Transcript

0:11

Years. So, Eric, a little bit about Eric. He is a professor of athletic training in the Department of Park Recreation exercises Sports Science, and serves as an agile faculty in East Kentucky University Center for Wilderness Medicine outdoor public safety area. Has served as an department chair of exercise and sports science at EKU from 216 to December 22, prior to being the cherry served as the a tech program director for 10 years and all of us oversaw the transition from their bachelor's to master masters in Acadia accredited program. Wow.

0:51

That was easy. Doctor Fuze has authored a textbook chapter in nursing medication administration. He clinically practices as an athletic trainer serving as a director of sports medicine for festival sports. We direct some medical care and services of volleyball festival 600teen girls junior AUS Coast National band. Doctor.

1:14

Hughes has an extensive experience in emergency healthcare to critically injured athlete, public a chapter on emergency medication, his administration. He completed his doctorate of arts at Middle Tennessee State, Masters, an an athlete training at San Jose State University, and he's BS in athletic training and health education from Ohio University. So good to have you look forward to hearing hearing you break this down for us.

1:45

Well, thank you for having me. Hopefully, everyone is is joined in and can see me down in the corner screened in this all different. That being said, what I'm here to talk to you about is clinical decision making and ongoing assessment and risk tory emergencies, and we've already heard about initial assessments. We've heard about some of the conditions and things that you need to do. But part of your decision on how you're gonna treat that person and whether you're gonna transport them, whether you going to administer various interventions is gonna be based on your ability to clinically decide.

2:28

Right? And what are we gonna use to do that? We're gonna use a lot of different things in our toolbox in order to get to our differential diagnosis and and determine treatment interventions. Some of which we've got to make this quick because we're dealing with the respiratory system. And as as it's been said, if you wait too long to mess with it.

2:52

That can be a bad patient outcome. So we wanna do things quickly. Couple of disclosures, I don't have any financial conflicts to disclose with any of the products or anything that I'm talking about. Everything that I'm gonna talk about is generally my opinion as far as that goes, but it's usually based on evidence in the literature and I'm not promoting any service or product, I may provide things that I find may make your job easier in assessment with various vital sign equipment and things like that, but I have no vested interest in in those products. Also, I as disclosed in my biography, I've written a textbook chapter, but, again, there's no royalties from that that textbook ongoing.

3:46

And then I also served on our Kentucky board of medical licensure task force for developing our regulations on medication administration and evasive procedures for athletic trainers, and I bring this up as every presenter has that you need to practice within your scope of practice. But I also bring it up because I am an advanced EMT as well But some of the medications and things that I may talk about administering as an athletic trainer as an intervention are actually within the scope of an athletic trainer in Kentucky with our revised practice act, which is based off of the KD standards. So I would encourage others, if you can't do some of these interventions to get involved in in updating the practice act, if possible. I also do operate with the special operations team in the River Gorge in Kentucky as an advanced CMT. So I don't just have the credential.

4:43

I actually practice with that advanced wilderness team as a division of Park County EMS where I also work as a part time EMS provider. So Those are kind of my disclosures. The objectives for this talk, we've been talking about respiratory emergencies. We had an introduction of basic assessment and and anatomy, but you wanna get proficient at assessment and decision making skills that's what you need to do. So when you divide your treatment plans for respiratory, when you're devising these treatment plans, you know, what medication, what intervention I'm going to actually provide for this particular respiratory distress.

5:28

And then the importance and the process of how do you go about doing ongoing assessment? Because if you're administering medications, even if it's as simple as oxygen, which was mentioned by Chris and the previous presenters, you need to gauge how that patient's responding the intervention and the medication you're giving changes in conditions for the patient? Are they getting better? Are they getting worse? How do you trend your vital signs and how do you interpret that trending for respiratory issues and emergencies.

6:00

And again, we're talking about the the respiratory system. So some of this we need to do pretty quick, and some of it's already and ingrained in your education and your training, but we're gonna talk through the processes. Anyways. The very first thing is it's always gonna start as you approach your patient, which is often the case in in sports side of things. We're approaching them out on the field, on the court.

6:32

If you're dealing with public safety sector, military individuals, the tactical athlete, if you will. You're still likely approaching them. But occasionally, they approach you. Right? They come off to the sideline.

6:46

They come into the athletic training facility. Complaining of something. So as you approach that patient, what kind of position are they in? Are they flat on their back? Right?

