Transcript

0:10

1. If you're just jumping on board now, if you would take a second. I know you've asked us. We've asked us this morning of you just to let Caitlin know where you're from, and if you want to add your job setting as well. So as you do that, again, Caitlin, it's a pleasure to have you here this morning.

0:28

And we're gonna our topic is on the fundamentals of ventilation and restoration. So I'd like to give a little bit of background Caitlin. So Caitlin is a graduate of University of Northern Iowa. As you see, she is due credentialed as a EMT and athletic trainer. She's worked in a variety of settings, including orthopedic clinics, outpatient, rehab clinics, high school, and junior college, outreach, with a multitude of sports.

0:54

She's currently Aflac trainer at Jackson County Central in Jackson, Minnesota and was the 1st Aflac trainer where where she was introduced to sports medicine. So I know she's excited to be back there and, you know, talking with spoken with her several times in the work she does. She's been an EMT for several years and is also working diligently with the with the different agencies and cold water immersion. And working with ambulance services and hospital departments. So when she's not doing athletic training and she's super passionate about that.

1:30

And you see, if you follow her and encourage her to follow her follow her on social media, she loves to read, she loves playing games also doing activities with the local church, spending time with husband Riley, and their four year old daughter and three month old son. And 3 large dogs.

1:49

So Yeah.

1:50

With that Caitlin, I'm gonna give it over to you. Thanks again for being here.

1:54

Perfect. Thank you for having me, Ray. I'm really excited about this presentation. So I hope I hope that you guys are able to take something something good away from this. So my talk today is on the fundamentals of ventilation and respiration.

2:10

Sometimes it can kinda be a dry topic, so I'm hoping to keep this engaging and interesting. So here we go. So I have nothing to disclose. I do encourage everyone attending the information that I provide in this presentation do consult your supervising physician on your your own protocols and how you're gonna handle these types of respiratory situations Any equipment shown in my presentation is just for demonstration purposes. I don't have any endorsements or anything for them.

2:48

So I think that covers that. Alright. So we've got our learning objectives with this present patient. My goal is to delve into the essential concepts of ventilation and respiration in the context that we see them in sports emergency care. So we'll talk about terminology, the anatomy and physiology, and hopefully equip you with some skills to recognize the issues kind of when they first arise and to respond to a hypoxic conditions and ventilation issues in both pediatric and adult athletes.

3:25

In emergency care, when we take vitals and we are evaluating the respiratory rate or breaths per minute, What exactly are we evaluating? So what's happening during those breaths? What is our end goal? Obviously, breathing is a good thing. But breathing in that term is actually the umbrella term that we use that encompasses the processes of ventilation and respiration.

3:49

They are ventilation and respiration are, in fact, 2 parts to a hole. They are not interchangeable, and we need to understand what happens during these processes in order to provide the appropriate emergency care. So we'll start start off by kinda looking at the anatomy here. So for ventilation, that's where we'll start. It's the mechanical process of moving air in and out of the lungs by creating that negative and positive pressure changes in an inside the chest cavity respectively.

4:21

So inhalation is an active process that involves the contracting of the diaphragm downwards, the elevation of the ribs by the external inner muscles, the interchondral portion of the internal intercostals. And at times, it's assisted by the sternocleidomastoid, the scalenes, and pec minor known to us as the accessory muscles. So this increase in thoracic space creates that negative air pressure in the chest cavity compared to outside the body, which draws the air from outside into the lungs. Exhalation is a passive process. It's caused by the relaxing of those inspiratory muscles.

5:03

Now force exhalation when we really push that air out, that utilizes the respiratory accessory muscles, which are the abdominals and the internal intercostals. So ex inhalation, excuse me, is the active process. Exhalation is passive. So when we look at this chart, it kinda shows I'm sure everybody remembers this from Physi Physiology class. But it shows kind of the overall volume that our lungs are capable of holding.

5:37

So we know that adequate breathing means that enough air is getting into the lungs, but how much is enough? We know that our tidal volume is how much air is moved in one normal breath and our minute volume is how much air has moved in one minute. So to illustrate this, in a 100 kilogram adult, The average tidal volume is about 500 milliliters, but only about 350 milliliters of that will go deep enough into the lungs to reach the alveoli. The rest stays in the trachea, the bronchioles, and other mid lung areas, which are called dead air space. So that a 150 milliliters of air that does reach the alveoli to undergo gas exchange is called alveolar ventilation.

