Transcript

0:11

Speakers coming your way. Kate Samoda is a certified athletic trainer, national restard ENT. And so she at Northwestern, she coordinates, care for the baseball team, oversees the emergency, planning response efforts, including the AAP maintenance of emergency equipment, emergency training CPR, and focused force medicine staff. Before she got to Northwestern, she was in Emerson College, Boston, University University of Georgia. She has an extensive experience in large scale event coverage and preparation, including service on the Boston Marathon Medical Committee.

0:52

She's been a volunteer since 2013. She is a graduate of Boston University, degree in athletic training, and from the University of Georgia with her master of science in kinesiology. Kate, welcome to our symposium and the floor is yours.

1:10

Thank you. Alright. Can you guys see just this slide show? Or can you see the presenter mode?

1:20

We can see the we can see the slideshow, and we can see you. So Perfect.

1:26

Okay. So like Ronnie said, my name is Kate. I am an athletic trainer, EMT, up in Boston, Massachusetts, and I work at Northeastern University right now. So we are going to talk a little bit this morning about the respiratory system. We're going to focus mainly on the anatomy and then how to do an actual assessment in an emergency situation.

1:47

And then later today, you guys will get more info about specific conditions and how to manage those. So I have no financial disclosures to report, and one kind of caveat to all of this is that you need obviously need to practice within your scope given your State Practice Act and directions from your met your supervising physician. So all of this that I'm gonna talk about is how I would practice here in Massachusetts, but that could vary a little bit for the rest of you. So some of the things we're going to talk about in this presentation, we're going to go over review the anatomy and physiology of the respiratory system. We're gonna talk about common assessment findings and people who are exhibiting normal breathing and abnormal breathing.

2:37

We'll talk a little bit about the connection between breathing and hypoxia and then we'll touch on some of the common, you know, prehospital conditions that we might see. In these patients who are exhibiting respiratory distress. Alright. So just a quick review of the anatomy So the respiratory system obviously includes any of the structures that are involved in the process of breathing, you know, in the primary function is to provide the body with oxygen and eliminate carbon dioxide. So moving on to the upper airway.

3:16

So the upper respiratory system consists of the nose, the mouth, the pharynx, and the larynx. So the pharynx is obviously the mucous membrane lined portion of the upper airway can be divided into the nasopharynx oropharynx and the high buff bearings. And then the larynx is the cartilaginous portion. It contains the the glottis, the crichoid cartilage, and the vocal folds. So really important for the production of speech.

3:42

Some of the primary functions here are gonna include air warming and humidifying to maintain our temperature and moisture barrier, speech production, like I just said, perception from aspirating food or other foreign substances, barrier against infection, and then olfaction as well. So injuries to the upper airway A lot of times are not going to be emergencies. Right? We could see nasal, dental, facial fractures. As long as the airway is clear, the these are generally not going to be emergencies.

4:15

We can see blunt trauma causing a perforation or injury to the fairings or larynx. This is gonna be pretty rare in our sport setting. This will be most likely to be seen in a car accident, but certainly possible. So definitely something to keep in mind. A lot of times, if there's a true emergency there, it's gonna be beyond the scope of what, you know, we as athletic trainers are able to provide.

4:36

So this is something we'll definitely wanna transport for. But, you know, as long as the airway is remaining clear, like, this is usually not something that's an emergency. So for the remainder of this discussion, we'll focus primarily on pathologies of the lower respiratory system. Right? So the lower respiratory system, we can think of as having the respiratory component and then the airway component.

5:01

So the airway component will improve will include the trachea, the bronchioles, and the alveolar ducts. And then the respiratory portion will include the alveoli, and then the capillaries that facilitate the gas exchange and form that air blood barrier. So just a review of the anatomy here too. The trachea is obviously less than an inch in diameter, and the structure is provided by cartilaginous rings. These are c shaped that have an opening in the back that will allow for the expanding and contracting of the esophagus.

5:34

And so this is gonna extend from the larynx until further down until it bifurcates at the level of the sternal angle just above the heart. And then moving on to trachea here, and then moving on into the lungs. We have the bronchi. So these are gonna be similar in structure to the trachea. But they have complete cartilaginous rings.

