Transcript
Rescue medications over you.
So this is gonna be an open discussion and to with David Pfeiffer, And bear with me one second.
I had another document I had here that was from Great.
So got things rolling here.
So good morning, David.
How are you doing today?
Doing really well.
Thanks for having me.
Yeah.
It's great to be here.
So for the audience, as I mentioned, we're gonna do a discussion.
We've got some focusing on rescue medication.
This is a great segue that Doctor.
Fuchs gave in, also with what the previous two presenters all the okay.
Shamota and Christopher Ludwig did on respiratory emergencies.
I think this will be kind of a Eric alluded to this, some in medications, not in detail, but we'll we'll tackle some specific medication.
So Like, it's a pleasure to have David Pfeiffer from Eastern Kentucky University.
He is the emergency care program with assistant professor with the urgent care program in eastern eastern Kentucky University.
He also serves as a coordinator for their online paramedic to degree programs He works as a paramedic for Powell County ambulance service and deploys to disaster areas national special security events in public health emergencies as an emergency management specialist, operations officer for the US Department of Health And Human Services office of the assistant secretary for preparedness and response.
In in addition, I know that David's been pretty busy recently.
Works with the Kentucky Board of EMS Education Committee and leads their wilderness paramedic task force.
He's Also, the board of directors for the Appalachian Center for Wilderness Medicine, and teaches and speaks about Wilderness Medicine throughout the world.
And is a founding coordinator for the Red Star Wilderness EMS unit in the Kentucky's Red River Gorge.
While vastly recognized throughout the country for its expertise in search and rescue with the wilderness medical society and I think I've gotten a lot of that day, but I think we could keep going on with the with the work that you do in the field.
And just really excited to have you have you here this morning.
Thanks very much.
Great.
So just as a as we get started here with everyone, so as we run-in, just wanna kinda get into couple of things here, what we have here.
Presenter has no other conflicts, again, would have any product or device identified in this presentation.
It's just something we use for demonstration on me.
And anything the audience asks, we're gonna when David may give us or give us as a specific example, but in no way is at an endorsement and the same thing for medications as well and same thing for myself as a moderator.
So really what we wanna focus on today in these next in this last session is we're gonna talk we're gonna talk about these are global objectives here.
Thing about the application or systems of self administration, but also that we have to administer the different routes for bronchodilators.
Specifically respiratory emergencies.
I'm gonna talk about really have a focus on beta 2 agonist, And for the use of the athletic used by athletic trainers, we see there are also other medicines we'll probably we will maybe discuss a little bit, get David's feedback on, which you may encounter as another provider might be applying that such as paramedic.
But think about that from a merge considerable for emergencies.
And then also talk about the cons this the unique considerations when assessing and managing a pediatric through the lifespan of the geriatric patient with the respiratory emergency.
So so what's discussed as a key function discussion points today just in these over overarching themes that we'll discuss in the next 30 minutes plus the questions you have and encourage you to push those questions in the q and a session, and we'll address those.
And since this is more of a discussion format, If you have a question during the presentation, go ahead and answer that, and then we'll answer it on the on the fly as opposed to waiting in the last 10 minutes.
The other side of this, as we've talked about before, if you have a question, just raise your hand with and we will I'll turn the mic on and and have you give you opportunity to speak with David as far as a a discussion point we had, maybe, bring some better context.
If usually there's one question, it may lead it into another question as well.
So, David, if you would, just kinda give an overview.
I think the audience mostly knows this, but give a this overview of what the the role that the beta 2 agonist play in as a rescue medication for, obviously, in the field or prehospital care for those various emergency situations.
And then, you know, how their administration how the administration varies depending on patient population.
Yeah, thanks.
And if I sometimes have a tendency to just keep on talking, keep on talking, right, like any any college lecturer, I guess.
So if I start talking too long, you just cut me off.
Give me a little time out symbol.
We can have the opportunity for questions or whatever.
Yeah.
So when, you know, when we talk about beta 2 agonist, I think the one that comes to mind for almost every kind of healthcare provider is probably albuterol.
Right?
And it's important though to understand that there are many different kinds of beta 2 agonists and to separate the rescue beta 2 medications from ones that would not be considered rescue medications.