6:24

Alveolar ventilation is dependent on both the tidal and minute volumes, and both tidal and minute volumes are affected if the patient has an altered respiratory status, whether it's too fast or too slow, so this leads to decrease volumes overall, which means less alveoli over ventilation and less oxygen. So this is where we can kinda start to see where hypox see it comes into play, but we'll we'll get to that in a minute. So the force inhalation and exhalation is where we see on the graph. That's where we see that total vital capacity of the lungs as it pertains to the inspiratory and exploratory reserve volumes. So the very bottom of the chart there is where we see the residual volume, and that's where that dead air remains.

7:09

That dead air does not get oxygenated. It doesn't undergo that gas exchange. It doesn't nothing to oxygenate our blood. It just is kind of there. It's dead air space.

7:23

So in ventilation, the air gets into the lungs with the end goal of getting enough alveolar ventilation to allow for proper oxygenation of the blood, but what about respiration? So respiration is the exchange of the gases. Just like air travels in and out of the lungs based on pressure changes, so do the gases in the blood through a process called diffusion. So pulmonary respiration is the diffusion of oxygen and carbon dioxide between the blood and the alveoli through those little capillaries. The alveoli are the only place where blood is oxygenated in the body.

8:00

The blood releases It's carbon dioxide into the alveoli for expulsion, and the oxygen in the alveoli transfers to blood where it binds the hemoglobin of the red blood cells. So this gas exchange is happening constantly as the circulating blood undergoes cellular respiration where the cells themselves exchange oxygen and carbon dioxide with the blood around them as it circulates through our body's tissues. So we've all heard that air goes In and out, blood goes round to round. Any deviation from that is a bad thing, and really it's not wrong. The respiratory system can't do its job if the circulatory system isn't doing its job.

8:40

So without circulation, we don't get ventilation. And without ventilation, we don't get respiration. And without respiration, we've got big problems. So the body determines the need to breathe through its respiratory drive, which the brain controls through chemoreceptors that detect the various levels of oxygen and carbon dioxide in the blood. If there's too much carbon dioxide and not enough oxygen, It will usually prompt the body to increase the respiratory rate in an effort to correct this.

9:12

The sympathetic nervous system also kicks in and we see it increase heart rate in an effort to circulate more blood and thereby increasing oxygen uptake by the body's tissues. So during activity, there is an increased demand for oxygen. So we see that increased heart rate and the increased breathing rate in an effort to meet those demands. That's where we could get into the weeds of aerobic and anaerobic respiration and the krem cycle. But we'll save that for another talk.

9:40

That's That's not my not my wheelhouse today. So this increase in pulmonary Cardiopulmonary demand is normal during activity and there is likely still adequate oxygenation happening. So hypoxia is when the oxygen levels in the body are inadequate to meet the body's needs. So in some cases, which as athletic trainers, we likely won't see this as much, but in say a COPD patient, the body is used it's used to running on lower levels of oxygen, so they won't have that same respiratory drive. But with athletes during activity, that's not really something we need to concern or be too concerned about especially when we do see that increased heart rate and increased breathing rate.

10:29

Anyone who's run and is out of breath knows what that feels like. It's not necessarily hypoxia. So there are a couple contributing factors to cardiopulmonary failure, which like I said, if we don't have the circulatory system functioning, we're not gonna have the respiratory system functioning. So the 2 go hand in hand. So there are quite a few reasons why someone may be experiencing hypoxia, and some of them are more likely to run into as athletic traders in our world, and others were more likely to see in the EMS world.

11:07

But it does pay to be aware of when and how it regardless of the setting you're in or regardless of your patient population. So with ventilation disruptions, The breathing mechanism isn't functioning like it should, whether it's from nerve damage, affecting the inspiratory muscles, penetrating chest fluid and that affects pressure within the chest cavity or problems within the airways themselves, such as mucus buildup or bronchoconstriction. Something physical is causing that mechanism to not work as it should. So in respiration disruptions, We can see illnesses such as congestive heart failure or COPD exposure to carbon monoxide, which binds to hemoglobin in place of oxygen, or at higher altitudes where less oxygen is inhaled in each breath. So that's gonna disrupt the normal respiration Smoke inhalation can cause both ventilation and respiration dysfunction.

