem is focused on uh addressing the uh large wound that they found that isn't bleeding, but uh had at some point been bleeding because there's a pool of about five hundred mils of uh blood inside the hoodie. Um

I want to talk about again? Uh it's on their anterior right neck. Uh anterior right neck. Okay. Yeah, and I do want to point out like there is no swelling or subcutaneous air that is appreciated. um uh around the neck or the chest in that area. Um there's no air that seems to be leaking out with positive pressure ventilations.

Uh so uh anyway, they get that bandaged and they continue working on cutting the rest of the hoodie off. But Chris, it's at this point one of the firefighters, an AEMT I'm calling Lur.

Shouts out, The patient is not breathing, starting CPR And then they kneel down next to the patient and start performing chest compressions on the patient. Um, and there are I I've experienced this several times in my career where something happens and you are so stunned that you think I must have done something wrong. I must have missed something. I have missed something completely because this doesn't make sense. And this is where Tim finds themselves in this moment because they're like

What what ha did what changed? I I don't understand. Why are we doing compressions on this guy? But they start to kind of go with it because that Why why wouldn't we? You know what I mean? Obviously this person knows something I don't. Exactly. Um and so at this point, well compressions are just starting, Ick, the medic supervisor, uh says from

I guess d in the background. Hey guys, let's just work a few rounds and then call it. Uh basically because this is a trauma code with a patient entrapped under the car. Um so okay, Chris.

We have and by the way, this is just the start of an amazing EMS twenty twenty episode happening. And so these started three episodes. At a minimum. With the caveat that uh We weren't there. Uh what what do you think would be the main culprit that is going wrong with this scene right now? No PIC. And I think you knew I was gonna say that. There's no leadership.

100%. Yeah. Yeah. Th there there's really no leadership. You have Tem who's kind of trying to lead uh from a point of also doing everything'cause nobody else is. No one's really focusing on the patient and everyone seems to be kind of coming in

It it almost reminds me of a scenario of like, uh there's a mannequin on the floor and we're gonna have students one by one come in and run this scenario by themselves.'Cause that's what this looks like, right? There we have a patient and then people are one by one coming in and everyone seems to be running a different patient right now. Right. And okay, my slight anger this is very slight anger with Tem. So Tem don't

you're you you are I'm mad at mostly everybody else. Yeah. Fuck you Tem. Fuck you Tem No more birthdays. Um anyway. Uh but Tem you know to Tem you you You're actually doing the best a out of everybody. I'm not really that mad at you. I I kinda take it back but If I was in Temp Spot, the change I'd make is i is I would loudly there are times to get loud, this is one of them.

Hey guys, we have a patient who's agonally breathing here. I need your help and we have to focus on this patient. If it's bad if I was on scene, because I've actually had nightmares, like literal wake up from nightmares where I have a group of people who just won't move on a critical patient.

I've had those literal nightmares before. And so this is a very triggering call because this is my nightmare where I'm trying to get everyone to to fucking, you know, pull your head out of your ass and help me because I can't do this by myself and they're not. That is when I would probably start getting loud. Hey, guys.

This patient needs our help. Get him to work. Cause my problem is is this is so obvious that we should be focusing. I'm I'm angry, really angry, and I'm hoping it's not just the beer speaking, but Uh I'm this call is triggering me left and right because it is so obvious that this patient needs our concentration and so obvious

That we don't need to be focusing on anything. Yes, we do need to focus on getting the car off of them, but if we have a second unit en route or the second units there, we have enough people to work on this guy now and he needs it now, and he does not need one person. And it is not Tim's fault all by themselves. The only thing I can fault Tim for is not being loud enough to everybody.

Hey, everyone, this patient's dying. We have a chance to save them. You guys need to focus and say it. And it's hard when you're Tem because you're the EMT, right? And you're a paramedic partner. Yeah. But in what Tim did do when Tim focused just on talking to sis. If I was gonna have sis do anything, sis should cut, I should bag. Because we've talked about being PIC.

Sis should be the one being PIC. If we're only communicating with SIS, then you know if they're gonna be anything, they should be the PIC. Uh and it's better to be cutting off clothes and assessing as a PIC than it is to be focusing on bags. That would be my own my my my only change. What you're describing is like this is like trying to herd cats.

You know, and all these cats t you know, uh s and these are all cat names, uh you know, really when you think about it. Uh You have a cat named Sis? And Tem I don't know. Why not? Lure makes sense, I guess. Yeah. Uh yeah, lu lure does make sense. Uh yeah, but like you're trying to I think that's the the problem is you're you're right. Like Temis in the position where he recognizes the the critical nature of the of the

the patient and he's the only one really trying to make headway into treating that. And all these other cats are, you know, like chasing laser pointers. And they're not that no one else is lasered into the fact that this this patient is sick. Okay. And Some are chasing laser pointers. Some are doing fuck all.

Well you know, one guy I don't know, one guy's got the the ball in the thing and he's doing compressions and he's chasing back around. So and here's the worst thing about this, is like what I'm worried about now, Spence, and and and I'm just going nightmare fuel here is As far as I know, this patient has a pulse, is not arrested, does not need CPR. They need respiratory support, right? I mean, you and I are on the same page there.

Yep. Let's let's take it a step further though. Now we've got a supervisor chiming in, Ick, being like, hey guys, let's work a few rounds. And my worry is now the group thinks this is an arrest. And I don't know about you, but my trauma arrest protocols say to start punching holes in the chest. Yeah. Could you imagine starting to punch holes in a chest of a guy who definitely does not need it? I mean, like do they have a trauma rest protocol?

Uh no, so like the best that they have is like, hey, if your patients uh if you have a trauma patient who's going into shock, consider tension pneumothorax, they don't actually have a like, hey, you y your trauma patient has arrested Here's what you should do. Generally speaking, as a system, no, it's not. But uh For this one call.

Uh yeah, so several compressions later, uh uh Lure stops compression compressions because the patient uh just gasps uh and startles. the everyone, really. Uh except for Tem, who goes like, Okay, th I th they're pretty sure they're alive. Which side note here

Not necessarily. I've gone on plenty of people who are asystolic and gasping. Uh that gasping doesn't mean they're alive. But this sort of is one of those moments where like Tim kind of regains like, wait a minute, they had a pulse when I last checked.

So they check a carotid pulse on the uncut side of the patient's neck and boom, it's there. Uh so they say, Hey still there, by the way. Yeah, guys, uh he does have a pulse and it's strong. Um But because it was kind of like a code was starting, they do have the defibrillator pads out, uh, and so they finish placing those pads on the patient's chest, and their partner says, Hey man, go grab a backboard.

So uh Tem leaves to go get a backboard. Uh, as Tem returns with the backboard from the ambulance, the firefighters essentially like lift. Or the tilt, I I'm not sure. I'm not a firefighter. I don't know. There maybe there's a yeah, it's like, oh, we pulled the McBurney's Car tilt maneuver. Um Yeah. Yeah. So the either way as I get a previous volunteer firefire, the McBurney's car tilt maneuver is totally what we use. Yeah. Nice, nice. I uh I know enough.

To like I know survival firefighter, I guess, would be the There you go. Like, oh yeah, McBurney's uh car removal tilt uh maneuver. Yep. No, it works. That's fine. Yeah. How do I say in Firefighter, I'd like a beer my friend will pay? That's Oh hydrant. First in, last out. And then you walk away. All right. All right. So uh Challenge coin. Challenge coin. There it is. So they tilt You broke me, damn it.

All right. Uh so enough of the car is tilted or lifted to that allow the patient to be ex extricated, i.e. just pulled out and onto the backboard. Uh they get moved directly onto the backboard. Manual stabilization of C spine is maintained by one of the many firefighters on scene unnamed firefighter on scene at this point.

Um, the patient is secured with spider straps onto the board. Uh uh quick note, no one assessed the patient's back. Um probably would have been worthwhile, but uh yeah, I get it.

Um, once the patient has moved out onto the stretcher, uh, Tem notices that this is when the BVM gets connected to oxygen because That's where it was. It wasn't before. And uh they kind of recognized like, Oh, yeah, uh Sis asked for oxygen, but it never came. So um Anyway, uh s the bottle gets set to fifteen liters per minute. Uh the patient is moved into the ambulance, and uh paramedic firefighter Faye

uh who is on scene as well, announces to the sis and Tem and Ick uh that they will be writing in to assist with this patient. Systemic! I just got it. And that uh firefighter lure will be accompanying them. Um yeah, so uh Nice. Do we have to have Firefighter Lure? I mean, Yeah, we have Firefighter Faye and Firefighter Lure coming in. All right. So what should happen next and what problems do you think this crew might encounter given what's happened so far, Chris?