So beta 2 agonists come in a few different forms.
You have short acting, kind of a medium duration acting, and then long acting agonists.
And, you know, some examples of the long acting beta agonist, which are abbreviated laba or laba.
One of the most probably well known ones in that category, I think, is a theophylline.
And then there's just other kinds of, I guess, derivatives or analogs of albuterol.
Cell methanol.
I think 4 methanol is another one.
Under a variety of different, you know, brand names out there, you know, and we see these commercial on TV all the time for these, you know, kind of, like, daily use inhalers.
That are designed to prevent the onset of some bronchospasm.
And, you know, there's other kinds of medications that aren't really beta 2 agonist per they do the same thing, so some daily steroid medications that patients might take or other kinds of medications.
So, you know, to boil all this down when we're talking about acute respiratory emergencies, we're basically talking about albuterol or similar drugs, very closely similar drugs like Salbuterol.
So, basically, buterals, right, in the generic form.
And so on the EMS side, we we tend to give these through nebulizers.
Either the kind of pipe style nebulizer has a little cupola with a with a a perpendicular pipe on it mouthpiece.
Or through a mask nebulizer.
So these are devices that you can essentially has a little cup.
You squirt a little bit of buterol out of an ampoule into it, attach it to a oxygen source at about 6 liters per minute of flow, and it nebulizes that liquid.
And the patient can can breathe in.
We can also attach those nebulizers to bag valve masks or CPAP circuits or other kinds of emergency respiratory devices that we would use in EMS.
Now some EMS agencies are also gonna still use metered dose inhalers, and certainly the patient.
Might be carrying a meter dose inhaler that you could assist them with.
And what's really interesting is that there's actually pretty compelling research indicating that the use of a spacer on a meter dose inhaler is non inferior or in some cases superior and effectiveness to a nebulizer.
So I'm not totally familiar with the athletic trainer scope of practice throughout the contract, learn a little bit about it from collaborating with Eric.
But if you're not allowed to use nebulized in your practice setting or you simply don't have access to nebulizers, but the athlete has a meter dose inhaler, putting a spacer on it, and then coupling that spacer with proper coaching of the patient for how to actually, you know, take a breath in.
Bring up, press that meter dose inhaler.
If you can give them, you know, a few puffs of albuterol out of that meter dose inhaler, again, in many cases, non inferior, or in some cases superior to nebulizers and the cases in which it may have superior effectiveness is actually in children So if you have young athletes, you know, kind of child age, sometimes they have a really difficult time.
Tolerating the nebulizer and using that spacer with them can actually have a greater effect.
So I think that's probably the top level overview of beta 2 agonist and how we deliver them and answer to that first question?
Yeah.
I think you I think that's a great overview.
I think the a couple of things just to make note of for the and I think you've alluded to this is one is, you know, using those options and and The other presenters have already talked about some of the guy I was having the spacer, and you're you're having the nebulizer and have those different modes.
Yeah.
The problem gets into it, Lisa.
I know my experience was doing with with EMS, writing when I was working with EMS is that you know, the various patient populations, if you put a mask on someone, they they're gonna fight that.
And that's where that metered, you know, I would say for, you know, you may not have the have the direction.
Does it and it goes back, you know, the clinical protocol have in physician direction as paramount.
As to what you are allowed in within the scope of practice.
But having that that spacer, there's that's not a there's no law interest here.
You can give them they they're still going to administer self administration.
Mhmm.
But also, you know, having that nebulizer with the mask, you can put it in direct mode, bring it to the side, at least give them the opportunity where they're not feeling cons that get claustrophobic, so to speak, where they're fighting you and and have that alternative.
Now there is a flip side to that coin as well, which is that if your patient is starting to progress into true respiratory failure and you would need to assist them with a bag belt mask, Of course, your metered as inhaler is going to be challenging to use right in that application.
However, there is a little bit of a hack.
So like you mentioned, I'm a I'm a wilderness medicine guy.
Wilderness medicine has a strong ethos of improvisation and kinda some arts and crafts of making things work, you know, because you oftentimes have limited equipment out there in a wilderness.