6:59

Your worst case scenario, not moving, period to not be breathing till you get up to them, or are they as in this upper picture here coming in and sitting down and and leaning forward, and that's a tripod position, and tripodting is a position people who are having respiratory distress tend to lean into because it allows for the maximum space in their lungs to try to move air. So that's why you'll find a lot of asthma patients. Maybe out on the field with their hands on their knees trying to breathe. If they sit on the bench, they're leaning forward like this. So do they have any of that going on?

7:40

And do we know if they are our patients or our athletes? Do we know of any pertinent medical history? Do you have a quick card quick sheet that's gonna reference things like this person's an asthmatic. This person has a history of x, y, or z. What medications is this person on.

8:02

All those things can be very, very important. For example, if you're dealing with women's soccer and you have an athlete that suddenly has shortness of breath and pain in that chest, and you happen to know from their medical history that they're on birth control pills per se, again, You can start to suspect that they don't have asthma and other things, things like a pulmonary embolism, which Chris has already talked about. That medical history is very, very important as well as that positioning. That being said too, are they using accessory respiratory muscles? So in between their rib cage or the his muscles sucking in down under the neck, when you look at them, are they having a hard time communicating.

8:53

In other words, can I speak to yours and then short burst sentences things along the lines? They're nostrils, the nasal areas. They're flaring out really, really large, trying to get air in. These are all visual clues that you can be assessing as you're approaching them, trying to talk to them. And then as was talked about in primary assessment and the earlier thing, what kind of noises are you hearing?

9:21

Are they wheezing? Do they have a high pitched weave like Strider, which should alert you that you really have a critically critical airway situation going on versus snoring respiration. What's their skin color like? And then in the case of pneumothoraxes, which Chris touched on more from traumatic ones, and these are late signs. You hear all the time and textbooks about jugular vein distension along the neck or tracheal deviation, those are late signs in those cases, but again, depending on when you're being brought into this or if it's a significant trauma.

9:60

And again, Here's our other question. Is this trauma? Is this medical? Right? Are we dealing with somebody that's asthmatic?

10:10

Okay. Or did they receive a blow to their chest? They and maybe this is secondary to a root fracture or secondary to falling from a height? Do you have a cheerleader Jimness falls from a great height, lands on their back, maybe not on a padded mat, and now they have an actual contusion of the lungs, that's creating blood filling up in there. We've got to decide.

10:38

And those things, when you look at this person and you see multiple things going on. If they're tripoding, they're having difficulty breathing. And they they've sharp pains in their chest, but they don't have a history of asthma. Now those things are gonna be red flags that I need to activate my EAP. I need to get EMS there.

10:59

If it's a known asthmatic and they're ri plotting. Okay. Then we need to do some initial interventions, maybe give albuterol to them and see if that relieves it. And if it's not, then activate. So your transport decisions, how quickly you're gonna activate, and depends on your resources.

11:18

Right? You may want to activate the EAP and call 911 sooner depending on your resources and what medications you have available or If you're not able to carry out buterol and as an MDI as an athletic trainer or beer in our state, and that athlete didn't bring their medication and doesn't have it, then you're probably gonna move to activating it sooner. And that's just on that initial looking at that. Right? That initial patient assessment that we have going on.

11:52

So now here's where I'm gonna give you a little bit of a warning, and I'm gonna get up on a soapbox. If any of you've heard me present, Now some of my other emergency care talks, I get on this, but it's a very, very important point that we're gonna spend time on And I'm gonna talk to you, and it's about vital signs. You have heard about vital signs in each of the presentations. But notoriously, in my experience, my opinion, based on what I've seen, athletic trainers are not very good about doing vital signs. Let alone what is needed for clinical decision making and respiratory cases of vital sign trending, you have to get baseline vitals, which has been talked about.

12:35

And taking those vitals on every patient. Unfortunately, because a lot of the injuries we deal with are orth pedic in nature, when we see a patient, a lot of athletic trainers focus in on that focused exam and do that and now take vitals. But I challenge you. Think about when an athlete goes to an orthopedic's office, goes to a primary care physician's office, goes to the emergency department. What are the first things they're doing on that patient as they room that patient?