Everything. Um, okay, let me kind of recap in my own words, kind of what we have going on. All right. Patient is now out from under the vehicle. They are on a backboard. There is a manual stabilization of the C spine. Have we put a collar on yet? Uh the c a collar does get put on in the ambulance and the C spine was maintained as they loaded him in. Okay, but at the at this point where you were asking me what needs to happen next, we don't have a collar on?

Uh let's say they do. They're in the ambulance, all these there's gotta be a plethora of p yep, collars on. Alright, collars on. Uh yeah, cool. Call collars on. The very next thing I do is now that we have the legs exposed.

I want to redo a quick head-to-toe and double check for exsanguinations and any bleeding that needs to be controlled. Um I know it would probably be obvious if I'm actually there, but I figured I want to ask the question at this point because there's some other things that I thought would be obvious that hasn't happened on this scene. So Uh, you know, uh the very next thing I would do is now that we have the patient out from underneath the car and we can see the whole patient.

Let's do all once over. Since we have enough people, we can easily do this. Hey, you, whoever you is, do a head to toe. Look for bleeding. Stop it if necessary. And for the rest of us, let's get a set of idols. Yeah. Yeah. So that's what I want. And I'm assuming we are we're we're B VMing this patient. Yes, we are still BVMing this patient.

Okay, so what I want all right, so let's get a set of idols, let's have some person be doing a head to toe, and let's make sure that what we're actually doing with that B VM is gonna be effective. If we have the people and it certainly sounds like we fucking do Uh let's make sure we have somebody uh i if we can and we're still BBMing, let's have one person maintain a mass seal, one person squeeze the bag. Yeah. No, I I think you're this is a perfect moment. Like it this is a chance

to kind of reset the chaos of the scene. Yes. Right. Like you're in a different environment. You've got lights. That's a big and it's not as loud or as, you know, car tilty on you perhaps as outside. Um this is a moment where uh a person can establish themselves as PIC and start directing care. And you know, there's gonna be this is gonna be one where I I my anticipation would be that people have a lot of ideas and they're nervous given the chaos that previously happened.

So there's going to be people who are shouting out like, All right, I need to get an IV or All right, we need to do this. But this is the moment where you go like, Guys, hold on. We need to get a we need to know what is wrong with this patient. Make sure we are not missing any life threats. Let's get a head-to-toe assessment. Let's listen to lung sounds.

Let's let's get a baseline set of vitals because we're bagging this patient. We need to know if that is effective, if you know we're hitting the targets we need to, and then we can go from there. But Do this first. Yeah. And here's the thing, you got four people, right? I mean you actually have more. Are we driving yet? No, no. We are we are just in the back of the ambulance and uh yeah. So the re so the way I do I got four people, it's like okay.

Uh yeah, you go ahead and get that IV. You go ahead and do a thorough head to toe. You see bleeding, you stop it. Go ahead and get the monitor on them, guys, let's get a quick set of vital science and let's reevaluate this airway.

Done. Everyone's like, Why am I gonna start getting a tube? You're gonna wait until you reevaluate the stairway. I'm P I C. This is what I need to have done. Okay. Yeah. And if someone starts challenging it, be like, guys, we're we're gonna we're we are gonna lose more than we will gain if we're not organized. Yeah.

So yeah, and and that and that's fucking true every time. Yeah, every time. All right. Anyway, but yeah, no, I I think what we need what you need to do now is someone need to step into that PIC role, reset this scene. Yes. All right.

Well, uh, drink up'cause uh that doesn't happen. Uh mm, yeah. So uh Fay uh takes up the uh paramedic firefighter, Faye. sets up uh takes up the airway seat, or the you know, captain's chair, as it's often called, uh, in the back of the ambulance, and announced to the crew of Sistem and Lur Uh system failure, systemic failure. I got it. But I got it. That's not at all what it is. Uh we need to get an airway. Uh

So uh Sis opens their jump kit and grabs out an eye gel, but is told by Faye, no, I want an ETT. An ET tube. So, uh, let's Take another quick sidetrack onto more system issues that uh may or may not uh definitely will uh come into play. So 99 Problems Ambulance Service uses King Vision Laryngoscopes. Uh those are high angle laryngoscopes. Well the fire department uses C Macs, and these are standard angle like Mac blade angles.

Yeah. Simply put a C Mac, by the way, guys, just think take a standard direct laryngroscopy MAC blade, that's the one with a slight curve, put a camera on the end of it and a monitor on top. That's it. Yep. That's it. Simply put, these different Loryngoscopes require different techniques to use for the same. Entirely different techniques, even different equipment. Yes. service. I I don't believe anyone in this area has RSI.

uh nor does it allow for post-intubation sedation. Um uh and per tem the crews who have uh administered s sedatives outside of situations in which you're giving sedatives because your your life is at risk. Um th those moments get very, very, very scrutinized by the uh medical director. So not only is there no RSI, there's no post intubation sedation protocol. Mm-hmm. Mm-hmm. Yep. Oh my God. Imagine how often intubation happens with that knowledge. Uh very rarely.

Yeah. That that I mean, I don't know that. I'm I'm assuming I Tem did not say like it could be that he's like, Oh yeah, tube every one a month. I Fuck, that would be terrible. Especially without the nation. But uh if I were to apply what little I know of EMS uh broadly to this area, I'd be like, no, then what this means is that no one is doing that.

Um except in dead people. Yeah, you have made you have made innovation uh the you've made the reasons to innovat so rare, the criticism the and scrutiny so high that no nobody would do this. Yeah. Yeah.

Alright. So uh back into the call. Um so Tem at this point, because Faye has said no, I want an ET, uh fetches out their King Vision and hands it to Faye, who starts prepping equipment. Um now remember Fay does not use King Vision. Fey uses a C Mac. Right. Keep that in mind. Alright. Uh so Tem uh

is setting up for an IV start on the patient's left arm. Uh they note that the patient is not on the monitor. Uh so they tell Lure, who's down at the patient's leg, hey, can you put the patient on the monitor? Um And sis uh is adjacent to Faye up at the airway uh and is assisting Faye in getting equipment set up. And Tem realizes at this point, no one is providing BVM respirations to the patient.

Tim points this out to Sis, their partner, and says, like, hey, are you are you're not begging the patient? And Sis responds, We just need to get an airway. I'm just upset. Um I'm so upset that what I recommend for this crew is to head on over to flightbridgeed.com. And sign up for the precon uh probate. It's a class that is uh put on by master your medics and it talks about uh how to approach. Probably

to result in better patient outcomes. And I'm pretty sure it's gonna talk about a lot of stuff that you did not do. So head on over to fast twenty head over to flightbridgeed.com slash fast twenty four. Get signed up. It's going on june tenth through the twelfth in Wilmington, North Carolina. I will definitely be there. Spencer won't because he sucks. Yeah. How's that the product play Spencer? Ha ha ha.

My hat's off to you. I uh Uh but okay. Now I it sounds like I'm I'm joking or or poking fun. Uh I'm not because I literally I I do actually mean that. I mean it has to be fast twenty four, it should be, but I mean like y but the the problem the big problem here that I see is like This is what happens. Everything that's going on right now is what happens when you set crews up for failure by not providing them the like good training. The kind of training that you would receive.

At the fast twenty four pre conventions. Um or pre cons pre conferences. Yeah. But but it's true, right? I mean, w we have made innovating people So impossi such an impossibly small window. You'd never hit it. Uh and like there's no like the biggest problem here right here, you and I have talked about this time and time again. RSI needs to stand for really slow induction, right? Like

Slow this down. This is uh I think I said this about other episodes too, so people are gonna think I'm just full of shit. But it's actually true. Um I was actually telling you about it on my way from work'cause I got off work this morning. Before I headed to the studio,

AKA my house. Uh and um my sounds better, we had a hell of an airway yesterday and I the crazy thing is I started out using a C Mac and finished with a glidescope. And a glidescope it it's not a King Vision, but it's the same high angle thing. And the usage between them is so different.