One of the things that you can do with a meter dysonhaler in that trailer population is if you remove the albuterol cartridge from the MDI, and place it into a 60cc syringe and orient it to make sure that, of course, the straw, I guess, that it's flexed, you know, like, a little w d forty straw top is, you know, of course pointing out of the tip of the syringe.
You then remove the rubber plunger head from that plunger.
So that black rubber, you know, head of the plunger, just peel it right off.
And that is going to allow you to actuate that plunger in the 60cc syringe and actually fire that MDI cartridge right out of the tip of the syringe.
Now then, you know, so where does that go?
It it would get screwed on to the medication port of a bag valve mask.
Not every bag valve mask has It's basically a feature that you would have to order when you're purchasing your BDMs.
But I'm gonna take a guess that if many people pull out their BVM after this presentation, some portion of them are gonna have it's a little inlet port basically right at the neck of the BVM where it would attach to the mask.
It has probably a little plastic cap on it.
And it's designed for a couple of things.
You can fit various kinds of accessories onto the BVM for it.
You can use it to fit a monometer on the side to measure airway inlet pressure.
You can use it to attach certain kinds of the entitled CO to sensors to it, but you can also screw a syringer right onto it.
And so now I can squeeze the bag and tie the fire into that plunger, and now I can actually convert a meter dose inhaler to an in line NAB essentially using a background mask for my crashing bronchoconstriction patient.
That's a great med hack, so to speak.
It'd be worth it.
I mean, almost a presentation itself just on the you're using that integrated Wilner's medicine into the infield care as a you know, the the various hacks.
Just something real quick with that just to note also is just something to think about know, I'm gonna move on.
But for the provider, one is you definitely don't wanna try that what he described on the first side of it.
You wanna get back his neck.
After what we've done at first, but also think about, you know, your you brought up a good point of you don't want this the the albuterol that to to escape in open air Mhmm.
Simply because it's it is a it'll it's a heart rate.
It'll jump your heart rate up in blood pressure.
Even in the provider if you're in Haley.
So you seem to be aware of that as that as you're the provider being aware not to don't wanna get a dose of that as well because it it may cause some adverse effect even for bystanders.
One thing we we, I guess, goes in line with this.
Its administration is we we haven't I've and discussed a lot of them.
We'll talk about just ask about a mean it's just a way that what are the look look at the 6 lights for medications.
It should be built in the protocol is, you know, what is the right of the patient?
You know, what's the is the medication the right for the patient is it right for the is do you have the right medication?
And do you have the right dose?
And, again, that gets back into I don't think we have time for today, but talk, you know, what you have a browser scale for pediatric drugs and whether it's by dose volume, or by color, how it's coded.
The timing of it when it occurred and when you apply again or self administration Think about the route of administration and I mean, the route and then how you're documenting it.
So just something that's as what David mentioned, as I would say, just to we're they're doing this all the time, and I think even Eric gave a great, you know, a chart they're just easily used, and you could easily document that before the intervention.
And and as we move on, you know, think about for everyone is that you applying a medication or not applying a medication briefly.
Maybe you talk to us, David, isn't intervention.
So every especially when you're doing emergency care, getting the time you spend, not doing something, whether it's taking vital signs, etcetera, you're you're impacting intervention process.
So if you would, think like, what are some of the any uniqueness in terms of, like, far as the your your physician direction, per physician direction, if you would, like, is it there's a if the if the medication does you have that prescription, but it but that application has not been effective.
Mhmm.
We're we're for you as a paramedic in the office of Wellner's app even for providers who would have access to self administered, if it's not being a if it's not they're not seeing the efficacy of the treatment, where do they go to?
Or do we own this first 5 minutes or so?
So a lot can happen in that first 5 minutes.
And so a few things that we might consider if albuterol is not effective is we would my next choice would probably be probably ketamine.
Ketamine has a bronchodilatory effect.
It's not through the beta 2, mechanism, but but through other mechanisms.
And so ketamine has a bronchodilator effect, also has a nice kind of anxiety effect.
And that can actually make it easier for that patient to be more compliant with whatever therapies we are trying to give at that time.