5:56

Then they'll divide into, you know, each of the lobes and then further divide into segmental bronchi 2. So if we think about it like a tree, the trachea is gonna be the trunk, and then the bronchi will be the branches. So the trachea brings air from the mouth and the nose in towards the lungs, and then the bronchi are responsible for actually distributing that air throughout the lungs. And then moving on further down, The bronchioles have a diameter of about a millimeter, and they lack a cartilaginous structure. Right?

6:23

Their structure is provided. Smooth muscles, so we're getting into these, you know, smaller, finer structures now. So everything above the bronchi is considered to be airway and part of the non respiratory tissue. And then as we move into the lungs, we have the alveolar docs, the alveoli. These are comprised of a single membrane, and they allow for gas exchange into the pulmonary capillaries where it will eventually get back into the circulatory system and perfuse the rest of the body with oxygen.

6:55

And a lot of us work with kids. So just a couple pediatric considerations to think about here. Right? Basically comes down to their anatomy as immature. Right?

7:03

Their structures are smaller, softer, they're more pliable. Their tongue takes up more space in their mouth relative to adults. So this means that their airway is more likely to become obstructed. And since their head is larger proportionally, their neck will be naturally flexed like you can see here in this top picture compared to the adult on the bottom. You know?

7:24

So if we're working on their airway or anything near their head, we might need to Sorry. My doorbell just break. We might need to place a towel or a bolster under their shoulders to get their neck into more of an extended position. And then a couple physiological considerations too. They have higher metabolism, so they have higher oxygen, demands and more limited oxygen reserves.

7:49

So we'll see that in kids, it's more likely that we're gonna see a true respiratory emergency. Right? Their airway is more likely to become obstructed. They don't have the reserves that adults do. So a true respiratory emergency is going to be more likely in kids than adults.

8:05

Whereas adults, a lot of times, we'll see a respiratory emergency being acute exacerbation of a preexisting condition, like a cardiac or, you know, infectious disease or autoimmune or something like that. Alright. So now getting into a little bit of the physiology. Sorry. Something is happening outside.

8:31

So ventilation is a mechanical process involving the movement of air. So this is breathing. Right? And then respiration is the physiologic process involving the exchange of gases. So actually perfusing the rest of the body with oxygen.

8:48

Alright. So the diaphragm is our prime mover for breathing and then the accessory musculature, like the intercostals, the abdominals, our neck and facial musculature. So the scalients, sternocleidomastoid, will also assist in breathing. The diaphragm remember is innervated by the C3 through C5 nerve roots, which is why it's really important if there's any concern for spinal cord injury that we have immediate access to the airway in case they're no longer able to control their diaphragm, and we need to ventilate them. Alright.

9:21

So now the actual, like, process of breathing. So during inhalation, the diaphragm and accessory muscle contract. So the diaphragm moves inferiorly and the intercostal contraction causes the rib cage to move up at out, so this results in increased volume and decreased pressure within the thoracic cavity and allows air to move into the lungs. And then during exhalation, muscle relaxation results in the diaphragm and ribs resuming their resting position. Right?

9:48

So the thoracic cavity will decrease in volume. And will increase in pressure, and this will force the air out of the lungs. And then during exercise or if we're sick, we may need to forcefully exhale in order to maintain adequate perfusion. So, you know, usually controlled unconsciously by the by the brain or subconsciously, but it can be controlled consciously as well if if we need to. And it's important to keep in mind that adequate ventilation does not necessarily guarantee that the body is actually receiving oxygen.

10:24

So in respiration here. So this is the process of actually of the body actually receiving oxygen. So with external respiration, oxygen is entering through the airway, and then the gas exchange between the alveoli and the pulmonary capillaries will bring oxygen into this regulatory system. And then internal respiration is the process of a of a tissue actually receiving receiving oxygen from the capillaries. Right?

