Transcript

0:11

Doctor Fuchs, how are you doing today?

0:14

I'm doing well. How are you doing, Ray?

0:16

I am doing fantastic. It's great to have you here again, on our on our program and bring another great topic in. I know this is something that, you and I have spoken with on just at a conference, a meeting, on the phone. A couple of different things here and there is where that, where we excuse me. Where this particular practice comes into.

0:41

And I think very much a timely topic because we're getting into we've had some higher end, scenario based trainings. I know I've done a presentation too that gets into this exact same thing. So, with that, I'm with those of you who don't know or may not know who doctor doctor Eric Fusch is, he's professor of athletic training in in the department of arts, recreation, exercise, and sports sciences, and also certain serves as an adjunct faculty in, Eastern Kentucky u is that Eastern Kentucky University? And then also serves adjunct faculty for the Center For Wilderness Medicine and Outdoor Public Safety. He's had he's been previously been academic side and program director for athletic training, their accredited program.

1:31

He also does extensive amount of large scale medical event coordination services, including, some of those events or the, excuse me, the, the, the the the volleyball tournament. I'm I'm I'm drawing a blank on the name, Eric, of what it what it is.

1:50

Out in,

1:51

Arizona. He's done some other work with the flight that, with the, in Cincinnati with other race mitts in the flying pig marathon and makes other rather, other types of, activities. And, also is a he's also where this is really gonna kick into is not being having served a number of things within the athletic training profession. He also serves as a member of the Kentucky Board of Emergency Medical Services Task Force and developing protocols and and requirements for the Kentucky's Wilderness Paramedic Certification Program. And then, also, does additional training in other areas as well.

2:32

So, he's been expert expert witness or or, with the Reibert Koning Group And, whole list of things that I could keep on going on, but, it's always fun to talk to Eric. And I'm just gonna and leave it there, and, I'm gonna give it over to you, Eric. So have you here today.

2:51

Well, thank you, Ray. Appreciate that introduction. But the topic that I'm gonna be talking about is separation and scope of AT practice and emergency care. And while there is separation and we can do different things, we're also gonna talk about there is overlap and there is merging. And both sides, the EMS professionals as well as us as athletic trainers, need to understand the, impact of both of those on caring for a patient.

3:27

So in the one picture there, you can see I brought students and myself. We went over to our local, EMS agency, Madison County, and we were doing a training on spinal motion restriction and equipment removal that their training officer requested because they cover a lot of youth football, and often there isn't an athletic trainer out there. So there's skill sets that they need to know. There's skill sets that we have that we can train them. We overlap and where that care does.

4:00

And then in my other hat, I am besides an adjunct faculty in the wilderness medicine center, I'm an adjunct faculty in our paramedic program. And then I'm an active EMS provider for the special operations unit for Cal County EMS in wilderness medicine, and I do PRN work on that ambulance. So I have my hands in kind of both hats, in clinical practice. So as we go through this, my disclosure slide, just things that I've done. There's no financial, disclosures for this talk.

4:37

What are my objectives? Help you identify areas of overlap and scope of practice with each level of EMS provider and understand that there are different levels of providers in EMS and their scope changes, ATs will be able to identify how to define the roles and responsibilities of the EMS providers during various sporting events, and ATs and EMS providers will be able to identify methods and techniques of preplanning and training to assure we give quality and a professional practice with EMS providers during medical emergencies. With our ultimate focus, what's the best thing for our patient? And so scope of practice regulation and control. So as an athletic trainer, you know your scope of practice is defined legally by the state that you work in.

5:31

So state licensure or I think there might be 1 or 2 states left with certification. And then there's California, where I used to live and work, that has no regulation. But your state license is gonna define things that you can and can't do. You also have the board of certification, which gives us our domains of practice. And then within your scope of practice or your state, You definitely have to work under a physician by BOC, but then whether you have physician orders, whether they have to be verbal, written written protocols, you have all that.