So if they are kind of resisting that nebulizer or they're fighting a backup mask being applied when they're still conscious, but crashing, ketamine is gonna help facilitate that.
So that's one option.
Another option is epinephrine.
So just like the mechanisms of using epinephrine for anaphylaxis, it would be appropriate for severe bronchoconstriction refractory to albuterol as well.
So epinephrine is a non selective beta and alpha agonist, but it does have a direct beta 2 agonist effect.
And so it can open up those bronchials very, very powerfully, you know, kind of one of the downsides with that or, I guess, considerations is that it's also gonna dramatically increase cardiac workload and therefore oxygen demand for a brief period of time because it's a fairly short short half life, very very short half life.
So, you know, we have a patient who's struggling to breathe, and I can actually add well, now we're going to increase that deficit.
Until, right, the bronchials open up.
So it's a medication more associated with an inextremus crashing, you know, respiratory patient, but that would be in that consideration as well.
We also might consider magnesium sulfate.
Magnesium sulfate is not a bronchodilator I'm sorry, not a beta 2 agonist.
It is a smooth muscle relaxant via mechanism of action on the calcium channels.
Of the muscles.
But max sulfate is used in the paramedic scope of practice for a variety of conditions related to muscle spasming.
So that could be premature labor contractions.
It could be very cardiac conditions where the cardiac muscle is sort of irritated, but it is a bronchodilator as well.
And it actually has a very, very high efficacy in refractory asthma patients.
So if if listeners are familiar with the concept of the NNT, the number needed to treat, it's a metro for how many patients would need to receive a given therapy before you'd see the positive impact of that therapy on a statistical basis, the number needed to treat for max sulfate in the setting of refractory asthma is lower than the number needed to treat for aspirin in heart attacks.
And aspirin is the mainstay, the primary field treatment for somebody having a heart attack.
So in other words, max sulfate is very, very efficacious in in refractory asthma.
So then we have some steroids.
So steroids like SoluMedrol, for example, is Verint is very, very commonly carried by paramedics.
It's not a quick acting agent.
It can have a relatively quick onset but the full therapeutic effect of that Solly Madrigal is really over the course of hours rather than than than kind of a it's not a rescue drug.
In other words, so it's not gonna be our first line treatment.
But after I get those airways opened, with those other first line medications I mentioned, we would probably add Solly Medrol into the mix to try to prevent a recurrence or refractory kind of the situation.
That's a great you you had a great So my initial thoughts were you going to listen as I'm listening to you is not just think about the albuterol administration, but what may also apply for you gave example, give the epinephrine and EpiPen as a as a secondary push.
You you know, basically what you again, go it goes back to you know, this whole but for physician direction, your state practice act, what that may apply to in the in the patient setting you're in.
So or with the different patients you may encounter.
So leading into that is that that, you know, as an athletic trainer in the field, we may see anyone from okay.
There's a coach who may be in the thirties or maybe seventies.
You may have a pediatric patient from 12 or, you know, ten years old.
Briefly, what is the what are some key considerations just to think about Forbes Administration I think you've talked about this some degree where they may be more resistant than the actual application, but anything from a from a clinical side just to be thinking about the from a pediatric to Mhmm.
The adult to geriatric patient care.
I think the first thing is with children, really with any adult I mean, any any any patient, but particularly with children, I would encourage people to consider the spacer on an MDI as mandatory.
I spent a long time in my career in EMS thinking to myself, you know, you know, MDIs are are helpful.
But but the the research is really overwhelming that spacers make a massive difference in the effectiveness of the therapy from MDIs and and really the delivery of the drug.
So when you're using just a MDI, up to about 90% of that drug can get deposited just in the oral cavity.
When you use a spacer, we're basically flipping that statistic.
Right?
Now much more of the medications going down into the lungs.
And so the research indicates that using a spacer can increase overall MDI effectiveness by about 70%.
And you still have to coach the patient to take a breath at the right point in terms of when you hit that MDI.
Cartridge.
But, you know, it's it's it's making it much more likely that they're actually gonna breathe that that medication down into their into their lungs.
And we can all imagine how much more pertinent that is to a child who may not be able to come imply very well with instructions to begin with, and it's certainly gonna have less of a ability to do that if they're respiratory distress and they're sort of panicked.