12:07

So that's something to keep in mind. But again, not as likely to see it as athletic trainers as we would on the EMS side of things. With circulation disruptions, Those are pretty straightforward. If you don't have enough blood, you don't have enough oxygen, whether we're dealing with hemorrhage or shock, Without blood, oxygen can't circulate and gas diffusion can't take place. If we do have enough blood but we don't have enough hemoglobin, then our red blood cells just automatically have a decreased carrying capacity for transporting oxygen.

12:43

Maybe instead of transporting all four oxygen molecules, it can only transport 2. Well, that's 50% right there. So just things we need to keep in mind, but all of these can contribute or lead to a patient. It can lead to them experiencing a hypoxic state or condition. So let's get into hypoxia.

13:07

So normal respiratory rates in adults range between 12:20 breaths per minute. Adequate breathing, we know means that the rate is within normal limits, its regular rhythm, lung sounds are clear and equal bilaterally. There's equal and bilateral chest expansion and breath depth. And it requires very little effort on the patient's part. It's easy.

13:29

So we wanna make sure we're we do the the look listen and feel when we're assessing this. So just like just like any other time, we're we're using our senses to evaluate the patient. So in normal respiratory rates in children, they're they're a little bit faster with everything. So normal school age children, their respiratory rate is 15 to 30 breaths per minute. And they have much the same signs of adequate breathing as adults.

13:57

So you want to look for the same things during that primary ABC assessment. There should be normal chest expansion by laterally, minimal effort, quiet breaths, good muscle tone, appropriate interaction with their environment, and a reasonable response to your presence. So they're not like, if you're a stranger, they're shining away. They're they're turning into mom or dad, that kind of thing. Now that's mostly for, you know, smaller children.

14:23

And depending on what age athletes you're covering, that could You might not see that. It might be more applicable to how patients behave as adults. So it really comes down to your situation. But we always need to be aware of the risks of hypoxia, especially when our patient is doing anything other than breathing normally. So there's a reason that breathing is the 2nd letter in assessing the ABCs.

14:50

Anyone with inadequate breathing is at risk for hypoxia if the underlying cause is not identified and corrected. So in respiratory distress, where there's still adequate breathing taking place, but their condition is less than ideal that can rapidly deteriorate into respiratory failure, if not, acted upon in a timely manner. So in respiratory distress, you may hear abnormal lung sounds with or without the stethoscope. Sometimes it's very audible to the naked ear. The patient may be coughing, maybe they're sitting in a tripod position, hands on knees, leaning forward.

15:26

They might have increased respiratory rate, but they're not yet to the point of hyperventilation. Their skin color, if you want to take a look at that, does it appear normal, or are they starting to pale? And the patient may seem nervous or anxious, especially if they feel they can't catch their breath. That's when we start to see kind of some onset of some anxiety, some panic. So with being short of breath, They may also only be able to get a few words out at a time instead of speaking full sentences to you.

15:58

So most of the symptoms of hypoxia in children are the same as adults, but children do give us a few more clues to watch for. So they these clues include kinda earlier use of the accessory muscles for inspiration. You might see nasal flaring on inspiration. There's sounds with breathing such as strider. Those kinda upper airway sounds get to be a little bit more obvious.

16:26

They might be grunting on exploration. That's not a fun sign. And neither our abdominal retraction where those those abdominal muscles are kind of sucking in, and they might have more of a limp muscle tone. So just kinda generally lipidic to just kind of so they they kinda clue us in a little bit differently than adults do. So in respiratory failure, there is now inadequate breathing and where the patient was noisy breathing before, they might not be making sounds now.

16:59

So that is that is significant. We need to watch for that. They may be breathing too fast or too slow. They might have irregular breathing patterns. So here in respiratory failure, this is where we start to see cyanosis develop or that bluing of the skin.

17:16

As the brain is deprived of oxygen, we may also start to see the patient's mental status deteriorating. And remember that once brain cells die, they don't come back. So keep talking to your patient, keep evaluating their alertness, constantly be checking those ABCs, and be ready to provide ventilations for them. Because what they're doing at this point is not sufficient on their own. So treating hypoxia comes down to administering oxygen to the patient.