10:56

So We've got oxygen rich air entering the alveoli during inspiration, the oxygen deficient blood, and the capillaries passes around the alveoli. And will become oxygenated. The oxygen enters the blood and carbon dioxide enters the alveoli, so that can be expelled, and then the oxygen rich blood will exit into the circulatory system through the pulmonary through the pulmonary. Capillaries and beans and all that. Alright.

11:30

Now just a little bit about respiratory control. So respirations regulated in the brainstem. So as carbon dioxide, concentration increases, the blood becomes more acidic, and then the chemoreceptors controlled by the medulla can sense the change in pH and will adjust the respiratory rate. So if carbon dioxide is high, the respiratory rate will increase in a carbon dioxide is low, the respiratory rate will decrease. Normal blood pH is about 7.4, so it doesn't take a lot of carbon dioxide.

11:58

To drop this pH, so it's a super sensitive system, hyperventilation will usually occur when the pH hits about 7.1. So, like, this is not gonna be super relevant to us, people with chronic illnesses like emphysema, COPD, things like that will have elevated levels of carbon dioxide in their blood just as a baseline. So this causes damage to those receptors. So respiration will be controlled by the hypoxic drive and dead. This measures oxygen concentration rather than carbon dioxide.

12:30

So as the nasal just, once the oxygen levels get too low, the respiratory rate will increase, but this isn't as sensitive as the carbon dioxide system and, like, normal operation. So this will kick in at a lower oxygen concentration. So they will have so that's why they have elevated carbon dioxide kind of as a baseline. And their respirations will obviously be less effective due to the chronic illness. Certain medications and drugs can inhibit the body's ability to control respiration as well, most notably opiates.

12:60

So if we have anyone who, you know, is a post op, and still on their pain medications or using those drugs recreationally, then they could be more we could be more likely to have a respiratory emergency with those individuals. Alright. So now we'll move on to actual the actual assessment of it. So this is gonna be focused more on just understanding kind of the EMS system and how to evaluate the respiratory system in an emergency. We're not gonna focus too much on exact lane.

13:28

Specific exam findings related to each condition that will be a little bit later today. So the like, the emergency at, like, at its core here is really is due to the body not receiving the oxygen that it needs. Right? And this is caused by disturbances in either ventilation or respiration. It's super important to be timely here because we can only survive about 4 to 6 minutes without oxygen.

13:54

So after about 4 minutes, we start to see permanent brain damage, and then death can occur within 6 minutes too. So we wanna be timely with our assessment and our interventions and trying to manage these patients as quickly and as effectively as we can. So the 2 kind of categories here are gonna meet apnea and dyspnea. Right? So apnea is the absence of breathing.

14:18

This is pretty straightforward. They are not breathing. We'll assess their airway in circulation. We'll provide rescue breaths or ventilation, and we'll prepare for transport. So the rest of our assessment here is we focus more on dyspnea.

14:32

So difficult or late word respirations. So we wanna you know, our the goal of our assessment is to determine the cause and then know, from there, determine the appropriate intervention, administer that intervention. So transport may or may not be required. Oftentimes, it will be you know, but if it's something like asthma where they can take their inhaler, they might be able to manage that, you know, without having to go to the hospital. So the components of our evaluation are gonna be the scene size up, the primary assessment, or history taking, or secondary assessment, and reassessment.

15:04

So seeing size up, this is an ongoing, you know, evaluation. This is something that all of us do without even realizing it. And it starts from the moment that we are aware of the injury, the illness, whatever it might be. So, you know, if we're at a practice or a game, and we see, you know, we witness the event occur. That's great.

15:26

We know what's going on. If we're in the clinic and we get called or radioed up to the gym, you know, our scene size up will start from there. From the moment we We arrive on the scene. We wanna gather information about the safety of the scene. We wanna obviously keep ourselves safe first, above anything because we can't provide care to the patient if it's an unsafe barrier for us as well.

15:52

We want to figure out what sort of personal protective equipment we might need gloves mask, anything like that, which wanna try to gather some information about the mechanism of injury of the nature of illness. So a lot of times for us, This is gonna be a little you know, we'll know right away. We're on the fields covering practice, covering the game. We see a collision. You know, we know what happened.