So amazingly different that you can you simply cannot use it the same. You cannot pick up a high angle uh laryngoscope and expect to use it correctly if you've if you have not been trained on how to use it. It's a different tool. It it's like picking up a wrench when all you've ever used is a hammer. You know? I mean you might think it's self explanatory, but there's tricks and there there's ways that'll make things successful. It's not. So anyway. Yeah. I um

I think no no I think I think you're right. I think this is one of those things where the system has set everyone up for failure. Um this is this is kind of like that old school You know, like airway before everything else was like, No, we can't Yeah, don't BBM because we need an airway. And Everything that we have learned r basically goes counter to that now. It's like no into intubate once you have the patient.

able to survive that. Um this is yeah uh and th there's so many th we're we're gonna talk about a lot of this at the end, probably not all of it, because fuck me, there's there's so much No, there's so much. But like the other thing too here, man, is is like th this I don't even know I have seen no assessment of our B VMing in the first place. How good was our B VMing leading up to this point? Yeah. Is this an old call or is this recent? Uh th this is

Post COVID. Yeah. No, this is within the last ten years. Yeah. Uh oof. All right.

So uh along with uh Sis, Tem, Ick Faye and Lur. Uh we have uh three other firefighters uh who just kind of fill in to the space in the back of the ambulance. They're unnamed because The they're they're just there occupying space. Um Yeah. Yeah. Um There you go. They're part of the environmental problem. Yeah. So Ick, the supervisor, is standing at the side door of the ambulance and by the way, just letting this shit show happen, I guess. Like Mm.

I have so many thoughts on this supervisor that may be unfair Uh because this is the lens of one call, but it's kind of telling if they are like if you're not paying attention, yeah. Like either you're mm, yeah, mm, uh So uh yeah, like maybe they didn't hear the like we just need an airway exchange, but i they should be noticing that no one is providing positive pressure ventilation to this patient.

So mmm uh like are ignorant or bad. I I don't know. And there's no difference to the patient because they're just getting fucked. That's that's mm. Anyway. So uh more on this. Faye asked for an eight point oh ETT Given the largest ETT that ninety nine problems has, which is a seven and a half. Um no big deal there.

Uh we do know that the setup included having suction ready, they had a stylet out, they had the syringe, they had the n-title CO2 uh device plugged into the monitor and set up and ready to go. So in regards like in terms of Fays set up.

solid ish in terms of the rest of the in terms of the equipment setup, sure. Yeah. Um but yeah. So uh before we move on to their attempt, let's talk about the same. Do they have a backup device? Uh they do not have a backup device. Uh no, so that that would be one piece that they definitely should have. Uh but Well Okay. I I've I have no faith in them getting this tube. I mean they they they might but I'm just gonna go.

I have no faith in it happening. Uh yeah, put money on it because uh you'll win. All right, so let's talk about the secondary assessment that we have so far. Uh we do know from Tems Positioned that the patient got on the monitor, and Lure, uh, who's down at the feet, has cut the patient's pants to assess the legs. What they found about the legs, we don't know. We do know that the pants were cut.

Um so Tem basically was like, I don't remember. He might have said something, but everything was going bad at this point. Um so yeah. Uh we do know we also don't know about pelvic stability. That's another piece that could come into play here. Uh the patient's chest is visibly bruised on the right side. No one has listened to lung sounds. The monitor isn't visible to anyone at the airway spot.

Uh but we do know that peri intubation vitals from the monitor that Tem was able to visualize were a heart rate of 90% and an SPO2 of 80%.

I'm assuming we're not denied at all because no one's begging for this person. Yeah. So yeah. All right, cool. I mean eighty percent is pretty good if you're agonal, I guess. So uh Faye goes in for the intubation attempt and uh presumably can visualize the chords, but as they try to advance their stylet-filled 7.5 ETT. down the channeling of the King Vision, they quickly report that they are unable to advance the tube. Uh put a pin in this for our lessons for later, because

There's a reason that it won't work. Um the King Vision. Uh I've used King Visions before in in terms of at a trade show only. I've never used one on a patient, so I'll make that clear. Um I don't remember, does it use a specialized high-angle style? Uh no, so I I guess

We'll talk about this now. No, so the King Vision channeling according to'cause I like you, I haven't also used a King Vision uh outside of getting to uh play with one for when I used yeah, I I didn't care for it on the mannequin tell you I was checking but But uh the ch ones with channeling, they do not need a stylet. In fact, you should not use a stylet with them because that will m that the high angle means that it kind of lines it directly up and you use

You use the laryngeoscope essentially to uh it has a built in guide. Okay. Gotcha, gotcha. That's it. We'll talk about that later. But uh but they have a style in it when they shouldn't. Okay.

So the King Vision and Tube uh remain in the patient's mouth, uh as Fay says like I can't get it to pass, and Ick steps up to the plate and attempts the intubation, changing nothing except that it's now ick instead of fay. They are also unable to get the tube to pass.

So um uh Faye asked for a standard Mach 3 blade and a 7.0 tube, uh while uh Ick is trying this, and uh essentially when Ick can't get it switches out for a m standard MAC three blade seven point oh tube and secures the ETT, which then is confirmed with lung sounds uh and uh auscultation and N title CO two.

Um auscultation over the uh epigastric area. Lung sounds, no epigastric sounds, positive end title. Um so Tem believes that the total time for the patient not being bagged, like from intubation setup to finish. Uh, took about two minutes, but I'm gonna take this with a grain of salt because time moves weird in high stress moments, and I think we tend to short like

Even in the best of situations, people are really bad at guessing time. That's been my experience. Maybe there's one person who has it down to a T. They're like, no, I know that 37 seconds has passed. Uh but anytime I'm working, I I find I'm like, Oh, it only took me a minute. No, it actually took me two. It took me three. Uh it just felt like a minute. So he feels that time that that not a lot of time was lost in terms of positive pressure ventilation, maybe.

Probably not. Um so I'm always the opposite. I'm always like, God, this is taking too long and someone's like, but it's been fifteen seconds. You're fine. So Um so the lung sounds on that uh uh when they listened were noted to be diminished on the right side. Hey, good news. Now we have a set of vitals. So the patient's GC GCS is still 3, heart rate remains 90, blood pressure is 138 over 78. Uh respirations uh B a V B VM, I'm assuming, are twelve a minute. Uh that seems like a standard rate.

Uh because I know that they are being bagged. Um N title CO2 comes back at 46, and the patient is now 95% on 15 liters per minute of oxygen. So uh yeah, Ick asks sis, all right, hey, uh you gonna be transporting the patient to the trauma center? And sis says, no, let's go to the closest, because airway was a concern. Uh

And if you're going like, wait a minute, is it though because the airway wasn't? Because they just they just got it innovated. Well what else is the non trauma center gonna do? Yeah. Uh I don't know. They will later tell Tem that they just didn't think that the patient would make it to the trauma center. Okay. So um again mm I

What's what's the difference in time i in in travel time here? Uh so it's ten minutes to the closest or thirty minutes being giving the longest estimate to the uh to the trauma center. Okay. Um I would I would say that I do not have enough information right now on hand to say that that is a valid concern. I I think that's the fairest I can be on that statement. What the information we have.

Says No, you should be able to make it to the other hospital. Unless yeah, but anyway. Um so the supervisor uh okay's this and calls in patient report to the closest hospital on behalf of the crew. Tem gets up and starts driving the ambulance. Uh lights and sirens. So fail and blur ride in. Uh 10 minutes to that closest hospital. And here's what we know happens in route.

Uh several IV attempts were made by Cis before Lur successfully placed a places a tibial IO. Uh a liter of unwarmed normal saline was pressure bagged into the patient. Um, I did ask about any kind of heating, uh given that it was you know cold outside. Um and Tem does not recall any heating measures being taken, like a blanket, warm air, etc. So

Uh at the receiving hospital the patient was quickly placed on a ventilator, they had warming procedures and blood products started and were taken to CT. I do have follow up, but uh we're gonna have to wait till after we review this call. So, Chris

Um remind us why we're angry. So end of call. System and Ick of 99 Problems Ambulance Service responded to a single vehicle rollover with a partial ejection. They thought it was two people, turned out to be one. Yeah. They arrived to find a twenty zish ish male unresponsive diagonal breathing, partially trapped under a car. And uh there's some difficulty in getting the immediate life threat managed a as well as some appropriate uh inappropriate CPR.

uh that gets performed. Most of that difficulty getting the immediate life threat managed is has nothing to do with the patient and everything to do with the cooperation of our uh additional responders. Of all the cats responding. Of all of all the cats. Uh the patient gets extracted from the scene and moved to the ambulance on a backboard. Uh eventually uh Sis and uh Tem and Ick are joined by the ambulance firefighters, failure uh

Firefighters Faye and Lure. Le Le Lear? Failure? Failure? Whatever. I didn't notice. Uh yeah. Uh good patient care is uh thrown completely aside. Well everyone uh fixates on the most important thing ever. Uh just just get in that tube and just letting the rest uh go go to the wayside.