17:45

How you do it depends on the patient's status. In some cases, you may be able to correct it on a conscious patient without much effort. But in more severe cases, you might need to use artificial ventilation. So one other thing about kids is children are scary As a moment too, I can confirm. But no, that's not in the sense that that is.

18:08

So in this sense, in the emergence sense children are scary because they compensate really well when their bodies undergo negative changes until they don't. So when kids crash, they crash hard and fast. So it's especially important to be familiar with the signs of hypoxia in adolescence, and be able to intervene in a timely manner, especially working with youth sports. So we wanna watch those ABCs closely. Your patient will start off with an increased breathing rate and volume and normal mental status.

18:38

This is expected. This is a normal physiological response. Keep an eye on it. As they start to decompensate, their breathing will slow and become shallow, and their mental status will start to decline as well. So as hypoxia takes its toll, especially in kids, the muscles used for breathing will tire.

18:58

So if your child patient is working hard to breathe initially, and suddenly they're not. This is a huge red flag that they're deteriorating and you need to act. So The big takeaway with kids is remember that your child patient will appear fine for longer than an adult patient will. But when those compensating mechanisms give way, they will crash quickly and respiratory distress will quickly become respiratory failure. Kids may stop breathing, but their heart keeps going, whereas in adults, usually if they're not breathing is because the heart stopped.

19:31

So regardless of age, if the signs of respiratory failure are present even if there's no cyanosis. Your patient is still in respiratory failure, so don't wait to initiate your emergency care. So interestingly enough, hypoxia does tend to occur more frequently in people of color. So despite this, This particular patient population tends to receive less supplemental oxygen due to their pulse oximeter readings being skewed by their darker complexion. So because patients with darker skin tones have different clinical appearance, it's especially crucial to know what the condition progression looks like on darker complexions and not to rely solely on just one method of assessment.

20:16

So when their skin starts to show pallor, we say that someone is looking gray. And in darker patients, this is most evident in the lip and inside the mouth. However, overall complexion can also undergo that color shift too. So due to decrease circulation, you can expect to see a yellowish tint kind of appear in brown skin and more of an ash gray shift in darker skin, darker brown, and black skin. When cyanosis occurs in these patients, they will appear blue.

20:47

The degree of appearance depends on their complexion much like Tyler does. In lighter skin patients, they will have more of an overall blue coloration to them. In darker patients, it will be less apparent globally but will be more obvious in areas such as the the lips and mouth, the nail beds, conjunctiva, the palms of their hands, and soles of their feet, Because this change may not be immediately obvious in our darker patients, we need to make sure when we are doing our due diligence and assessing them that we're really seeing the patient when we're doing our examination. Missing any of these clinical presentations in a patient with darker skin that could spell disaster for them. So, obviously, as prehospital caregivers we need to be on our game and we need to know what this looks like in the populations that we serve.

21:41

So you may be asking, okay, but what about hyperventilation? Hyperventilation presents its own unique problem. It's normal to see increased breathing rates during physical activity as we discussed when the body is working to maintain homeostasis. But when the breathing rate is abnormally fast and deep, that's when we encounter hyperventilation. So some tachycypnea is hyperventilation, but not all of it is, but all hyperventilation is to keep to keep me up.

22:10

So it's kind of the the rectangle thing. So even though hyperventilation is, in fact, increasing the amount of oxygen in the blood, it is blowing off too much carbon dioxide, and we do need a balance of the 2 in order to maintain proper system functioning. So we may laugh when we think about breathing into a paper bag, but there is somewhat some method to that madness. So doing that allows the patient to re breathe the expelled CO2 and restore the levels to normal amounts. It's one of the few ways to conservatively treat hyperventilation, which to correct, we need to just decrease the we need to increase the c 02 levels, excuse me, and decrease the oxygen levels.

22:53

So we can do this through using the paper bag, We can do it through per slit breathing or by covering the mouth and plugging on the nostril purposefully limiting that air intake in short term. But If the hyperventilations are truly getting to be too quick and too shallow, this can lead to decreased alveolar ventilation. Breathing too quickly means the lungs don't have time to refill, which leads to decreased minute volume despite the quick rate and thereby decreases overall title volume. So we want to correct hyperventilation as it happens so we can prevent that secondary hypoxia from occurring. So as athletic trainers, we often work with adult and pediatric athletes.