And scared and nervous and and basically being a child without the, you know, wisdom and life experience to kinda know, oh, here's a Here's a healthcare provider.
They're trained to help me, and I just need to kind of follow their instructions best I can.
So I think with children and MDI is is a a a spacer, I mean, is part is part and parcel to using an MDI.
So you might not be carrying the MDI.
It might be on the patient or, you know, It's their prescription for in in, you know, in some cases.
So so add a add a $14 spacer to your kit, and they can be, obviously, you know, reused and re washed and stuff like that.
And a quick note again from the wilderness perspective.
An improvised bottle spacer, again, on an evidence based level, is just as effective as a as a space as a commercial spacer.
So if you cut a little hole in the bottom of a water bottle, slip the MDI into it, and then you have the obviously the lips of the bottle or the screw cap would be that the person is sealing their lips around, that improvised water bottle spacer is just as effective in in as a commercial spacer along many different metrics, including rates of hospitalization, rate incidents of needing to follow it on with second line drugs, like the ones I mentioned, so on and so forth.
That's pretty cool.
Right?
If you don't have that commercial space or already in your kit, and you have a child who has a respiratory event at a athletic competition tomorrow.
Cut a water bottle, make a spacer out of it, and and that would be a good thing to do.
Now if we kinda go to the other end of the age spectrum, obviously, with geriatric population.
You know, I think honestly, there aren't too many special consideration for that population other than understanding that you know, there may be additional challenges with ventilatory support for those patients because as get older.
We have decreased lung compliance naturally.
We do have some stiffening of tissues, cartilage, and and that kind of stuff.
And so in general, it can be a little bit more difficult to use a bag valve mask on on elderly patients.
Not dramatically different.
It's not, you know, it's not necessarily gonna make or break their treatment, but it can just be a little bit more challenging compared to a child or a younger adult who has just, you know, generally much more compliant long is much more compliant chest and that kind of thing.
And so I think what that means is that it can be even more challenging to maybe deliver beta 2 rest medications through that bag belt mask and really get them deep into the lungs on those kinds of patients.
And so that would be a consideration for really, I think, sitting down with your medical director and talking about what are our strategies gonna be for doing that.
They make in line nebulizer kits to be able to really put a oxygen powered nebulizer on a second oxygen powered source.
You know, between the bag and the mask so that we have, you know, 100% oxygen at high vol volumes coming through a bag of mask, and then nebulized medication, 6 liters per minute being aerosolized that the bag of mask isn't gonna push.
So it's really just kind of a logistical question of, okay, we're probably gonna need a couple of auction cylinders.
We're gonna need that special inline NED kit.
So on and so forth to to just make it, again, practically a little bit more a little easier to really get those beta 2 medications down into my elderly patients' lungs if they do go into that degree of respiratory distress.
And then I think there's just always the general considerations of, you know, if we're giving medications that increase cardiac increased heart rate, you know, like albuterol.
And we are increasing blood pressure and increasing heart rate a little bit.
There's a consideration that should be in your mind about am I actually going to basically cause maybe now a cardiac problem with my hourly patient, kind of theoretically, they might be more likely to have a heart attack.
Basically right, as we give beta 2 agonists that, you know, increase their oxygen, cardiac, workload, and and and metabolic oxygen demand, epinephrine, for example, does constrict arteries, and so that could make it a little bit more likely that some sort of narrowing of their arteries just from age related, narrowing, and hardening of the arteries and so forth might lead to a heart attack.
Now that is not a reason to withhold those medications.
That is a possible risk of giving them in in elderly patients.
But obviously, if you don't give them their rescue medications, they're gonna die from the respiratory distress.
Right?
It's gonna go to respiratory arrest and cardiac arrest anyway, but it's a consideration for using those med occasions to kind of just be aware of that we can precipitate potentially some second line kind of cardiac effects in that elderly population.
That's that's a great point.
You know, I think the to what you mentioned is, one is just make sure you're within the clinical protocol considerations or guidelines.
One is you wanna have the you need to have the the necessary equipment there like the spacer.
You have it there.