6:09

And even then, your hospital organization, maybe you're part of a large clinic, may have institutional policies and procedures that also restrict who can do what or when and where you can do it. On the EMS side, first off, there are different levels of EMS providers. And so understanding that when you're preplanning your EAPs and when you're trying to, care for a patient and know what your scope is and things you might do, and I'll I'll bring up some examples of this here in a second, you need to know the level of the responder. An EMR is the lowest level, and it's emergency medical responder. Then you have EMT, and then you have the advanced EMT, and then you have national registry paramedic, and then you have these APPs, which are advanced practice paramedics.

7:06

There's critical care paramedic. Some of you may have heard of that. The one most people are familiar with is the flight paramedic certification, and then there's actually WPC, a wilderness paramedic certification. So those are advanced advanced practice, and their scope, sometimes, like critical care paramedics, can treat on-site and not necessarily have to transport somebody. And right now, just to show you that other professions are evolving, there is a proposal with the National Highway Transportation Association for a paramedic practitioner that will have a master's degree requirement that could evaluate, assess, treat, and render, treatments and medications without transport.

7:51

So every profession is evolving out there. Just something to be aware of. But for EMS, where this gets a little bit more difficult is the state may have licensure or certification or registry, but then the state can define the protocols and the scope for those level of providers above. The only thing that they cannot do according to the national, the national scope of practice defined by the NHTSA, National Highway Transportation Authority, is they can't lower the skills. They can give them more advanced skills, but they shouldn't be taking certain skills away that are in the national document.

8:42

So there was a standardization, and that came about after Katrina and some of the other large scale disasters where they're like, look. We need to know what is standard operating. What is the base level of education and skill set? But a state can increase those. And then you have national registry, which is the NR in front of those that a lot of people take.

9:07

But whether they have to maintain national registry to maintain their state credential will vary state to state. So for example, in Kentucky, you do not have to keep your national registry. You still have to do continuing ed and meet the state requirements, but you don't necessarily have to maintain it. It's just an easier way to do it. State protocols.

9:29

Every state is gonna have a board of EMS or a controlling board just like we have in athletic training, and they will define state protocols. Now those state protocols, this is where EMS comes down to your local level, and this may be why in your town or your city, you may see EMS providers doing all this. You travel to another city that's only an hour away, and their protocols are different because they may adopt the state protocols, but then the agency so, like, my how county EMS agency and medical director can say, yes. You can do these things, or we wanna add these things and can can change those protocols. And they have to submit them usually to the state to let them know this is what we're doing with our providers.

10:21

So there's always gonna be this. This is why my big emphasis in all this is get to know not just do an EAP and do a simulation with them, get to know them, participate in some of their continuing ed, sit down, talk to them, have discussions because that's how you're gonna help understand. And if we look at what is scope of practice for standard of care, and this is putting my legal hat on, and this is actually taken out of the the national guidelines, but it still applies in athletic training for EMS. You know, your your scope of practice deals with the question of what are you legally allowed to do? Right?

11:08

So what can you do? Standard of care deals with, did you do the right thing and did you do it properly? So for a long time in Kentucky, before we updated our practice act, we couldn't do rectal thermometry. It was the gold standard. It's the standard of care, but we had a our our state AT licensure board send a thing to the attorney general for a ruling as to because we had some people saying a rectal thermometry procedure was invasive procedure.

11:37

And at the time, our scope of practice said, you can't do invasive procedures. The attorney general actually concurred that the way the legislation read, it would be an an invasive procedures. So, again, it may have been standard of care, but legally in Kentucky at the time, you couldn't do it. That's all been changed. Don't anybody start writing people in Kentucky.

12:00

We've got that fixed. So we have standard of care, and we have scope of practice. And in reality, athletic trainers are educated. Right? We have our KD standards of education.

12:14

That's what you've been trained to do. You've been able to perform a skill, then you become BOC certified. That means you've demonstrated competency in the skill, and that's done both based on the programs you're teaching it, and then you pass a BOC. Then most of us, except if you're in California, have to apply for a license, which allows us to legally practice. And then credentialing is sometimes above and beyond, like, you're authorized by a medical director in the case of EMS to do additional skills.