23:33

So when would we potentially see hypoxia or respiratory distress, what conditions would we encounter? So we'll start with asthma. Asthma attacks are triggered by any number of things. And we see restricted airflow from bronchostasm and mucus buildup in those small airways leading to the alveoli. It usually affects x more than inspiration due to the lungs being able to pull that air into the lungs through the negative pressure change, but then it can't passively exhale so that air gets stuck and it's unable to be expelled and we see that buildup of carbon dioxide.

24:09

Asthma attacks do not trigger the hypoxic drive. And with asthma attacks, when we see breathing rate increases, that's not the hypoxic drive. That's more likely due to increasing anxiety or panic because they feel like they can't breathe. In anemia, there's a lack of healthy red blood cells or hemoglobin, which means a decreased ability overall to transport oxygen. The oxygen may be diffused in the alveoli, but if there's not cells to carry it or hemoglobin combined to, it's useless.

24:38

It's not going to do anything. Different illnesses, many lung infections lead to inflammation throughout the airways, especially in the lower lungs, and, you know, where we house our bronchioles and the alveoli, we see that increased mucus buildup in the airways which limits alveolar ventilation and hinders that diffusion. And we see this with pneumonia and bronchitis and COVID So definitely be aware of how the different lung infections affect those airways. In anaphylaxis, we see not only the blood pressure drop due to vasodilation, which leads to decreased perfusion, but we also see similar symptoms to that of asthma with bronchoconstriction and swelling of the airways, decreased tidal volume, and impaired diffusion. So think back to when we discuss pathological causes of hypoxia, one of the causes was painful injury with a rib fracture.

25:38

Right? If it hurts too much to breathe, that we'll see a decrease in that minute and that title volume. We're not gonna see as much air exchange because it just it hurts the patient to do any of that. In pneumothorax, it might not be common in sports, but we could potentially still see it. So this one is it's interesting.

25:60

It's multifactorial. We have 1 less long to pull in air if if it's collapsed, which leads to decreased tidal volume. And decrease perfusion. Plus, if air is building up inside the chest cavity from an open chest wound, hopefully, we never see it in athletics. But we know that there's a risk.

26:20

It may put pressure on the heart and healthy lung, which can further exacerbate the patient's breathing difficulties, then we start getting into tendin pneumonorex. Again, something more likely to see in the EMS side of things, but, you know, we have EAPs for a reason. In sickle cell anemia, we know that red blood cells when healthy are round but it's in sickle crisis. Those round cells have turned into little cresence, which can physically block the vessels leading to decreased circulation. Of the oxygenated blood, but they also physically can't carry the oxygen.

26:54

They're the wrong shape. Pulmonary embolism were not as to see that in athletic training. But with COVID and blood clots being more kind of there's a higher risk for them after significant trauma or after surgery. We do need to be aware of their presentation as well. So when deep vein clot forms and travels to the lungs, it can block any one of the arteries in the lungs big or small.

27:23

Which physically inhibits that circulation and diffusion. So risk factors for blood clots that we may see in our athletic populations are smoking, use of oral contraceptives, pregnancy, clotting disorders, chronic illnesses, different lung infections, or just just different infections in general and hormone replacement therapies. All of those place our patients at higher risk of blood clot. So be aware of those. In shock, we have disrupted circulation, whether it's decreased blood volume from significant bleeding or low blood pressure fear caused by any number of things, the body circulation is deficient.

28:03

So oxygenated blood isn't being moved as well as we need it to be. And then another one, choking. Obviously, if the airway is obstructed, we're not getting oxygen, we're not getting ventilations or respirations, There's no oxygen getting to the blood, and then it's not getting to the cells. So these are kind of it's by no means, an exhaustive list of all the things that we might run into, but it it tends to be more of the common ones or the more likely ones that we as athletic trainers might experience. So how do we how do we know besides clinical symptoms if our patient is in hypoxia?

28:44

We can look at their oxygen saturation with a pulse oximeter. So normal oxygen saturation on room air is 95 sent or higher. So while pulse oximeters are not always the most reliable method of monitoring this, they are useful to get that numerical value to the arterial oxygen supply when taking those vitals. So it's also the type of thing where if you if you are going to be administering oxygen, if you have some and you're gonna be putting your patient on it, grab a pulse ox reading beforehand so we can monitor that intervention If you do not have a pulse ox ready and available, do not waste time trying to find one You don't need that reading per se. It's not gonna make or break your treatment.