13:06

They're taking vital signs. As athletic trainers, unless they are presenting with the true gen mad, fever, sick, cold, flu, or we're doing physicals, You have an ankle sprain comes in. I would bet based on my observation of clinical instructors, we don't measure or take vital signs. And where I really came away with a passion to get on a soapbox about this was I was at a CE event and a well respected paramedic and our colleague of mine Remember my Red Star team, and he's got years of experience, and he was presenting a topic. And he pointed out that The time to get good at those skills is when you're dealing with the noncritical patient.

13:60

In other words, to be able to effectively rattle off a set of vital signs, which as as argument said, in a critical patient every 5 minutes, you need to assess them. And then in a noncritical, every 10 to 15 minutes, you should be reassessing. And if you give a medication, if you're able or if the patient takes some medication, you should reassess vital signs to see if that medication is working. But the way you get good and the way that you know you can get a pulse, a blood pressure, pulse ox, all those things quickly is do them when it's not as critical. So that's a mindset that you need to get into.

14:42

But if you're dealing with respiratory to stress, you really need to look at doing vitals, and they're very, very important. And Again, vital signs is nothing new. It is taught in anaphropic training education, but doing them on a regular basis and getting good is important. So when we're talking about making our clinical decision, I already said, first impression of the patient, How do they present? That's going to inform our activated AP transport decisions.

15:20

Then after we've done that, If they are obviously, if they are not breathing, don't have the pulse, you're gonna go straight into your AP for cardiac arrest, and do your CPR and and all those things. But let's talk about these other conditions when we're dealing with asthma. So we need to assess vital signs. Right? And what are our vital signs?

15:44

Well, we need to take pulse. We need to know what their respiratory rate is and what the quality of it. Right? And when you take pulses, if you think this person's critical, you wanna take at least the 32nd pulse times 2. Right?

15:59

Because if they have an irregular heartbeat, then we wanna capture that longer. If they seem stable, maybe we're just doing it to practice our vital signs, you could probably take one 15 seconds, multiply by 4. Or you can put a pulse ox on the individual, but that won't necessarily give you quality of the pulse, but they'll give you what their pulse is. Then respiratory rate. A lot of talk has been done about SVO2, but what is their rate?

16:32

Have you counted their breath? How fast are they breathing? How slow are they breathing? And then what's the quality of their respirations? Okay?

16:41

Ostilating on the fields. This is extremely important. And do you have the stethoscope and the equipment with you when you get to your patient. It's one thing if they're coming into your facility because they're starting to have an asthma attack, etcetera, and we have all this equipment right there. But are you planning for on the field how you're gonna assess this?

17:02

And, again, we have various fanny packs, various sling packs, and things that you can put a lot of equipment into so you could have it at your quick disposal to get these done. But when I'm oscillating lungs, sounds at least know what normal is, if nothing else get really good at listening, and this again goes back to my earlier statement. Are you practicing doing assessment of lung fields on your noncritical patients? So you hear what normal is. Because then when you hear something abnormal, you know, there's definitely a problem going on.

17:36

And then learn the more the vesicle sounds, the wrongky sounds, the wheezing sounds, and things like that that you may be able touscultate. And know which fields we need to oscillate in. Taking a blood pressure, being able to determine what their shock index is or the mean arterial pressure is also very, very helpful, but getting a quick blood pressure. Whether that's an electronic one, like the picture that I'm sitting in the middle of on your screen, the Walter Allen, or a manual blood pressure. Get a blood pressure.

18:13

What does it tell you? The nice thing, like I said, I would give you tips and tricks that would one that's on the screen that I have no financial interest in. You can slap this on somebody. It gives you blood pressure pulse. It gives you mean arterial pressure, which is what map is.

18:30

And then every 5 minutes, just push the button in it. Collects that information. And later, you can go down to the review box, and you'll have it all there for charting on your patient, or as you're treating your patient, you can go to review and see what the previous was to see where they're at, and that tracks it. Again, not that expensive overall and and cost of things. So something something to consider carrying around.

19:03

But at the same time, a manual blood pressure cuff works just as well, and you can calculate map using the formula, etcetera. Pulse ox. Everybody learned about pulse ox after COVID for sure, but SPOT has been talked about. Are they sagging above 97%? Is that sat falling?

19:21

Was it low? And now we've done an intervention, which I'm gonna talk about various interventions, and is it trending to get better, or is it getting worse? And then probably one that is a completely new vital sign or gold standard that has talked about in EMS that may be fairly new to public trainers, and you may not have heard of it as something called entitled c 02 assessment. And this used to be done using floor metric devices purple and yellow colored devices that you put between a BVM. When you're ventilating a patient, But now there's actual electronic entitled c o t u that gives you waveform capnography as well as a n title c 02 number.