16:13

We want information about the number of patients that will help us determine what sort of additional resources we might need. Right? If there are three people, we might need help from students, other athletic trainers, physicians on-site, you know, things like that, or we might need to call we might need to call EMS right away. Know, that's we can figure that out from the scene size up too. And this is gonna be ongoing.

16:33

This will be this isn't something you're just gonna take note of once and then move on. Alright. And then the primary assessment. So this is, you know, the goal of our primary assessment here is to evaluate and treat immediate life threats. Right?

16:49

So we wanna form a general impression, determine that she's complete. We want that in the patient's own words whenever possible. So I can't breathe my chest hurts, whatever that might be. Will assess their level of consciousness, assess ABCs, perform a rapid scan, make a transport decision. So a couple, like, more specific things we wanna take note of in the primary assessment.

17:09

So our general impression, is the patient stable? Are they unstable? Do we need to take spinal precautions? Is it a trauma situation where they could have a cervical spine fracture for level of consciousness. Are they alert?

17:23

Are they responsive to verbal stimulus? A painful stimulus? Are they unresponsive? Are they oriented to, you know, person place time and what happened? ABCs, obviously, you guys talked about earlier in the week is the airway open.

17:37

Are they breathing normally? Or is the circulation normal? What is the disability status so we can talk about glasses glaucoma scale. We can look at their pupils. We can assess circulation sensation motor function, especially if they're concerned for a cervical spine fracture.

17:55

If we're concerned about a stroke, we can use the mass stroke scale rapid scan, so we're just gonna quickly inspect and palpate the rest of the body, make sure there's no you know, major bleeding or anything that would indicate that there's an immediate by threat, and then we can make a transport decision from here. So if anything is abnormal in our primary, we wanna activate the EAP right away and call for a transport. And this is something that I think, you know, for me going through my EMT coursework, was, you know, kinda put things in perspective for me. I think as athletics in our athletics training education, it was you know, the primary assessment and versus the secondary assessment, there's a little bit of a gray area between those. They weren't super well defined.

18:38

So I think this is kind of the key takeaway from this whole presentation is that if there's anything abnormal in the primary, you immediately call right away. We don't and don't get distracted by anything else, you know, elsewhere in the body. Right? So if there's you know, we see a collision, and there's obviously, you know, an angle fracture. There's notable angle fracture, but the patient's also complaining of chest pain.

19:03

Right? That's fine. They're not gonna die from that ankle fracture. They could die from the chest pain. So we wanna not get distracted by other things going on, and we wanna focus on the immediate life threats.

19:14

So that I think, you know, that was kind of, you know, helpful for me and something that I think about, and then I try to teach our students It's like how to how to focus more on, you know, what's right in front of you versus what could be going on elsewhere in the body. You know, kinda think more like an EMT in that sense. Alright. So, you know, assessment of the breathing specifically in our primary. We can get a sense of the rate.

19:42

So anything outside of normal for their age range would be considered inadequate for the rhythm. Is it a regular breathing pattern or irregular. The quality and depth are, you know, is the chest expanding? Normally, is there or is it not? Is there, you know, gurgling or wheezing?

20:06

Or snoring respirations, anything abnormal there. So, basically, you know, if they're calm, they're talking to us normally. They're not in respiratory distress. Right? If they're using smaller word clusters, you know, if they're reporting shortness of breath, if they're feeling anxious or restless, if they have pale, cool, clammy skin, if they're any mental status changes that indicate that the body is not getting oxygen.

20:28

If they're in the tripod position, you know, so trying to support their upper body on their thighs, that would indicate, you know, something inadequate, something that might requires to activate the EAP immediately. Alright. So then moving on, So whether we decide to activate after the primary or not, we wanna take a history next. So either while the ambulance is on the way or while we're trying still trying to make a decision. And the history is gonna be, you know, especially important here because like we talked about it, you know, a lot of times the respiratory emergencies are gonna be the cute exacerbations of other conditions.

21:10

So, you know, how did the dyspnea start? What makes it better or worse? Is it continuous? Is it intermittent? Is the breathing painful?

21:19

Is there any coughing? Or is that cough productive? And we wanna try to obtain information about the general health status of that patient too, right? Any chronic medical conditions? Do they have any allergies?