29:34

Just apply the oxygen. It's got no prehospital contraindications, and your patient is in more danger of not getting the oxygen, then it would be providing it if it's not needed. So hopefully, you're not just gonna go off of the pulse ox reading. But you're gonna use it as a tool in the toolbox and assess the rest of your patient's clinical signs and symptoms apart from that reading. So most pulse oximeters, the good thing about them is they're small, they're portable, they're easy to read, easy to understand, They're easy to stow in in kits and packs, and most of the time they're pretty reliable.

30:14

There are times where they may not be as reliable and that's they're usually battery powered. So if the batteries are bad or if they're dead, you're gonna have issues there. If your patient has carbon monoxide poisoning, They're gonna have a higher 2 reading than they actually have because like we said, that carbon monoxide binds to the hemoglobin in place of the oxygen so it can actually kind of fool per se the pulse oximeter. If they have on fake nails or nail polish, those those big acrylic nails are are a big trend right now. That is going to affect your pulse oximeter reading.

30:52

If your patient is exceptionally cold or if they have decreased peripheral circulation, you're not going to get a good reading. Or if your patient has dark skin like we talked about. If your meter is functioning, but you can't get a read on the finger in its normal placement, turn it sideways. If that still doesn't work, you can switch fingers or even try a toe. And if that still doesn't work, you can try their ear.

31:16

But again, don't waste time waiting to apply the oxygen until you have that that saturation reading. You're not gonna base your treatment decisions solely on that, you're going to use all of your clinical clues. The most important thing is that you recognize the high epoxic condition and you initiate the appropriate intervention right away. So to wrap up, ventilation and rest integration are both processes that occur during the function of breathing, but they are different and are not interchangeable physiologically Even though in the field, we may just refer to the whole process as respiration. Kids can be tricky as their bodies can compensate really well for only a short amount of time.

31:58

Adults fare a lot better on higher amounts of carbon dioxide. Watch your kids when they're in respiratory distress closely for signs of decompensation. When it happens, it happens fast. So don't wait until you see those signs to initiate emergency interventions. Hypoxia can happen from a number of causes, especially from underlying health issues, but as serious no matter what, so we wanna get your patient on oxygen as soon as possible.

32:29

So thank you for having me. It's been a pleasure, and I hope you were able to come away with something useful from what we've discussed here. I'll be happy to field any questions at this point, but I won't hold my breath.

32:44

Great. Caitlin, fantastic information. I know everyone feel free to if you would ask any questions you have to Caitlin and you can put those in the q and a or the chat. Either one, we'll look at those. But in the meantime, I do have a couple of questions.

33:01

I think one more of a conversation. You hit some you hit on some really key aspects of just understanding the oxygenation, you know, ventilation and understanding what it means to have oxygen or too much. You know, I think of the, you know, like the song and a lot of others like oxygen, you get too much. You get too high, too little, and you're gonna die, you know, that whole thing. I'm not gonna sing that, but you get to you get to drift.

33:27

Oh, come on.

33:28

So, yeah, maybe another time. So I'd be paid well for that for the audience. So it's mentoring her money. But, anyway, you mentioned about you know, talk about Carbonic hypercarbonic drive. Someone's hyperventilating.

33:40

If you would, just gonna talk a little bit about the role that know, you you mentioned having a bag, but having the BBM, how much more effective that is just to get the person, you know, as a controlling or if you need to just getting that positive pressure ventilation to get them under control rapidly so you don't have a rapid deterioration. You can kind of you know, your thoughts on that.

34:03

Yeah. I think the BVM or bag valve mask is it's a really useful tool if if you have one handy, if they are hyperventilating because it is going to assist them with proper lung filling. It's not it's not gonna let them continue to do those those shallow little insufficient breaths. It's gonna make sure they're getting enough air in And then by doing the regular rhythm, because you using that, you would wanna slow them down. So you would wanna say, you know, match match my breathing rate.

34:36

I'm gonna help you breathe. It's it's gonna help kinda bring them down out of that elevated state. And, of course, we're making sure then that they're getting enough oxygen. And if we slow their breathing with the BBM, we know that their blood gases are gonna balance out. And it's it's a really useful tool, especially if you have one handy.