If it's a backup and you don't have it, then or you've run out for whatever reason, then you seem to have I think you you said the best consult with your medical direction, your medical director, and work through that plan in advance.
That way, you know it may be more than that.
Another thing which was with this as David alluded to you alluded to was simply they're they're just not trained in using an an an an NBI.
Or the mask as well.
That's just something that you have to you have to be able to overcome that, and that's just a but you have to do that good practice.
I think the one goes back to simulation training You have to go through you have to go through that scenario to to appreciate what that looks like from that.
So moving moving forward a little bit from a from the dosing or at least more from a how we your the timing of dosing.
Think about the ALS response.
So whenever in the in the general population, when you make a when when you're making a call, when a call comes into to EMS and they're dispatching a unit, they're just they're responding to what information has been provided already.
We know this already.
So it's really important that whoever is, if you're having a respiratory distress, respiratory issue.
You need to say respiratory because otherwise and David, you know, alluded to this, you know, there it's gonna be a basic Somebody's not feeling well.
Are they gonna expect a BLS unit when they actually need an ALS unit with the with appropriate medications And but it goes back to initially is that a fish if you can talk a little bit about the importance of how what Aflac trends and other providers that are not EMS trained.
Yep.
What the what the criticality, I guess, that's the right word to even say, of doing the rapid assessment, getting trending vitals, think you talked about this.
If you do administer, you know, albiro or epinephrine before advanced support support gets there, then you're gonna see that spike up potentially in blood pressure.
And that's a trending vinyl, but you don't wanna be fooled by that either, but they're necessarily better.
Looking at the overall totality of how they're what they're what they are for them, of course, 8 to 10 minutes.
You can discuss a little bit the importance of that in your experience.
Yeah.
Sure.
So, you know, just just I think remember to when you're treating patients to try not to get tunnel vision.
Right?
And this comes with experience.
It comes with, you know, the more fidelity simulation training, you can do the the better, but it's also a matter of a little bit of mindful reflection.
You know, you really can train your own brain to maintain situational awareness and not get tunnel vision.
It comes with you just have to be, you know, mentally very focused.
I mean, I say, like, there's a voice in my head.
I'm in really critical situations where I'm saying to myself, usually silently, sometimes actually a little bit out loud on my breath or Right?
David, you know, take a breath, take a breath, look at the whole picture.
Look at the whole picture.
Right?
And what I mean by that and kind of what I'm saying here is, When you have a respiratory distress patient, it's not as important about whether or not the blood pressure is now 20 points higher than it was 5 minutes ago.
What's more important is how well is my patient oxygenated?
What is their mental status?
What is their work of breathing?
What is their skin condition?
Is their heart rate strong and and bounding, or is it weakened, Freddie?
And and so I don't necessarily care as the paramedic responded to that scene, was their heart rate 110 when you first started treating them and now it's 115?
That's not really what I care about.
It's whether or not I had a normal heart rate at baseline initially, and now it's super fast and weakened threading and and and tachycardic.
And that that's, you know, that broad and and and and how is my patient oxygenated?
What is their respiratory tube?
What is their work of breathing?
And that kind of stuff?
So try not to chase specific numbers as much as you're trying to keep a overall picture of what is that, what is that presentation of the patient.
And so that's the first tip.
I think the second tip is It is very helpful when we're responding and we're getting ready for that patient handoff moment.
What treatments did you render?
How many of them did you give, and what was the effect on the patient.
Right?
So if you've been giving them multiple meter dose inhaler puffs, and there's no improvement.
That is very pertinent to me as the paramedic about what I'm gonna reach into my bag and pull out next.
And what medication that we're gonna we're gonna use.
If you've already been given them a lot of albuterol and that albuterol is not working, I'm probably gonna skip the albuterol and head straight to one of those second line drugs as I mentioned earlier.
And then the third thing, just in general, I would say about this, concept.
I know it's it's probably not directly related to the question that you answered, but it's gotten me thinking about this.
Many EMS providers have no idea what an athletic trainer is and what your scope of practice is.
And I know many people in the athletic community have post nominals in EMS.
So I see, you know, NREMT or Ronnie on your screen, you know, Eric is advanced EMT.