21:31

Is this anaphylaxis? That we're dealing with? Are there any recent surge surgeries or hospitalizations? Right? Could this be a pulmonary embolism, smoking status?

21:38

Right? Anything that might clue us in you know, to what is going on or what's causing this abnormal breathing. Alright. So then our secondary assessment, so we're gonna get a set of vitals and then we'll do a more focused respiratory assessment. So depending on, you know, what you found in your primary and whether you chose to activate and then where you are also, You may or may not have time to complete your secondary assessment.

22:01

So for me up in Boston, I have 3 level 1 trauma centers within a mile of our field. Last time I had to activate the EAP, the response time was only about 90 seconds. So ambulance was there before I was even off the phone with dispatch. You know, but if you're in a more rural setting, you could have 10, 20, 30 minutes to continue to do your secondary assessment. Until EMS arrives.

22:27

And then that's valuable information for you to be able to pass off for them. So we'll talk about vitals a little bit more on the next slide, but repeating a lot of the breathing assessment that we did in the primary, looking for chest trauma looking for equal chest expansion, listening to the breath sounds and lung sounds, assessing the skin, the pulse, the blood pressure, all of that is gonna be important to do in our secondary So some of the vitals we wanna get will be a heart rate. So this is gonna be more likely to be tachycardic in these patients. Wanna do blood pressure. So if the blood pressure is low, that could indicate that there is an issue with oxygenation, they could be getting into that hypoxic state.

23:07

Oxygen saturation. So our normal range, if we put a pulse oxon, it's gonna be 94 to 99%. And it's a really helpful tool, but you know, if they have calluses or nail polish or poor perfusion, we might not get a reading at all. And if it's reading is a 100%. That could mean that the pulse ox is either malfunctioning, or there could actually be carbon monoxide poisoning.

23:30

So at the end of the day, it's just a tool we wanna treat the patient in front of us, not the number, but it is valuable and can give us information about what's going on distillate and in the extremities. Respiratory rate, breath sounds, lung sounds will continue to do repeat this stuff from the primary assessment. Are the pupils equal around reactive to light? What is the skin color, temperature, and condition. And then if we have a glucometer too, we can get information about their blood glucose, especially if it's someone who might be diabetic.

24:00

Alright. So then our reassessment. So we're gonna continue to assess respiration and perfusion. We're gonna continue. We're gonna administer or adjust our supplemental oxygen or any other medications, and then we'll reassess our need for transport.

24:15

So reassessing the chief complaint monitoring for changes is the patient's condition changing or improving? Are there any new complaints? We'll continue to repeat the primary assessment, and we'll get additional vitals. So for a stable patient, We wanna do we wanna get a new set of vials every 10 minutes, and then for an unstable patient every 5 minutes, and make sure we're recording these each time. So we can, you know, track the changes over time and look for trends, but also have a baseline to compare to, and then that's valuable information for us to pass off to EMS into the hospital when they arrive.

24:48

And then we'll reassess our interventions. Do we need to give out do we need to adjust our oxygen? Do they need another dose or another, yeah, another dose of the inhaler? Do they need glucose? Do they need an EpiPen?

25:00

Whatever that might be. Then we'll reassess our transport decision. Right? If we've, you know, worst case we call for an ambulance, they get there if the patient has approved and they don't need it. Or I guess not the worst case.

25:12

That's the best case. But, you know, the worst case would be if we don't call for an ambulance, If there is something wrong in the primary, we didn't call for an ambulance, and then the patient is deteriorating in that. We've lost some valuable time. So, you know, I would always recommend air on the side of activating the EAP when, you know, even if you're unsure. And patient can always refuse transport if you need to.

25:38

But, you know, again, kinda like our scene size up. This is gonna be a continuous assessment. We're gonna continue redoing the primary. We're gonna continue getting vitals until we either, you know, transfer care of that patient to EMS or until we feel confident that they have recovered. Alright.