34:57

I know in EMS, we we have BDMs everywhere. Athotic trainers maybe not. So that that might be something to think about in your emergency bags having a BVM. It's not just for for rescue breathing, it can help kind of calm that elevated that tachypnea with a hyperventilating kinda panicking patient if they can stand the mask on their face.

35:21

Yeah. I think this is part of that trying to get the mask. I think it's Mike pushing the mask away or where they may have someone, especially because they have a whatever their condition may be, but it's more of you're trying us to get them under control. You know? Mhmm.

35:34

They're gonna they're gonna crash one way or the other. And just trying to get the and and with that, my thought is you're just trying to do something as rapidly as you keep and to make sure there's some not something else that's underlying. Especially if you're having very several minutes trying to just to understand and, you know, I think you might have great point about, you know, just acrylic nails or, you know, even bipod patients. There's been some research shown that that the pulse oximeter is not accurate. Some help there's some health disparities in population.

36:08

So I have to be aware of that, but just trying to find what available information you have and that go on that. And the easy thing is is we're all trained in BBM already as provide a BLS provider level. So if you don't have oxygen, I think there was a question about state regulation, but there was one in the last presentation. Birth presentation about application of oxygen and state laws, whether it's rescue or therapeutic or not. And the one thing is we don't you have to just give them just pushing air, you know, getting oxygen oxygen versus no oxygen to the component.

36:44

So the other question that I had is you you would just kinda talk about about the pediatric athlete. And I think that's always a challenge. I think I've had I always have More so, if you're an event in, like, a youth soccer game or a flag football, kid gets hit in the chest. You know, the parents wanna run out. And, you know, one is just having the importance, you know, about the importance of your medical time out with the officials and controlling that, but also how to control the situation or in your experience of controlling parents from talking a lot to the to the to the youth athlete Mhmm.

37:23

When you're just trying to get them controlled, and you can't it's just it creeps I think you mentioned earlier was you almost creep this his this their their anxiety level kicks up even stroke. So just, if you wouldn't mind, sharing a little bit about that here.

37:38

So one of the best things that you can do in a situation like that is utilize the parents. So they're they're gonna be on scene anyway. They're gonna be involved whether we want them to or not. We can't blame them. I mean, their parents, that's that's what we do when our kid is in distress.

37:56

But utilize the parents to your benefit. So instead of having the parent freak out and the kid freak out, channel the parent into assisting you by by kind of directing the parent to calmly talk to the kid or calmly comfort them, you're not only going to bring your patient down, but you're also going to bring that hyperstate of the parent down to And overall, that's gonna create more of a a calm environment where you can actually do your job and and assess that athlete. And We're also keeping that panic at bay so that that kid can catch their breath. If they if they did get hit in that solar plexus, they're winded, they got the wind knocked out of them. It's a scary feeling, especially when they don't understand what's going on.

38:46

And so being able to use the parents to keep the kid calm it kinda gives them a channel to to kinda focus that energy on instead of just freaking out not being able to breathe. It kinda gives them something to focus on. So as much as we get frustrated sometimes with parents running right up to us when we're working with their kid. Sometimes it's a blessing in disguise, and you can you can kinda turn the table, so to speak, and use them to assist yourself in a way, if that makes sense.

39:22

Oh, yeah. I think, as you were mentioning, I sort thinking about how I've done that before and not even not even really thinking about it. I just get the the parent involved in or the coach even, you know, they're they're concerned and rightfully so is if you're asking them questions and they're answering the is giving the the your patient time to breathe, not talk, and you're still you know, they're they're still engaged because you're getting critical information from them, but let them provide that because the patient may not be able to. They know them better than than we know them as well. Great.

39:56

I do have here's one question. Just popped in just then. Is so one-sided pale hand is associated with a breathing problem or something else.

40:07

That's a great question. I would say you need to look at all of your clinical clues. So what what's their global presentation? What's the environment you're in? Do they you kinda start thinking, If it's environmental, do they have re nods, that's something to think about.

40:27

Is it more of a circulation issue? You're checking those pulses. You're looking for that CMS on all four limbs, and you're checking to see is it diminished on the one side. That'll tell you it might be more circulatory If they have other global signs of hypoventilation, then that could be a sign of hypoxia kinda setting in. But, again, it's it's kinda what we always talk about in athletic training.