20:10

And the picture off to the left showing 2 portable devices. One has the SPO2 on it, plus it has an entitled CO2 measure. The only reason I bring this up is if you're dealing with airway and you're administering oxygen or you're administering various ventilatory treatments for asthma and other conditions, You can put this in line with what you're doing, so it goes in between the the mask on the patient, and the PBM or the mask and the oxygen cylinder, and it's gonna give a feedback. And once you learn how to interpret it, you can realize, oh, they're having a lot of bronchospasm, which would be consistent with asthma. Right?

20:59

If I got somebody who's hyperventilating and I can get one of these between them and the oxygen device that I put on them, I can see is it true hyperventilation, or is it not? But the other reason I bring this up is is in a lot of programs and a lot of places, have added supraglottic airways, which are main stairways, besides the MPA and the OPA, and the gold standard for tube placement for ET tubes and monitoring placement even in supraglottix is doing in title CO2. I'm not this would be a whole separate lecture, but I just wanna bring it up since I know a lot of athletic trainers are starting to get into using those supraglodic airways and for sure there. But it's another IBN device that can be given and gives you a real time indicator of ventilatory stats. Okay?

21:55

Temperature we know about, but temperature is important. Chris, just talk about various infections. Do we have a viral pneumonia or a bacterial? What's their temperature. Is that impacting?

22:07

Are they asthmatic? But as one physician I once heard said, patients can have as many comorbidities as they choose and please to have, so they could be asthmatic, but they're also dealing with the bronchitis. Not a great combination, but we need to make sure we're treating what needs to be treated. So and then blood glucose, checking their blood sugars, again, diabetic patients, which will, you know, 2 small respirations and different changes in respiratory patterns. Based on if they're hypoglycemic or hyperglycemic can be an indicator instead of checking blood glucose.

22:46

These are all your vital signs. Right? We need to get better at assessing them, especially the basics, respiratory rate, pulse. Blood pressure SPO2 temperature, and then definitely doing a a BGL. On your patients and use those patients that aren't as critical to get better at your skills.

23:08

So when it is critical, you can do these very, very quickly. Right? So when we're assessing vital signs, we reassess a critical patient for someone that we consider in significant distress every 5 minutes. And we're looking for their change in stats. And so Are their vital signs getting better?

23:32

Are their vital signs getting worse? But we have to take into account What interventions are we doing? Are we just providing oxygen? Or is this an asthmatic patient Here we got to. We got some baseline.

23:48

Now they're taking their inhaler. Okay? They're inhaler. They're albuterol. Hopefully, it's gonna help decreased the swelling, decreased the spasm, and improved respiratory.

23:58

So their SVO2, which was down, should go up. But if I understand my pharmacology and this is understanding trimming your vital signs, their heart rate may go up more. Why because of the medication that we're administering and its effect on cardiac system. So We want to see the vital signs trending. Are they doing right?

24:19

In other words, SPO2 is getting better. Yeah. Heart rate spiked. K? But that makes sense based on the intervention we get.

24:29

If you give somebody a nebulizer, k? Which is a breathing treatment. So whether they do it with the mask or they do it with the pipe or they hold it, I have a mask that's that's pictured there on the far left, and the person gets that breathing treatment because a lot of athletic trainers carry oxygen already, which is a prescription medication by the way, So as long as your prexact allows for prescription meds, well, if you add having albuterol and a nebulizing mask, which in Kentucky, we can do. We can also use AtraMed and some others. Put that in, hook it up to your oxygen while you're waiting for EMS to get there.

25:06

And start giving them deep breathing treatment if their meter ghost inhaler hadn't been working, which they may need. But if I give them that, I need to know what I should be seeing in my patient from a clinical decision? Are they getting better, or are they getting worse? Another example for this besides my asthmatic would be we talk about Narcan and we talk about opioids and and drug overdoses, which can happen in schools. It can happen to patients that inadvertently take too much of their opioid opioid medication after surgery, and that's going to depress respiration.

25:50

Right? It's gonna get it down And now we need to get that back. Well, if we administer NARCAN naloxolone, I should start seeing their SPO2 come up. Hopefully, heart rates coming up as their respiratory drive improves, but it may or may not happen. But I need to be able to check that for any of the medications I'm giving.