Uh equipment issues uh also prevent the ETT from getting established very quickly, uh, as both Faye and Ick uh fail to innovate uh the patient. Eventually Faye gets it uh when they use equipment they actually know how to use, uh, and use a uh slightly smaller tube, the seven point oh. And uh then we go to the wrong hospital shortly after that. And uh yeah. Sorry, maybe it's not the wrong hospital. I just I feel like it is.

More more than a feeling. Oh boy. Well, uh Spence, I know what I want to talk about, but what kind of things uh what kind of lesson topics can we uh I I think I wanna talk a little bit about But one of the uh human traits that falls in uh in into this, I I see a lot of target fixation on on this. Especially once we got that airway. Yeah. Yeah, with that airway especially. So I think that's worth talking about.

I think there are a lot of system problems um that I hope you're gonna be able to provide uh some enlightenment on. Uh'cause I just kind of like I'm like, yeah, that seems bad. And I feel like there's uh you know, but uh you are much better at that piece than I am, uh I guess. We'll see. Well um yeah, what about you?

Uh well yeah, I wanna touch base on those. I wanna talk about the importance of scene leadership quite a bit in this one. Because that that to me was the crux of the problem. Uh kinda all I mean there It's one of many problems but if you have good scene leader leadership you can get past some of the worst protocols. Um Yeah. You can have no you can have ninety nine problems but your scene leadership ain't one. It's the All right. Um yeah, so there's uh yeah, scene leadership.

Uh talk a little bit more about airway decision making. I mean, I don't think it's necessarily a bad idea to manage the airway in this patient. It's not. It's just it's how they went about doing it and forsaking all else.

And that target fixation you mentioned. And then the other thing too is um I briefly touched on this later on, but um speaking up. Now given ultimately I'm gonna kind of project what I think is i is a problem, a major problem on this scene to where sometimes even speaking up can be difficult, especially when you're in Thames

situation. Yeah. Um, you know, Tem's position because it it's easier to speak up when you're in a leadership role. Uh how about this? When you're the one when you are in a role where you can take PIC. uh and have the credentials behind it, it's a lot easier to speak up. When you're Tem and you've been an EMT for one year and you're almost a paramedic, um It's speaking up becomes harder. It does.

You know, and and even if you do it, it may not be effective. You know,'cause you have to convince people who uh allegedly have more training than you to do what their training is telling them to do.

And unfortunately, part of that, especially if we're talking about delay, means that someone may it may have to be like, oh shit, I should have been on this. In other words, you're not just asking people to do their job. You're asking them to admit error, at least on some level, for not getting to it in the first place. And humans don't like to do that. Um so anyway, yeah. Um I'll let you start while I gather myself, talk about whatever you want to talk about for a bit. So perfect.

All right. Well, let's talk about the idea of target fixation because that played a big part in this. And, you know, like Chris and I I I came into EMS right I think at the tail end of you know, where where it was recognized that like, hey, if you get the tube but you kill the patient in the process of trying to get the tube You know, like that's not a win. Um so

But we see this in all sorts of things, like distracting injuries. Um, there there's all sorts of things and situations that can arise, not just this call. uh where target fixation is the problem. And essentially what what it is, it's you're focusing on one piece or one aspect or one goal, uh of the overall goal. You know, like if our goal is to get the patient to the hospital

uh as alive as possible, like with as you know, like with as much you know, we talk about we don't save lives, we s you know, we secure percentages. Right. Like like like you if you want to give this patient the highest chance Uh Then you know, like that's the overall goal and getting an airway like in this call is just one aspect of that. If you do it well, it might be beneficial. But if you do it badly, you have a and and you focus solely on that

outcome, then you have it and you can do so to the detriment of the patient. Um so uh yeah, like by fixating on this outcome, uh on just we need to get the airway uh They essentially accomplish a they accomplished the opposite, right? Right. And so a a perfect analogy for this is actually where the term target fixation comes from. And what it is is it's fighter pilots attacking ground targets. And

Target fixation comes from that'cause what'll happen is the fighter pilot will fixate on that target and target's not quite in range, don't quite have to crosshairs on it. So we gotta hold this cause eventually you have to pull up, right? Yeah. Otherwise you end up dirt diving. And what'll happen is like, all right, got the crosshairs on, boom, missiles away. And then unfortunately, you didn't leave yourself enough time to uh to follow up. And so while you got the missiles off,

You then crash into the hillside. Or and that's kind of where the term target fixation comes from. Or you're doing your trench run on the Death Star and you're just like stay on target. Stay on target. Yeah, and the and the TIE fighters are coming in from the side and you know, everyone's like, Pull up, you gotta get out of there and it's like, No, I gotta stay on target and then that guy dies. Yeah. And hey, who, uh...

Who ended up doing it? Yeah, the guy that turned off his targeting computer and relaxed. And reached out with his s reached out with his senses. That's right. Yep. Yeah. Yeah. And then he was all clear, kid. Yep.

So here's the thing. Uh why why does this happen? And I think A lot of it arises from pressure, uh stress. Um when we are stressed, that induces that kind of gut level thinking, heuristical thinking, where we we don't we essentially abandon higher thought because there isn't enough space, there isn't enough time We have this perception that we gotta get this done. Um and that kind of stops us from thinking about the full thing in in in focus. We're essentially diving underwater and

You know, like we're running out of air, so we gotta fucking get this done. And the person who is able to kind of stand back, who has the you know, like and not all scenes have this. Like th you know, sometimes it's just you two and there are thirty thousand things that need to get done and Mm, that's a bad situation. But in a scene like where you have somebody who's able to sit back and kind of

survey over this and able to maintain that, you know, their head above water and see what's going on, that then this is less likely to happen. Um obviously not Not in this case, but uh yeah. So what happens there is in our in our gut thinking, we just sort of forget that Oh you know like we we lose that ability to track the overall point of what we're trying to do, what we're trying to accomplish.

Um, and we anchor uh onto ideas like we need to get an ETT because that's the only airway. Forgetting that like, hey, we were just a couple seconds ago, we were BBMing this guy. And prob potentially to good effect, you know, I I'm assuming You know, being charitable, let's assume that they were B VMing well. Um and

So they had time, but again, in this rush to that, you forget about that because we just gotta get this done. Um, I this sounds again like outdated training and knowledge where, you know, it's like it's an ETT or it's basically not an airway. Um And uh and that again that's just that prevents you know, forward thinking. So who does this happen to? There's me. Yeah. There is new yeah, there is no one his who is immune to this. And that's why it's really important to have like

you need a team to do this job. You no one can do this alone. Yeah. Uh because You need somebody who is able to take that role of overseer, essentially, and help keep things on track. Uh and they need people to respond to give them information to make sure things stay on track. So again, the the the mitigation for this is essentially.

We need to one, we need to be aware that this happens, right? And we we know to some extent that's why they're called like that's why we have things like watch out for distracting injuries, because we get fixated on the thing that, you know, looks grossest and troubles us the most. And then we forget that the quiet thing of not breathing isn't happening, right? Taking that and applying it more broadly to all aspects of uh an EMS call.

is is important. So recognizing that this is something that can happen to you, um, and then training for that, or just training in general to good procedural like, you know, competence. Um uh helps mitigate that fact because I guarantee that if this crew had been in a system where uh training had tr I I can only assume that this is there is an absence of uh ongoing airway training at this place.

uh or I should say an absence of quality ongoing airway training, because then they would have been able to kind of cohesively come together as a team, recognize the value of preoxygenation. Those those things, if you train on them enough, Then it you take it away from that like higher th like having to be a higher thought and it becomes more muscle memory. And then when you are stressed, that is what you're thinking of, or those things that you have kind of worked into muscle memory. Um, yeah.