25:59

And then just kinda bringing this back home. So our 2 the 2 sources of our respiratory emergencies apnea and dyspnea. So if we have apnea, so if the patient is not breathing, We wanna ensure that the air is clear. We'll provide rescue breaths. We'll assess circulation and transport immediately.

26:16

And then for dyspnea, if there's you know, difficult, labored, any abnormal sort of breathing. You know, we'll use kind of this this whole EMS algorithm, this whole primary, a secondary, assessment to identify our signs and symptoms of either hypoxia or respiratory distress. We want to prepare that patient for transport if they need it. We'll identify and treat other causes of the dyspnea. Right?

26:41

So allergies, asthma, whatever that might be. Will assist with any medications, oxygen, albuterol, epinephrine glucose, obviously practicing within your your state practice act and your limitations, and then we'll reassess our respiration perfusion interventions and, you know, either prepare for transport or, you know, prepare to, you know, return them to play or follow-up with your team position. So that is everything that I have. Any I guess we can open it up too. To questions.

27:23

You can hear me, Kate. Okay? Yes. Good. Good.

27:26

Yes. If you have any questions for Kate, we have a few minutes here before we transition to our next speaker. I have one cake that that Yep. When you have a athlete, your athletes are all often under exertion. So the respiratory rate is out of balance trying to compensate for the activity like you see athletes trying to kiss their breath and you're trying to determine I always think of Cross Country runners when they finish the finish line right in there, you know, like, okay, their respiratory system is all out of whack and you're trying to determine severity.

28:00

And so what if your numbers and your data is not matching up? Like, you get a pulse ox of a 100%, their blood pressure is this, their vital signs are this, their skin colors there. What if what if things aren't lining up And when do you know to activate EMS? What are the critical pieces for you to say This is this is a concern to the point where we need we need help coming this way when you have mixed signals on your information.

28:33

Yeah. So I think that's where, you know, you obviously get your vitals and that gives you information, but that's where you just assess the the patient. Right? What is their what is their skin doing? How are they responding to that bout of exercise?

28:48

Are they recovering within, you know, 5 minutes, 10 minutes, or are they deteriorating? If they're deteriorating, that's when I think you wanna activate the EAP right away. Otherwise, I think you can give it a little bit of time, and that's, you know, kind of that whole algorithm that we just talked about is repeating your primary assessment every few minutes, getting your new set of vitals, and waiting to see how they how they respond to that. You know, that's kinda I like the way that, you know, my my former supervisor at UGA framed it. And then anytime, you know, they were talking about in the context of Cross Country specifically, this is you know, the everyone's having an emergency when they finish those races, and it's kinda it's planned.

29:38

You know it's gonna happen. And that's you wanna be prepared for that. You wanna the people who are struggling, the ones who, you know, are able to support their own weight and walk versus the ones who are collapsing or you know, losing consciousness and then see how they respond over those next few minutes before you can make your decision.

29:59

Oh, to me, let's go back a little bit to the hypercarinic drive versus the hypoxia drive. And is it CO 2 or Ox in that controls the respiratory system, primarily controls. Which one?

30:10

In a normal so in a normal healthy patient, it's gonna be the carbon dioxide, the drives that.

30:17

I know when I first learned that, I went like, what? Like, wait a minute. CO 2 is trash. So trash is the driver of the breathing mechanism. 90%.

30:26

So relate that to the assessment process, like like, like hyperventilation would be a classic example. How does hyperventilation contribute to the whole dismantling of the respiratory system in relationship to that CO2 oxygen Yeah. Dynamic.

30:47

Yeah. I mean, so that's what's gonna cause the hyperventilation is that buildup of carbon dioxide side in the system when the blood pH drops below or to about 7.1 or lower. So it's, you know, the most important thing there, and that's why a lot of, you know, you think about the people, you know, breathing into the paper bag. That's all of that is, you know, theorized and designed to help them expel the air. More efficiently.

31:11

And, you know, when you think about even just, like, you know, when you take a yoga class, they tell you to breathe in through your nose, out through your mouth, all of that is designed to expel that carbon dioxide oxide. So that way, you know, you feel like you're not getting enough oxygen, but really the, you know, the problem is you've got too much carbon dioxide buildup in there. So that's all, you know, all of that is designed at theorized to help you exhale and expire that error more effectively. Yeah. Yeah.