26:16

I'm giving epi for anaphylaxis. Right? Same thing. We should see the airway open. SPO2 go up, but we also may see their heart rate go up.

26:28

So understanding what we're intervening, and this is the reason to reassess in a critical patient every 5 minutes because, again, it's the respiratory system. We don't want to mess with our respiratory system as far as isn't going to be giving us problems. We want to get them transported as quickly as possible. So you gotta know how to interpret the findings you're getting and use the equipment that you have. Like a BVM, if you are having to ventilate, maybe you're assisting ventilations on a respiratory depress system like Some are using an opioid opioid overdose.

27:12

Well, just know that a bag out mask holds about 1400 milliliters of air. And you don't need to pump that much air into them. So do we have peak valves on ours? Do we know our equipment? Do we have it?

27:26

And I know in previous presentations earlier this week, they talked about airway bags and and what equipment. So having the right supplies equipment and medication is also part of our clinical decision. If I know I have this, then I can start doing this, that may change when my transport decision is going to be made or when my EAP depending on your resources as well. So interventions in treatment based on your differential diagnosis of that presentation, that medical history of the patient, you need to plan for any interventions that you're going to do. And to do those interventions, a lot of them with respiratory requires various medications or oxygen, and they shouldn't say, or oxygen is a medication.

28:17

So what do I have? And I'm gonna use that I have, or is it patient assisted? And maybe in some states, that's all you can do free ismatic as a system with an inhaler. But let's make sure it's a rescue inhaler, not their treatment inhaler, that it's albuterol versus a a treatment medication that they may take. So we've got to know what they are, and then as I've already said, what interventions you utilize is based on what they're presenting.

28:47

So if they're tripodting, they have a history of asthma. It makes sense to give them albuterol. K? If all of a sudden this person's having sharp, shortness of breath, chest pain, no asthma, Why is that going on? Get more medical history?

29:03

Are they on any medications like birth control? Have they recently had which is very possible in the world of sports. Maybe they've had a major surgery or they had a large long gone fracture. Maybe a tibial fracture and they're in your clinic, and it's post surgical after the tibial nail has been down and you're doing some basic rehab, and they have a sudden chest pain, shortness of breath. Well, that could be a pulmonary embolism as a result of a clot.

29:34

Right? They don't have history of asthma. So you're using that assessment based on the patient's condition and the information you have to make clinical judgment. In that case, As Chris already alluded to, there's not much you can do other than supplemental oxygen and recognize it and get them transported as quickly as possible. So it changes what you're going to do.

29:59

And then if you do give an intervention as I keep you know, emphasizing, look for appropriate changes. If I give them albuterol, and they're taking it correctly and it's working, then hopefully their airways opening up. If their SPO2 keeps going down, we've got a problem. K? So things that we have to think about.

30:23

Interventions, if they're not improving the respiratory rate and quality, We either have to change those interventions. And for sure, if it's not improving and we haven't activated our EAP and called 911 at this point, We definitely need to do so. K? In order to vital sign trend, you need to know what What are normal ranges? What are the norms?

30:47

Whether you use this chart, other charts out there, do you know what baselines are for any of these vital signs that you take, you should know what a normal range is. Now an important point that was brought up in earlier discussions is our athletes too, if you're dealing with elite level athletes or athletes, you have to take into consideration they were just in activity. So that creates an elevated heart rate. How do we adjust for that? Or if you're really working with high level or lead or really fit athletes, Sometimes they have resting heart rates that are lower.

31:20

60 80 is an adult, but you may have an elite cross country runner, which EKU has several competing, you know, in the NCAA Nationals that might run a heart rate in the in the forties normally. So if somebody who has a normal heart rate of 40 has now had a heart rate of 80 and let's say they've done no activity, While 60 to 80 is normal for regular adult, maybe it's not normal. So we've got to take that into consideration, and that's where it gets back to you also treat your patient, how are they presenting, what's going on with them, you know, and the same for for some of the other vital signs. So you've got to take that into consideration, which can make your clinical decision making more complicated. But What helps is getting good with that noncritical patient and reviewing vital signs and thinking it through.