Well what I can tell you is if there was training on this it certainly wasn't applied, so Um Or i i if the well maybe the training is uh fixate and and forsake bagging, in which case they follow perfectly. Um Let the Death Star win. Yeah. Okay. Honestly, like yeah, I mean that kinda is the training. When when you um when you have a system that basically sits there and and um villainizes intubation.

Uh y in a in a passive aggressive way. Yeah, your training does kind of actually set you up to do exactly what happened. So I don't know. That is the training I guess. Anyway, maybe not I don't know. I I don't know. I don't work in that system. But um the other thing too is like, you know

This is where scene leadership can really come in, right? Because I've talked about it before. When you're the PIC, the PIC is not necessarily the smartest person in the room. The PIC at their best is a conduit of information. Yeah. And that is what it the i PIC is not a rank. PIC is an intervention like starting an IV or getting in our way. That's all it is. You are a conduit of information, and your job as PIC is to take in info and make assignments.

And if that is your sole job, it gets almost difficult. to only take in one source of information and only take in one a and only perform one assignment. You know what I mean? Yeah. Like so when your whole job is to make assignments, like yeah, you you're gonna get you're you're gonna have to actively reach out and get information. feed it back to your team and make assignments. And if that's the case, it can almost be it makes it harder, not impossible, but harder

to get involved in target fixation. Um and so uh yeah, the la I mean, I could spend all day on scene leadership on this one, but a lack of scene leadership I felt yeah really contributed. to things going uh askew. But again, like in a patient where we have an airway problem and we really seem to have Airway protocols that don't arm us to really deal with an airway appropriately, uh, especially with no post sedation protocol, which is

Ridonculous. Yeah. Um, then I then yeah, we are setting ourselves up uh for this to happen. What uh because I mean again, even if you are a good leader, like what tools do you have? Yeah. No, I yeah, yeah. Yeah, no, one hundred percent. And I I think that's I think this is kind of the the difficulty of a call like this is that I well, you know, like the crew have They the crew on this call did not perform what I would describe as excellent patient care.

I think that's what and I ha I hate saying that. I hate saying that, but I I'm sorry, go ahead, man. I cut you off. But no, no, no. But I think that the fault The the higher uh like the crew is thirty seven percent. at fault and the system is the rest of it. Uh like the sixty three, yeah. The because there are so many problems that can that I can just sort of see In this one call. And that's that's tough to say. Like I I mean, maybe I'm speaking flippantly, but I really do feel that.

This is one where given what we know of this system, the system oh the like this outcome does not surprise me. Um right. No, it doesn't. It a system should not rely on their cr like you you You shouldn't have an EMS system where your crews

basically have to perform at one hundred percent and cannot make mistakes for things to go well. A system should be set up so that your crews are can are appreciated as human and able to make mistakes and able to misread things and able to fall into target fixation problems or you know like Your system should be able to go like, hey guys, we use different equipment than this other company does. Be c be wa watch out for that because they are different techniques.

Like that should be built in so that people can know. Like your system should be there to mitigate problems. It shouldn't be the crucible that you have to make it through for your patient to survive. Anyway. Oh, go on. Sorry. I got woo one more thing I wanna I I wanna touch on. I I I know. But I I just I I kinda wanna touch on this. Overall A paramedic who has some known training issues. I'm putting them, you know, with with somebody else in a system that

Doesn't give me much in the way to do that almost seems to ignore advanced airways. Like you don't even have post post innovation sedation protocol. What are you supposed to do? And the patient starts waking up. Sir Extivate. So And so it's just one of the things where it's like, what did you think was gonna happen?

Yeah. What did you think was going to happen? This is one of those where you look back at it and it's like, yeah, guys, this was the outcome that you created. This is the outcome you went for. Whether you know it or not, this was the outcome you supported. Uh and here's what the system kinda and and again, I wanna make it clear. If we if we don't make it clear enough

All we can possibly do on this show is react to what we're told by one person. Okay. And so we understand that this may be a completely inaccurate representation. And so what I want our listeners to do is not sit there and think about, gosh, what system is this?

But rather think about what system could this be. And if this is a system, what are the problems with it? And that's kind of the kind of the way to to do that. Yeah. Um and what this looks like to me, this looks like a resource limited system to me. That it that has some cash flow issues. And what we have done is we have reduced training. We're reducing protocols to match the reduced training. And I will tell you the truth, it seemed like most of the providers on there were avoidance.

And so a as much as I want to be like sis here, you know, i is a problem. I'm not convinced that that sis is a problem. Sis may be a low performer in a low performing system. But I don't have based on the supervisor that just watched the shit show happen. Uh, based on a firefighter randomly starting CPR and someone that didn't need that, based on everybody but Tem not focusing on the patient, which is really the only reason you're there.

Um I I feel Like it is likely that every provider on there was avoidant and not confident. That every provider on there had a hole or gap in their continued training. That is what this scene felt like to me. No one, no one stepped forward because no one was competent enough to step forward. And when you have protocols written like that, I really start to doubt. that this system is really putting resources into training, into appropriate training.

And again, I don't know enough about the system to make that statement clearly. But what I'm saying is that if you are in a system where you're not putting appropriate resources into consistent high quality training, like the kind of training that you can get. at the Fast Twenty Four Conference happening June tenth through the twelfth in Wilmington, North Carolina. Um, then these are the kind of outcomes I want you to expect. Yeah.

Okay. I I I don't even want to say these are the outcomes you need to try to avoid because you're not trying to avoid them. This is just what you have to expect. If you're giving poor training, look forward to this. Yeah.

Um, let's do this then. Let's as we go through this, because we'll go through this in sort of our normal uh our normal aspect, but let's talk about if there's a you know if we get to a point where it's like, hey, the system owned a part of this, let's talk about it there. Um, rather than try and'cause I think we're gonna end up repeating ourselves a lot given that

the g if we talk about all the system problems up front and then go back and touch on the uh the interventions or the just the the flow uh the the call is it flowed. Um so Uh the first thing I and I'm glad we got to talk about this right away because that was something that really bugged me was All right, so we have a s we had that supervisor who said, Hey, watch out for this guy, he might suck. But not exactly those words, but basically the m the the measure. Um

And y you would set the we had all established like yeah, that's not the best way to do that. Um I given I wanna say and maybe this is me being mad at this supervisor because You know, like to some extent that's forgivable, right? Like maybe probably didn't get the best supervisor training, but the fact that this guy who's the supervisor stood back and let this shit show happen.

also could signal to me that this is just a person and there are there are supervisors who are really good supervisors and then there are supervisors who are Um uh people who have thrived in a bad system and Uh, aren't like, you know, and they're just like, yeah, my shit doesn't stink. And they're like, good, you should become a supervisor here. You're well liked. Nothing bad has happened to you, and they're not any more competent.

Than the next person. True. They're the kind of guy that would go, like, you know, I've never flipped, uh I kayak a lot, never flipped once. And uh Yeah. Yeah. That's crazy. And uh yeah. And then uh you know, when you you get'em out on a river, they don't know how to kayak. Uh yeah. Yeah. So yeah, that's uh uh mm. Anyway, I again it's one call and that's kind of dickish of me, but uh I I I I just

Well, uh th I think a good thing that happened on this call was the pregame conversation. Uh they talked about triage and uh, you know, Tem even thought about like, hey, the trauma hospital is Connected to this red. Yeah. Um you know, we're no, that was that was good. Uh if only the call would have ended there. Um but it didn't. And so so we get on scene.

And once they get on scene, there's there's an immediate failure to establish a clear PIC at all. In fact, no one just no one did anything. One person, as far as I recall, correct me if I'm wrong, one person approached the patient. That was Tim. Yep. Yeah, so no established roles. I think we have uh I think the primary assessment was good. But I think it still needed some pieces that were left out. Um like

I don't think it was good. I disagree, but go ahead. Okay. Uh I was giving uh I was giving some credit, I guess. Uh where I saw it was good was that, you know, there was the focus on, hey, is there any major bleeding that we can see that needs to be stopped right now? Uh I changed my opinion. The breathing they noticed you know, they were like he's taking agonal breaths. That's insufficient for continued life, although Yeah.

Mm. I I mean, life finds a way, I guess. Uh Yeah. Uh but I guess we'll find out. Uh other pieces uh that probably should have happened at that moment and you know, uh w for what it's worth, lung sounds are important. Listen to lung sounds because one of the things that in a trauma patient who is partially out of a vehicle, uh, there is a lot of force there. There could be a tension pneumothorax that would

r like quickly kill this patient. And that is one of those pieces that you want to be able to identify early on for, hey, guys, we had a pulse and now we don't.