40:54

You don't wanna just get tunnel vision on on the one area, you want to look at the patient as a whole. So that's a great question. That's one where I would absolutely say, what are the rest of your clinical signs, what are those signs pointing you to? If it's just if it's isolated to the hand and they are not, exhibiting any other signs of circulatory or respiratory distress, then my thought goes to its environmental or its localized circulation issues. But great question.

41:28

Great question. But that's that's where my mind goes to is, again, you you don't wanna just 0 in on the one thing you want to use that entire clinical road map that your patient is presenting with? So good question. I like Yeah.

41:41

It was it's a really great question. I just keep going. I I think of, you know, one thing that I know. I try to focus on. I think I'm I'm sure you can do as well and there's not so much trying to figure out what the problem what's the problem?

41:54

Like, it could what you mix on gray nose or or something else. It's just treating patients, problem, what what what they're presenting with, their their vital signs and treat those vital signs and just trying to put whatever intervention like you mentioned. Like, in this case, you're talking about, you know, using a bag if it's all you have. Using whatever the tools you have there to to resolve that or if it was hypo you know, if it was hypoglycemia, you're and you know that, you're gonna do the glucose read, and then, okay, you're gonna provide, you know, a glucose kind of a push or some other type of sugar just to get their blood sugars up. Whatever the case may be, and I think that's the just kinda hits a lot.

42:33

It really it's a really great question. I keep the, you know, the system what that looks like in treating the problem, and not get wound up. It's said at best, don't get wound up thinking, well, this has a problem. Well, is that hand problem going to is that going to cause a life threatening issue? It may be it may be a sign of something bad, but does it cause that as well.

42:55

So Mhmm. We've got so we've got about we start to wrap things up here. We got about 2 minutes left or a little less than that. Anybody else having any questions feel free to drop them in to Caitlin. And while I do I guess one other question I guess one last question is is maybe talk about the like, the pediatric patient.

43:17

Like, what's the why why you don't get alarmed or why, you know, even in their tripe in the tripod position, or they they look like they've been hit? Is there a reason to I guess, how do you man how do you manage it? I know for yourself being having 2 young ones running around that probably throwing, you know, you you're you're trying to use you're you're balancing that education with with mommy education. So to speak. So if you mind sharing your thoughts on that?

43:45

Yeah. So a lot of it, I guess, to me, just comes down to being comfortable with your knowledge and your skill set. It's, like, every time my my daughter, she jumps off furniture and she's crazy. I love her so much, but she it's amazing. I'm not great yet.

44:04

But you get kinda used to the presentation. So when something happens, you're looking and maybe, like, as athletic trainers and especially in EMS, we are so ingrained. It's so ingrained in us to just be doing that primary visual assessment all the time. And so that way you're gonna notice those things. When those things are off or something is not presenting right, you're gonna notice it right away.

44:32

So then it's just a matter of what do you know about what you're noticing? Is it alarming? Is it something where you just wanna watch? You wanna pull them off to the side and just talk to them. So with a youth athlete, I I watch them a lot, and a a lot of it comes down to for me, I'm watching their behavior.

44:52

Are they acting normal? Are they presenting with normal appearance? It comes down for me, it kinda comes down to that pediatric triangle, which I didn't touch on in my presentation. But basically watch the kid, do they look normal? If they do start showing signs of distress like that tripod position, then we're able to recognize it right away.

45:14

And kinda get on top of it before it snowballs into something worse. But, yeah, kids I mean, kids hide stuff. They they're really good at hiding stuff, so that's why it's important to to really know those subtle nuances with some of those emergency pediatric conditions so that you are able to pick up on it and be like, this kid is compensating for something and you're able to act on it before, like I said, before it, like, snowballs or before that Jenga tower falls. Because it it happens that fast. Kids are still gonna be honest.

45:49

No. You need to resilient, but at the same time, you have to put you have to gauge that with don't dismiss the fact they get hit in the chest when they go down for a minute. You have to get on the get a quick assessment from there. So With that, we're out of time. Unfortunately, we could keep talking some more.

46:06

We definitely wanna have you back again, Caitlin. Again, thank you so much, Caitlin, for joining us today. Everybody in the audience, we're getting ready to go to about a 14 minute break.