32:18

You can do some things like trending of vital signs, which this is something, yes, this pull this big charts cooled out of something we use in wilderness medicine, but I wanna bring it down and point out and events and things where I've seen this used We call it prolonged field care. If we're gonna be out there for several days or 10 hours or whatever with patient, we want a simple sheet we can just put simple symbols on, and we mark the hour, minute, and time we took the various readings, and you could simplify this and take off some of these other more advanced things. I've got marked on their heart rate. I've got marked on their SVO 2. I've got marked on their You can see by the abbreviations, what the respiratory rate is doing, and you can see it trended.

33:07

But if you're working large events, like, I also work with the flying pig, finish line medical. I've done the queen bee. We do rugged red and some of these adventure races down the river gorge wave finish line and you have those stations having a recorder who's creating trends on that patient that's in that makeshift treatment area that you have going, that's a great way to trend it. Or Again, a little investment, but that one device, you can just hit repeat, and you know what they are. But come up with the system.

33:42

Do you have somebody even if it's a coach and an emergency? I'm gonna give you vital signs as I take them. I need you to write them down. But have you practiced that as part of your EAP for a real emergency? Having somebody doing that can be helpful.

33:58

But, again, depending on your resources, but that's where training, rehearsal, and things like that can improve them. This is another chart talks about problem, what you've administered, the drug. And again, oxygen is a drug, albuterol, naloxolone, there's a thing. She may not need all of these things on your chart, I'm just pulling from from resources that I know I have as a way for you to create something simple in Excel that could be a quick sheet that any coach could just mark plots on for you or other helpers if you if you needed to trend it or if you're working large large scale events and things along those lines. So with that said, That's what I have for this presentation and open to questions.

34:51

Thank you. Thank you, Eric. We did have one question. Yeah. It was actually presentation.

34:58

Jesse had mentioned. Thank you, Jesse. Jesse did ask you a question about what is product that you were talking about to measure map. Ah,

35:05

okay. That's well, the It's a Welch and Allan. It's the 34100 Connex Pro VP is the BP cuff itself. And that device gives you BP, and it gives you the blood pressure, it gives you a map reading, and it gives you pulse rate and it records them as as you're doing it. And it's something that I think it's great to have in that trauma kit airway bag where you have your eighties and you have everything else that a lot of athletic trainers are putting together for a quick response because it's also got a long thing, and you can have somebody in a cold tank and be running that thing while doing others.

35:57

35:59

Excellent. Well, that brought me to my question on open to other questions, but the more I get into emergency medicine, the more I see technology of here, like in titer and mab, and pulse ox and blood pressure, and those are, like, incredibly wonderful tools But if you are staying this long enough, they will fail you in their application, their administration, and their data that you get. And the battery is going bad and all of a sudden you're so addicted to this wonderful information and all of a sudden It doesn't even show up sometimes. We forgot to pack it, like like, all the above. Speak to this a clinical assessment skill set to develop to where you're not dependent on all the technology that shows up on the scene.

36:52

So and it's a great point. And, again, I have worked for full because I've worked full time as a high school athletic trainer and teacher athletic trainer. I've worked as I had a public trainer in a college in in different settings. So to your point, it's very, very important. And I promise you also might other gig of wilderness medicine.

37:10

You can out there. Technology is not something you can just recharge or somewhere out there. So the basics of being able to take the respiratory rate by watching your patient. Right? Being able to take a manual pulse and understanding you know, what and calculating that rate out 15, 30 seconds, longer pulses for critical patients.

37:34

Right? Because if they have a regular heart rate, but a manual blood pressure, you should be able to be able to take a good set of vitals very, very quickly of those. Now pulse ox, yeah, that's gonna require a device. So you're not necessarily gonna do it, but you can look at skin color. Skin tone around their lips in the nail beds.

37:58

They're face. Are they pale? Are they diaphritic? Are their lips turning blue? Those kinds of things that you can utilize that don't require m positioning and those accessory muscle use, that's all gonna be there.

38:11

In my sling pack, so when I worked at volleyball tournament, all of our roving patrols have a sling pack. But in it, is, you know, even in mine, I have besides the mulch now and I have a manual BP cuff, I have my stethoscope. I have all that equipment to do a quick assessment right when I get to a patient. So it can be done if we learn to take those baseline vitals. Temperature, that gets hard.

38:42

We all know if you're dealing with heat, it's gotta be rectal. But even if you're dealing with some of the conditions, Chris, you know, you can feel them. Do they feel warm? They sweating? Do they have chills?