That yeah. That that would be the piece I would add. Um pelvic stability also a really good one to take because you wanna know if hey, like is this a p patient who's potentially losing a lot of blood inside? Um And yeah, it's difficult to do the uh the you know, distal leg assessment and I I don't know in lieu of not knowing whether it's a better idea to wait until the legs come out or be ready at the very minimum to throw some tourniquets on the legs.

Uh if you you know, like when they come out and you're Some prep work. Yeah, some prep work uh ahead of the game, uh probably would be solid. But I'm getting ahead of myself there. I I I just think there were some some opportunities that were missed. And again, if it's one person doing this. Um and also trying to make sure that like the the life saving interventions that they're asking for to happen also are happening, it it's really hard to to do that. Um

Cats are hard to herd. So Yeah. No, they are. Um

Yeah, I think so I I told you I disagreed with you. I I actually do I I agree that the walk up assessment was actually pretty good. Yeah. Where I think it fell apart is Once we got the patient out from underneath the car and there was better opportunity to continue that assessment, it just didn't happen. I mean we and we didn't we didn't reassess our interventions either. That's another thing to remember guys. Once you do an intervention, uh intervention, interventions such as

Bag valve mask, uh, you need to assess that that's working. That's a big part of performing interventions, right? Yes. Um, so that wasn't done ever, at any point, at least that was relayed to us. Yeah. Uh and we never I don't really recall anyone doing a head to toe after we got the patient out and seeing if there's any immediate bleeding, which I'd like to think it'd be obvious, but you know, still look. I just don't recall it being mentioned. And at this point

I'm not willing to give anybody any credit for anything I haven't heard them do. So Yeah. Maybe a thorough s head to toe was done after they were intubated and en route to the hospital when everything had kind of calmed down, but by then it's It's not I don't wanna say it's too late, but you got lucky. I guess, you know, like

You know, hey, are the lung sounds were the lung sounds abs like diminished on one side before intubation, or did that happen after intubation? That's important stuff to know. Um it It's rare that it would be you know, like usually it's the right main stem so the left side would be uh diminished. But uh yeah it It's still an important thing to have done beforehand. Um, I'm gonna throw this out there. No one ever checked a blood sugar.

I'm not gonna say it's the priority, but it's actually not a terrible idea. It does happen. We reviewed a call uh earlier on uh like early on in our thing where somebody had something similar happen. Um Oh, that's uh uh low and be cold. Well or sorry, that should have been low and be cold. God I know that was a great one. No, it was uh it was a trauma call you had brought.

Um well yeah. Uh so yeah, it it can happen. So a C B G can be important. So yeah, if there's time check on me, I'm not saying like all right, he's bleeding out, but let me get a C BG off the arterial spray before we before we shut it down. Oh hold on, don't plug it yet. Yeah, don't need the C B G. Where's the C B G kit, guys?

Yeah, absolutely. Yeah. Um so yeah, but let's talk about the treatments that they did do. Okay. Specifically the only one they really did, which was an intubation. Uh I I want to talk about the fluid Um I think my thoughts are kind of known. Uh I know you talked about uh with Q on this, but some of QS I know Q's also Q and I have had many conversations regarding airway and we're kind of along the same line, but yeah. My my biggest problem was with this was that um look.

The airway management may have been important. I don't recall much of an assa I I know there wasn't a lot of fluid or anything. I don't recall there being much in the way of airway obstruction on this patient. Um but you know, I I don't think the decision to intubate this patient is out and out wrong. No. The way they did it though was completely wrong. Um and I this is probably a patient, I'll think considered that I would have intubated as well. Um but

Uh this patient needed good quality bag valve mask work beforehand. They needed preoxygenation, because I've said it a lot, right? And that is that. if you have someone who is a healthy uh a a healthy patient, which this person's in their twenties. So if we're talking about healthy lungs, they're a good candidate for it, even though we do have bruising up and down one side. Yeah. Um, you know, but uh you this person's a good candidate for preoxygenation.

If uh, you know, that mix of air in the lungs is normally twenty percent oxygen, the rest is nitrogen, and then other crap. And argon. Argon, yeah, some Yeah, something like that. Yeah, I don't know. CO two's in there too. But um you know, you uh but you go in there and blood keeps circulating, right? Well if uh you know Twenty percent of that air in there is oxygen, the blood's gonna kinda run out of oxygen molecules to grab.

uh as it goes through if you're not replenishing them. Well, if you replace all those molecules with oxygen or as much as you can to get close to a hundred percent, then even when the patient's apne and you're going to innovate, That blood circulating still has a lot of oxygen to grab. And so uh you can have a healthy, a healthy set of adult lungs can last eight minutes, apne, before dropping below 90%. Yeah. That's huge. That's a lot of time to intubate.

Yeah. Now that safe apnea time goes down when you start adding in things like lung disease or pediatrics, those kind of things. Sure. Um you put children in the lungs, uh it's takes up a lot of space as it turns out. Absolutely. Yeah, one taller can actually take out both of them. But uh anyway. So uh but yeah, but that's generally yeah, we start talking about those things, yeah, that goes down, but you know

Preoxygenation is absolutely key. Um but yeah, that's kind of that that's my main take on it. And I wanna point out like in a patient where you we're suspecting a head injury, right? Because the vitals were solidly decent and the patient is unresponsive AF, right? Um so I'm in I'm in and and also like the mechanisms there. They're partially outside of their vehicle. I can't imagine uh unless there was like a pillow under their head and they're just like wow.

What luck. Uh SPF would probably yeah. I know SPF is softwood. Uh I don't know how SPF is softwood. Yeah. Um but that's a patient that I'm assuming probably has a bleed, right? Uh and You don't like One way to make things worse in a contained closed container is one, you have blood where it's not supposed to be filling up space, but two, you also have swelling from tissue that isn't getting oxygen.

adding to that. And so if you want to make somebody's uh uh brain bleed worse or the potential outcome of the what they could eventually undergo uh worse. Uh just deprive it of oxygen. Um that's yeah that's a great way to uh really negatively impact your pati your your your patient's uh likelihood of survival. Um it's It's important for all patients, but like, god damn, especially in uh in a patient where we're suspecting a head injury, uh, to

make sure that we are maintaining oxygenation. Um so Q brought up a really interesting point in regards to this and I I think it might be It could come across as controversial, but I think I understand their point and I I find myself agreeing with it. Um so the thought was, you know, and this was taken off the statement, no LMA, we want an endotracheal tube. Oh I see. Yeah. Okay. Yeah. Here's a here's an interesting situation, which is hey

Uh when you're in a situation where the airway you might immediately want to establish a solid enough airway. Like you're out, I don't know, on a fence with a car that might roll over, uh uh and you're not really able to ensure that you're able to get a good bag valve mask seal. Maybe you don't have the resources because they're all fucking standing behind you. Uh whatever. Like that is a good situation that you can drop an LMA in. And

And uh and th there might be some hesitation from people because they're like, Well, I don't know if it's the best airway. Well, I'll tell you what, it's better than uh a B VM. at this point, especially if you because it gives you one, you can then put an N title uh capnography piece on it, and you can start measuring, hey, actually I know it's getting a sa like I'm I'm getting solid air movement. I'm ventilating this patient.

And then two, the thing that I think people get trapped on is that they're like Well, once it's in, I will not change it. And that is not necessarily true. Uh and this is uh Q's point is that, hey, in a situation where y you know, like this, where it's like, hey, let's put in an SGA and Then once we know we have the airway secure, we've taken that pressure off us, we can m work on getting the patient moved.

into the back of the ambulance where we have better lighting, we have better conditions, and then we can reevaluate the SGA and determine if we want to keep that airway. Um and you know, and so I I am loath to take away an airway that's working, but this but I think there is a point where being flexible enough to say, hey, I'm gonna you keep this airway. But for the time being, because it's better than just bagging with a you know OPA in, but

being open to the ability of, hey, I can change this if at a later time I find that, you know what, I I think I can I have a high likelihood of success of getting an ETT. Um then you can be able to do that in the back of an ambulance with better conditions versus trying to do it on scene or going, I don't want to put in a SGA here because I think they need an E T Tube because it's better. So I'm going to just continue Shittier airway technique.