If you have those post nominals, think back to your training in the MS at your initial EMT class or whatever, and ask yourself, did my EMT instructor ever mention an athletic trainer as a part of that training?
And and and you you typically don't.
Right?
And so you typically don't don't learn about that.
And and so I would really encourage all of you, if you haven't already, call up your local EMS agency, and offer to do an in service presentation for them on what an athletic trainer is, what your scope of practice is, what your protocols and your general approaches to different kinds of situations are.
Every EMS provider out there, as many of you know, just like you guys as maybe what I would call, Superroll, F Life Trainers, who don't have EMS credentials, we all need ConEd.
We all need CEUs.
Right?
And so those agencies are usually gonna be receptive to you coming in and doing some stuff with their personnel, just explain what you do, and do some simulations with them about this handoff.
Do some collaborative training to understand that kind of mindset, and you will see how we approach a patient in the first couple of minutes or 1st 5 minutes or so of acute patient care.
And you can start to understand how your different kinds of care and different approaches might might be able to be integrated a little bit more more seamlessly.
If you do have those EMS post nominals after your name, that's a great foot in the door.
Right?
Because because when they when you send that email out and they see the inner EMT credentials, they're like, oh, one of us.
Okay.
Cool.
He kinda, you know, kinda gets us.
But if you don't have that EMS training, don't let that be a barrier or an intimidation factor.
And speaking to EMS providers, we're usually really eager to learn what these other healthcare roles out there do.
And so I know that, again, that wasn't maybe totally germane to to what you're asking, but but it came to mind as we were talking.
Think it fits in well.
I think, you know, you think about the initial first couple you mentioned, we talked about this already in respiratory and gets into perfusion, you know, having the necessary tools, it doesn't say they're getting better, but, you know, for example, having getting the portable the in getting entitled CO2 volume, we we've rely a lot on OK because of their pulse oximetry, and that's very that can be inaccurate to the most part versus internal CO2 is gonna tell you, hey, either they are for a poor perfusioner or they're bad.
At it.
And if they're bad, then then you know you you don't need that.
I mean, it's a you just plug it right in, and they have even the portable units put in on to give it give a sample of that.
That's gonna tell you whether they're whether they're good or they're not and and Eric discussed that gave some examples of that as well.
So if we think about what that does, it's not what they're doing and, like you said, at best, either they're getting better or they're getting worse.
Yeah.
They're not getting better.
This is why you're having a constant, you know, the the reassessment over their next couple of minutes.
And if they're getting better, then you can expand out the length of time between you need to do a reassessment and if they're conscious or their what their level of consciousness is, what other vitals are, they turn it back to normal, then you know that you make back, like, for example, oxygen, you know, what their what their SPO2 levels are.
It's important, but It helps you determine whether, you know, how much option you would apply, but they're gonna show that if you use that, you know, as doing that as well.
So And one quick note about NTEL CO2, it has become a mainstay of EMS in most parts of the country.
It's hugely powerful information.
So I might be covering things people have talked about earlier this week or something Eric talked about earlier today, but the the pathanemonic waveform on an entitled c 02 monitor for bronchospasm or bronchoconstriction is shark fin waveforms and have a shark fin morphology to each of those e ETC2 complexes.
So it's very powerful information to be able to look at that continuous end tidal CO2 waveform and see whether or not your bronchodilator strategy is working.
And so if you're giving a couple of puff of an inhaler or a little bit of time on a nebulizer or whatever, and those shark fins are not resolving, down into a more blocky plateau shape of a normal entitled c 02, you have a problem.
And you might wanna consider, you know, adjusting your treatment strategies or or, you know, something to that effect.
And so that's huge.
And then likewise, most respiratory distress patients who are suffering from bronchoconstriction are probably going to have a highly elevated qualitative internal COT level.
So that normal level of 35 to 45 might be 50, 55, 60, 65.
And that is usually the result of trapping of air in their lungs from that bronchoconstriction.
And so they're continuing to have, you know, cellular metabolism occurring on some level.
They might be hypoxic.
But their cells are still doing their thing and producing CO2 as a waste product, and it's kinda basically getting trapped in their lungs because they cannot exhale.
Properly.