38:52

Those can give you clues that there may be a febrile condition going on, but you're gonna have to take a temperature. At some point. But do I need a high-tech digital thermometer? No. I mean, did you make the old style?

39:07

Alcohol 1 style?

39:09

Yeah. Yeah. Good point. Next question I have, and and I'm waiting on others to join in here. We'll just got just a few minutes, but one that is very, very fundamental and basic.

39:22

I just want your opinion, but measuring respiratory rate we just say, let's measure their rate. Well, break down exactly how you do it. Do you do it 10 seconds, 20 seconds, 30 seconds, you go the whole minute. What's the plus and minus? Do you look at it and guesstimate it initially and then dial in?

39:42

39:43

Yeah. So and it depends on that initial patient presentation. Mike, if I get up to him and they're talking to me and and telling me they have asked on, like, I'm talking to you. They have a a pretty patent their way, and and they're doing okay. But if they're talking Yeah.

40:04

Doing and again, I'm purposely pausing. It's not technology. Right? They're having that then, yeah, I'm going to assess it. But how do I assess it?

40:13

I take it. At the same time, I take their pulse, put their wrist across their their chest, take their pulse, and then I keep watching. And, again, having one of these things, a watch I can't believe the number of athletic trainers and students I have to say they have to have a watch and one with the second hand. So change your face to a second hand on it. But then I will count it.

40:37

And the more critical there, if I consider them critical where I'm gonna take bottles every 5 minutes, then I'm doing at least 30 seconds. The same I would do with the pulse. And that's kinda how I'm gonna gauge, you know, how I'm taking that. And I'm still gonna take a rate even if I have a pulse ox, and this goes back to, like you said, technology. Great.

40:60

Because as was alluded to, and I think Katie's or the earlier presentation about, you know, you have ventilation and then you have restoration. Right? So do we have a ventilation mismatch versus a respiratory mismatch? And I'm gonna pick up on some differentials there of what I see if I do have SVO 2 and I can count the right.

41:25

Yeah. You know, I love your point at the beginning about practicing taking vitals when you don't have to take vitals because manual blood pressure is tricky alone and a healthy patient. And when you're under stress and crowd noise and talk about the difference between a blood pressure about palpation and citations while palpation is such a critical thing to know how to do, especially in an athletic environment.

41:53

Yeah. So if people aren't familiar, you can take blood pressure multiple ways. The the 2 most common is anuscultated blood pressure, which is we all learned, which is using a b peak of inputting the stethoscope over, you know, the intercubital faucin, and we're gonna take it. Then a blood pressure by palp is where you're going to find the radial pulse, the distal radial pulse, have applied the blood blood pressure cuff up here on the forearm, and then you're gonna feel that pulse and you're going to inflate the cuff till the pulse disappears. And then you're gonna slowly release that BP cuff.

42:36

And as it as soon as you feel a pulse down at the wrist, that's gonna give you systolic blood pressure. It is not gonna give you a diastolic But, again, if we're not able to use map and the high-tech things and we're out there, we know that above 90 or they're moving towards shock. Or we at least know where their systolic is? Is it staying normal? Is it trending down when we look at trending?

43:04

So we get information and if it's loud or you get a lot of crowd noise, you don't have that. The reverse of that, like you said, technology is advancing, it's great. Learn the old school ways because now you have a lot of these stethoscopes and others that will go right to your earbuds and things. And those are noise canceling, so you can combat it that way as well. And I point that out too if any of you are teaching and have a statement with hearing challenges, etcetera, for an adapted method because we've actually had to adjust that one year in our program.

43:44

Very, very good presentation. Always enjoy learning from others, and a lot of it reconfirms what already know, but every time I attend one of these, I learn I learn 2 or 3 things. I did not know. So thank you, Eric, for your time and commitment. To putting that presentation together.

44:03

Any last words, comments words of wisdom to close this out here,

44:08

No. Again, I think practice your vital signs. Do it on the patients that aren't as critical, so you you can nail it and you know what you're hearing so that when it really matters because you've been good at your job, you can get get what you need. And then the other thing is remember, if you add an intervention, you need to check the vital signs to see if that intervention is doing what you wanted to do and that the and that it's helping the patient. If not, that's a clinical decision making.

44:43

Maybe it's something else.

44:47

Very good point to bring home that that whole entire election. Okay.