Um and I again like My chances are for me, uh, if I drop an eye gel on a patient or a King Airway in a patient, um, and then I move them out into a area where like in into the ambulance, like I don't usually change. Unless there is something that spurs me to change.

But I like the idea. I think this that idea of being flexible enough. If your system allows, you know, like there are protocols that are like, Nope, don't do that. If you have an airway, like that's the that's you fucking did it. You've accomplished the goal. And to some part that's true. But I think it's also

I think in the systems that allow it, it's good it's a good idea to keep that flexibility in that, hey, maybe we re-evaluate it and we find like, yeah, actually the IGL, there's like blood or vomit that I can hear bubbling up inside of it. Or uh there's you know the it's It's working, but I'm not getting great oxygenation. It might be that I like maybe it would be better with a better airway that I can actually just push long. Maybe there's tracheal injury that

r is better suited, you know, uh, with an ET tube because you can kind of move the tube down past that point of injury. There there's all sorts of weird scenarios that you can come up with, but I think the point again is to be flexible. So um

You I think that that's another piece that should be considered here. But I again going back to the system, uh, because you know, first exam the system, this doesn't sound like a system that actually would give that much thought into it. You know what I mean? Like it sounds like No. Yeah. So the system kinda pretends it doesn't exist actually. Advanced stairways anyway. Um what do you have thoughts on that? Uh'cause uh what do you think? No.

No, I kinda s I I've kind of spoke my point my point on innovation and whatnot. Um I think for me, like though, uh I want to touch a little bit back on some of the disagreements uh that that that Tim had. And one of the things that I mentioned that earlier is that Uh yeah. I I I think Tem in instead of going to their partner and being like, Hey, can you help out? Uh getting the intention of the entire team, I think, was probably necessary.

Um and the thing is i it's okay to be assertive when patient care is is at risk. Yeah. Okay. Uh and maybe you piss some people off, but you know what? You'll get the chance to address it after the fact and clear the air, especially in a patient like this. Uh and one of the things that I wanna make sure that people do. One of the best things you can do when you disagree is to make sure that you speak in clinical terms. Right. Yes. Um now earlier

Earlier I was like, Hey, yeah, tell'em to fucking help and get mad. Um, you know. But I was I was also angry at that moment when I said that. Listen, I was angry, I might have said some things. I'm sorry. Yeah. But hey, good news

you're getting a chance to address it now, later, after the call. So But but the hard part about this though i is is like I I feel that this is one of those calls where based on what was going on Okay, so typically when you have a disagreement, speaking in clinical terms uh is is good. You know, make it about objective items like hey, we have an airway or we have agonal respirations.

uh, you know, when in regards to patient care and not about like your partner or their bullshit plan, you know, like trucks. Yeah. That's that's not what it's about. God you suck and I have to correct it again. That's not what's gonna Yeah. Um this works really well when you have two people who are treating in different directions. One of the the main issue on this scene that I see is that and and I think it's this Thames uphill battle, is that you had a patient that

As it was described to us, no one should have been standing around doing nothing. Nobody should. It was blatantly obvious. You have an unresponsive patient under a car. You have you either have another engine full case. Here's the thing. If you have another engine on the way, I highly doubt those four firefighters are going to start moving the car without them getting on scene. Um what I can tell you is that you have a patient with agonal respirations, uh

Fixing that is probably your priority before getting that car off anyway. Uh, because if it's gonna take you five minutes to get off the car and you don't address those respirations, then congratulations, you've recovered a body. So, uh, you know, depending on how hypoxic the patient's been already. Yeah. And so the problem I see here is it isn't like we had two responders trying to treat in different directions.

We had one responder trying to treat and six trying not and and and I mean this based on the way it was told to us, practically trying not to treat. Yeah. And so I see a bigger issue than a simple disagreement here. I think Tem was fighting a system of, again, like what appears to be six responders who are uncomfortable, who do not want to step up.

Uh until suddenly it becomes apparent that something must be done and then we have every responder stepping up and doing something in their own way. Yeah. One guy jumps in to do CPR. Another person starts screaming they need an airway. Uh but not that air airway, this w this airway. You know, and it's just kind of

Yeah. It's just so haphazard. And so while I think uh you know, yeah, I mean I I think Tem um probably needed to get the attention of the group. I think Tem was at a severe disadvantage with the system that they faced. Yeah. Yeah. Uh one hundred percent.

Yeah, so uh I had to look up the King Vision. Um the ch the channel blades, they allow for a six to eight millimeter tube because it was There was there was some concern that maybe the seven and a half was too big, which was why it wasn't going through. But those are again to be used without stylets. And so that is a training issue. Um and again going back to the you know ick and the system, uh, the fact that Ick, who's a supervisor for this service

w didn't recognize that the stylet was the problem. Again, just sort of shows that the lack of uh I guess f pr progressive airway training that these guys have. Um so anyway, we uh I've said enough about that, but uh just wanted to make sure it was in the

No, no, I'm I'm with you. Uh so the transport rationale, you and I kinda touched on it earlier. Yeah. Uh going to the trauma center versus the closest one. I think this patient should have gone to the trauma center. I mean, we had the airway established. Yeah. Um I don't understand why Sis necessarily thought the patient wasn't gonna make it to the other trauma center. I um because we didn't have a hypotensive patient. Yeah.

Um and I kind of actually I want to back up a little bit. Another treatment is why were we why were we pressure bagging a liter of normal saline into this patient? I'm gonna start with the I I think those are excellent questions. I'm gonna start with um Uh let's start with the this proposition. When is it appropriate to take a trauma patient who needs trauma services? Like and this guy is a this is a

a you know, on the trauma criteria, the national trauma criteria that goes out, this guy meets it. Like he meets the mandatory take'em to the highest level trauma center uh Above all else. thing. So when is it appropriate to take a patient to an alternative s uh hospital where we're essentially

delaying care that they otherwise would need. What is when when would be a good situation to do that, Chris? When whatever is going on with them, whatever thing you ha you are unable to resolve is gonna kill them quicker than getting them to Trauma. So air a air airway compromised. Or I have bleeding I can't get controlled. Yes.

Uh so airway compromise, bleeding that is uncontrolled, I think those are really good things. And airway is the most common one, right? It's like, hey, you can divert to whatever hospital you need to, even if it's at podunct, you know, like st cardboard cutout ER that's in the middle of the nowhere where like that one doctor who scares you works. Like that that's a good that's a good place to go because like yeah, you need emergent help.

Um I I can tell you anecdotally that I've had I've I've heard doctors push back on you like we y you and I worked in a system where a patient was uh went into c essentially you know traumatic arrest. uh due to a penetrating chest trauma and they diverted to the closest hospital because their patient had coded. And the hospital went, we can't help them because we don't have the cap we don't have the resuscitative capabilities that they need.

You there is no benefit to coming here. And our medical director at for at the time went, Yeah, I mean, they're right. There's not a hospital that's gonna be able to save this person. Going to the trauma the the trauma center. You know, that was still you know. 20 minutes away, uh, would have been a better call.

uh in that regard. So uh yeah and that's again that's that's gonna be different for in every area, but that's something to keep in mind, I think, uh on this call is that that that while there are permissive times where it's like, yeah, bypass and go to the closest hospital because you know Or not bypass, but rather don't bypass. Uh but

I yeah, I think in this situation to answer your question, I think that this is a overwhelming this is a call that clearly is overwhelming to the providers that were there. Um Just want to get rid of them. And they just they were like, I've I've I've had enough. I don't want this patient anymore. And they might legitimately just be afraid that like I don't know like this has already gone so bad. I don't know what else could go wrong? Like because yeah, they're peaked.

Well, this is more avoidant behavior. I I I think I I think we have um I think we have field providers that have been let down by their system and uh they are not comfortable with this patient. And they were legitimately just unsure about what was going on with this patient. And it was kind of one of those things where they were fearing what they didn't know.

Uh, even though it's kinda right in front of me. So so I look at this patient and I start thinking like, okay, why why would I go to the nearest hospital instead of the appropriate hospital? Well, our airway's established at this point. Yes. Okay. By the time we're making the transport decision, we're ninety five percent sat. Uh ETCO two was in the forties. I don't remember exactly what it was. But it was in the forties. We have a good two forty six.