31:40

What's the what's the thing here? No.

31:42

That that was it. That was it. I just when you covered that, I don't got the thinking, it reminded me of how odd And to be reminded, when you do an assessment of the respiratory system that is CO2 is the driver here, it's the one that controls the the you know, the the the breathing process. And when it gets out of balance, then the respiratory system becomes dismantled. It becomes start spiraling out of control quickly because lots of things.

32:13

So it's actually managing CO2 issue, not an oxygen issue, is to try to get to body back in balance. Excellent. Alright. I don't see any other questions coming in. The only last thing that I had was where does the role of a stethoscope come in in the assessment process.

32:33

When do you know you need it or don't need it to to accomplish an assessment element?

32:39

Yep. So that I mean, that's certainly part of your primary. So it's, you know, important to have on you and in your kit and readily available. I think that depends on what your chief complaint is. Right?

32:50

If they're coming to you and saying, I can't breathe or, you know, if you know the patient has a history of ASMARK, they've been sick recently. I think you can you jump right to that in your primary. If they're able to talk and they're forming, you know, full sentences and they're not in any acute distress. I think you push that more to your secondary assessment. But certainly something that you wanna have on you and have available and be able to to evaluate in in this emergency setting.

33:19

Yeah. Excellent. Okay. Well, no other questions have come in. Your always welcome to reach out to us, racist, maybe ask about if someone needs help in a primary assessment where to get help.

33:32

That's what Ray asked.

33:35

It's so

33:35

needs help in a primary assessment where to get help. Ray, are you talking about Like,

33:41

the patient needs help? Or

33:43

No. No. They're already learning how to do a better primary assessment. Where do you go to learn more about how to do a more precise primary assessment.

33:54

Gotcha. Yeah. So, I mean, with a respiratory focus specifically, I think a lot of that is gonna be covered in the next couple talks here today, you know, but talk to, you know, use the resources around you. You know, your team position, you know, physician assistants, other athletic trainers who have more experience. And then working with your local EMS too, that's something that we do a lot.

34:19

Every year, we'll do a training whether it's you know, we'll cover 1 or 2 conditions. Right? So this year, we did heat illnesses and cervical spine injuries, and we brought, you know, the EMS providers from our ambulance company that we contract with. In, and we talked about them, and they were you know, they're always happy to teach and happy to, you know, explain their train of thought and the way they think. And how they approach these patients do.

34:42

And I think that has been the most valuable for me is, you know, our medical director is an EMS or a emergency position by training. So he's always been helpful, but, you know, learning from the EMTs and the people who are doing this every day, I think has been the most valuable for me. So, you know, whatever resources you have around you or whatever the system you have in places, I think talking to, you know, everyone who's gonna be involved in the care of that patient ahead of time will help make your care more effective when the time comes.

35:16

Hi. We have one question come in and says for app visiting teams. Our athletes with visiting teams where you don't know the medical history. Coaches don't really know. They don't give you much information.

35:29

How do you obtain that key information in the assessment when the athlete is struggling to even explain it themselves to clear it on ours.

35:37

Yeah. Yeah. That's tough. And I think those are the situations where you wanna air more on the side of alright. We're gonna activate the EAP, and we're gonna send you to the hospital because you don't know the background of that patient.

35:50

You don't know what is normal or abnormal for them. You know, if the parents are there, if teammates know, you can get information from them, but that even that's always not, you know, super reliable. So I think You just need to if they can't communicate that to you, you just need to air on the side of of activating the AP and sending them even if it's something that you might give a little, you know, a little more time to an athlete, you know. But you just don't wanna wait around or risk anything worse happening. You know?

36:21

You're good. Now what? Alright, gang. You get this time to transition, Kate. Thank you.

36:26

Thank you so much. I know we're gonna have you back here somewhere, someplace, some other time to continue to contribute to the body of knowledge of of what we're trying to accomplish, and that is to help the athletic trainer understand more about emergency medicine and about a consistent flow of information. So thank you so much for getting the base