And so when they do squeak out a little bit of air through some, you know, wheezing, it's saturated essentially with with with CO2.
And so, again, if you're doing treatments and you you start to see that entitled CO2 number, you know, come down, then that would generally be a good sign that your therapies are effective.
If it's not coming down or it's going up, you know, that that would be a problem.
So entitlec02 is phenomenal, and there's a lot of different products out there now in various price points and various form factors.
To be able to do continuous and tidal wave form monitoring.
So right.
So audience, we have about 2 more minutes before we're going to sign up.
If you have any questions, feel free to put them in the q and a.
I think as we wrap this up, David, I think, you know, talking about the the that's the advancement That was one question I was gonna add.
You know, we're gonna talk about some about words and advancements that you having that portability of the entire CO2 is incredible.
Modality to use or or diagnostic modality to use, but also I think, you know, some of the think about the medical conditions, it's gonna be Like, for example, someone is in may have an app in having a sepsis or they're having they may have a rupture appendix.
They're not having an adenovate or having a or some type of other, you know, abdominal condition is not acute in terms of trauma, that if they're not having they're if they're it's gonna show perfusion or in their perfusion levels.
This is where it's really critical.
They may be having a diffuse abdominal pain and but they're they're already they're hypo they're hypo they're hypo perfused, and they're already in that that multiple you know, the functional syndrome in terms of the body's compensating.
It's just there one thing stacking or another, especially when you look at pediatrics.
Think that's probably one of the best probably would be one of the best modalities to have if you're working with pediatric athletes because they they have that the decompensation so fast, they're fine until they're not in the boot.
And you have a really accurate modality to use to assess and get in addition to your initial vital sign assessment.
Mhmm.
Good.
Alright.
I think we're we're wrapping up on the about a minute left.
Anything closing or or kinda high points you'd like to share, David, within the in the next minute.
About what we've talked about today or really hot points that they're they're taking on points for the audience.
Yeah.
So, you know, not to not to believe or any points much, but just to kinda put a tiny bell on things.
You know, keep in mind that overall picture of your patient, make sure you don't get those blinders on looking just at SPO2, or just at, you know, one thing or the other, just at a specific heart rate.
Look at that total picture.
Does the person sitting in front of you look to you like they are having trouble breathing, that they're respiratory distress.
And then those other kinds of specific vital signs that we can measure help to complete that picture, fill in that picture, give us a sense of the severity maybe or the nuances of that presentation.
But in general, you know, try not to chase specific rabbit holes.
And then I think the second big thing would big thing would be reach out to your EMS agencies give those EMTs and Paramax a chance to know what you do as a healthcare professional who is also engaged in emergency care but that as EMS riders, we oftentimes don't get a whole lot of training on on what your role is.
Yep.
All about collaboration communication, I think even fire departments as well, they want to have they want them their job easy.
So it it's it's incumbent upon them.
They want to know where who's there.
It makes for where if if you've if you talk to any idea, Mastercard, public safety official.
They're going on scene for anything, knowing not necessarily knowing who you are, but knowing what you do.
They're not really may know your name, but at least they have an idea or at least an understanding of what you're doing and how you're trying, you know, in in any situation we talked about to somebody yesterday like mental health emergencies.
Either you are on the boat or you're not on their or you're 4 against that process.
So they wanna find those allies early on.
And the same thing for going into any situation, you know, who can control the situation, who's helping them out, and get that rapid transfer, you know, from an EMS perspective, there it's this is a medical emergency, and they're trying to get in and out in 8 to 8 to 10 minutes at the most by the time they come on board and do that.
And that's a role that that any other provider who's not with it on an EMS unit, they're they become the biggest ally for the patient and and that transitional that that hand off to the patient.
So, David, thank you so much.
It's been a pleasure to have you here today.
I look forward to having you here do some other things down the line as well, especially, I think, some of the, like, the life hacks or so to speak, those are really would be, I think, interest among other topics within your expertise.
And, again, thank you for being here for this session today as we wrap up on respiratory emergencies.
Eric, thanks for having me.
Great.
Thank you so much.
Respiratory Medications and Diverse Populations
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Updated Jan 22, 2024
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