And we have a you know we have a good tube. And one of the things I and shock index is one of the things, guys, it's not gospel, but a shock index is one of the ways you can determine is someone volume depleted uh or not. And basically what you do to get your shock index. is you take your heart rate and you divide by the systolic blood pressure.

Uh in adults or basically anyone over the age of 13, a value of 0.9 or higher is shock index positive and your patients very likely hypovolemic. So let's do this math really quick. Okay, so heart rate of ninety.

And we're gonna divide that by a systolic blood pressure of one thirty eight, we get a shock index of point six five. This person's well below shock index positive. Yeah. So you have someone who's semi-dynamically stable, they have a heart rate in the nineties with a good blood pressure and an airway.

I again, unless we're missing something'cause of how this is told to us, I do not agree with sis that this is someone you need to take to the nearest hospital at all. This is someone who needs to go to uh a place with a trauma OR. And doing so, taking them to the nearest hospital is actually probably

It's either a wash and it's not going to really harm them or help them, or it'll harm them. Yeah. Because you and I have talked about this. Once a hospital has to a hospital transferring a patient to another hospital is not cut and dry. No. It's not.

And there's Mtala and you you'll sit there. A best case scenario is it's an hour before they get on their way to the hospital they should be. Well, okay, I won't say best case scenario. I would say a common scenario, even with critical patients, can be an hour. Yep. They can sit there. It's been done faster, I'm sure I've been part of things that have gone faster, but

Just bear that in mind. It's not cut it's not cut and dry. And when you do that, you're making a decision to potentially delay uh life saving intervention that this patient's going to need. And again, this just it boils down again. to a system that is rife with providers who appear uncomfortable. Yeah. I I agree. I and to the to to uh adding on to the fluid piece, the other piece that is often overlooked is warm.

And this is sort of this sort of adds to the really good point. This sort of adds to the like uh the the liter of saline probably wasn't necessary uh because it's a liter of it's also a liter of cold saline. In a patient who and w here's the problem with uh here's why cold is bad. Uh cold makes it hard for your body to clot appropriately. Um and so it adds to the you know trauma triad of death. Uh it creates

far more problems. And so it has to be treated aggressively. Um, you know, and and so like you got to turn on the heat in the ambulance. If you're gonna give fluids, ideally f warm fluids is the the the best fluid um and you should probably use fluids conservatively um and yep give them really when it's indicated um

You know, that that's th that that is what the evidence at this time shows. And maybe down the road they're like, actually it turns out everyone needs five liters. We were totally wrong about that. And then you know it happens. It does. Yeah, but I I I don't think that one's gonna go that way. But it it might. Yeah. Uh well, you know, uh Leave a Fed leave. Yeah, oh yeah, that's it.

Because they used to give them field and then everyone's like ah it's killing them and then someone's like, Oh actually it's not. It just turns out we give it to a hypercritical set of patients that die anyway. Um But well and here's the problem. The problem with both that I have with this is one, like you said, so both both hypothermia

Uh and large volumes of crystalloid fluids cause issues with uh coagulation. Yeah. And reduce your ability to coagulate. And someone who we do not want to reduce their ability to coagulate. Um so both those things leading together. So yeah, I was kinda disappointed when it when I saw the fluid. I mean I mean, yeah, spike a line, hang a bag, but uh this person's otherwise hemodynamically stable. It doesn't even look like their body's trying to compensate. Yeah.

You know what I mean? Like it's not like oh it's a good blood pressure, but it's maintained with a hundred and twenty. Yeah. You know. Or a heart rate of forty'cause they're in cushions, you know what I mean? Like then Right, yeah, exactly. Yeah. I'm not not really seeing anything like that here. So Yeah. So yeah, uh it was just kind of like all right, why are we giving a full liter uh pressure bag then? So

Anyway, um BLS. Yeah, I think this highlights the importance of BLS. Um listen. Uh one of the things I'm gonna say right away is that good positive pressure ventilation beats out shitty entitled endotracheal tube any tape. Oh yeah, ten ten out of ten times. Uh five out of five dentists agree.

Yeah, it's the same thing. The shitty f the shitty twenty four gauge in the hand is better than the eighteen you missed. Yep. Yep. You know, uh and in this case, yeah, the the B VMing that was that works is better than the ETT that isn't placed. You know, like that's yeah. Yep. That's the truth, man. I love it. So uh yeah. But and again, and that's that's BLS only. And l and let's really face it, this this patient in particular

Everything's kinda BLS. It I I would say that the if they had kept it at a BLS level. Yeah. Like if they had just said, Hey fuck it guys We're gonna assess. If the guy became hypotensive, that's a problem, right? Because well, no, but this guy in in this area at least, you can get that IV endorsement. Yeah. So yeah, having that IV available would be great. Even if you couldn't get the IV available, this guy didn't end up needing it, at least for the duration of this transport.

Um yeah, you could have BLS this guy, but like you said, man, it would have gone better. Um, there are things that that'd be nice to have, like obviously, like. If the bruising on the right side turned into a pneumothorax or attention pneumothorax, there's not much you can do at the BLS level. That's a problem. Yeah. But in terms of the interventions this patient ultimately needed and received for the duration of this call.

It all could have been done via BLS and probably better. Yeah. And so what so what what would you say that like I ideally if a BLS person were gonna run this call? Outside of like, well, actually backing the patient and uh and whatnot. What do you think the the key parts that they would take away from this would be? Uh you mean like what what what should they do? Yeah.

Uh good B VM, good face mask seal. Uh perform a good assessment. We've said it a hundred million times. The asset the difference between a BLS and ALS assessment is almost nil. Uh keep'em warm and get moving. Yeah. And that's that's really that's kind of the takeaway. Those are the important things. Yeah.

Yep. Yeah. And that's ultimately what this patient got, except for the delay in good ventilation because they really just had to get that E T tube. Yeah. Or the rapid transport because they were all yeah fucking around getting restricted by the E T tube. Yeah.

So or or initially fucking around doing nothing and letting one dude handle the whole thing. Yeah. And yeah. So mm. So here's uh Here's the follow-up. Uh the patient was found to have a subdural hematoma. They had a uh multiple uh back fractures, spinal fractures, uh bunch of broken ribs, and uh Broken arm, broken leg on the right side. Uh the patient, a a uh critical care team was activated to transport the patient to the trauma hospital. Um, but unfortunately uh

Yeah. Circumstances prevented that from happening and the patient was declared brain dead before they could uh get treated. So um yep. Uh so they definitely should have gone to the trauma hospital right off the bat then. Uh I I'm not sure. I'm not sure the circumstances. But I mean yes, uh in my opinion, yes. But would it have saved the patient? You don't we don't know that. Um but uh I can guarantee that if the patient was savable Yeah. This didn't help.

Yeah. And uh, you know, uh lesson for the patient side of this, um, don't drink and drive. That's uh yeah. Alcohol was a contributing factor to this uh this whole thing. So The yeah. Thank you everyone for listening to yet another episode of uh EMS twenty twenty. Uh angry edition. Yeah, Angry Edition. Oh my god, I already know the artwork is gonna be me superimposed on the incredible Hulk just getting angry. There better be cats. I wanna see cats. Yeah. Cats running from me.

Uh Yes, dude, that's it. Yeah. Anyway, so that's uh That's it for this episode. Uh yeah. So if you guys want to see me not raging and angry, then you can head to uh Wilmington, North Carolina, June 10th through the 12th for the Fast 24 uh conference. Uh head on over to flybridgd.com slash fast twenty four and you can get registered.

uh for uh this amazing conference. It's gonna have lots of awesome speakers. There's gonna be Scott Weingart's gonna be there of uh EMS Crit Fame. Uh and then of course they're also gonna have uh Jeff Murphy from uh Master Your Medics is gonna be there, which is awesome. Also, do not forget to uh sign up for some of the the pre-conference courses where you can learn how to not innovate like the people in this call.

uh as well as there's gonna be cadaver lab uh and just some other amazing courses. So head on over to flightbridgeed.com slash fast twenty four and uh get signed up and yeah I hope to see you there because I will definitely be there. Spencer will not. Uh'cause he's fake and just an AI. It's true. It's all true. All right everybody. We'll we'll see you in a couple Wednesdays. Bye.

Meow. EMS twenty twenty is a long pause media LLC production. Episodes are based on submitted calls. This episode was written by Spencer Oliver, reviewed by Kontu Kirio, audio editing by Chris.