12:49

In Kentucky, we have a form which has all of our we have a formulary of prescription medications that we can obtain, transport, and administer. But our physician has to sign off on that. So they would be credentialing us to actually access and get those meds, and the same with the invasive procedures from suturing to IVs to giving flu vaccinations. We have to be credentialed by our supervising physician. They have to agree that we can do those.

13:18

So understand that there's always gonna be areas that we need to understand. Now how does this impact actual treating the patient? Well, the first thing is is sometimes people like to say, oh, I wish people would stay in their lanes. And while I understand their frustration, the reality, if we're talking about interprofessional care, interprofessional practice, we're not gonna stay in our lanes. We need to work together.

13:49

We need to be respectful of each other's lanes, but we need to understand each other's lanes. And I'll bring this into a reason why here in a second. So hopefully, many of you out there have been to a roundabout, and roundabouts are becoming more prevalent. But the question is is oftentimes when people come to this roundabout, how do we merge? When do we transfer care?

14:14

So if you've never met with your EMS providers and you're out on the field and you're treating them and they're just getting there and you haven't done preplanning, you haven't done simulation, that's gonna make that merger a little more difficult. They don't know you. You don't know them. They may or may not know your skill set. So we have to know what to do, and how to merge, and what our skill sets are.

14:42

And this impacts transport decisions, potentially for some of you. So giving you an example, what should you do? Think in your own head. I don't have the Slido up here, but do you even know how to deal with an emergency vehicle approaching a roundabout? K?

15:01

I mean, most people know or are supposed to know, go right for sirens and lights, you know, yield the yield the right away. But I can tell you from driving an ambulance that some people don't even know to just go to the right. So but for a roundabout, do you know what to do? And what you're supposed to do, if you see the emergency vehicle approaching it, don't enter. And if you're in the roundabout, take the first right off the roundabout to get out of the roundabout.

15:35

That's what if you take driver's ed, you look it up, that's protocol. The reality is it's very interesting around here when we've added some roundabouts, and, it gets a little bit crazy. So if we're not sure that's a problem. And how do we prevent that? We do prior planning sessions.

15:57

You do your EAPs. You do them with simulation. You work together to create, collaborative interprofessional practice. At our state meeting, we're actually inviting EMS professionals and working on providing them CE to interact with some of the overlapping skill sets so we can interact on a state level to kinda help promote some things. So where is this important?

16:26

Well, in many states and something I've taught a lot of ATs to do, and in Kentucky, you can do an IV. You can start an IV. You can push fluids for your dehydrated patient, for your heat stroke patient. We know I can do that. But what do you have available as a responding EMS unit to your 5 k run if you're doing a bunch of community events?

16:54

Or it's your high school game, is that a BLS unit or is it an ALS unit? Because, for example, if you look at this, this is the national scope of practice. So, again, they could your state could allow for more man's things. But under I way IV initiation and maintenance, an EMT cannot, in the state of Kentucky, transport a patient with an IV line that has fluids being administered or medications. So if you're if if you're in a state where you can't do an IV, but you have a physician there and he starts an IV on them and you have a BLS unit, they're gonna have to call for an ALS unit to transport, at least in the state of Kentucky and most other states.

17:40

Look at the airways, okay, down there, which is an another thing. In some states, EMTs cannot use supraglottic because that's the national standard of care. Now remember when I said a state can increase the standard. They just can't reduce it. So, like, in Kentucky, EMTs can use supraglottic, and in many other states, they can't.

18:03

But depending on the airway you put in, what level of provider do you have? And those are important things to understand because while everybody thinks every ambulance has a paramedic on it, these days, like other health care professions and nursing feeling shortages, that is not always the case. So this is an example of, hey. We've got skill sets. EMS needs to know that.

18:30

They need to know we've got a patient here. When you're giving them patient information, we started an IV in that so they can send the correct responding. That's where our skill sets are gonna overlap. But understanding the restrictions too when when the unit gets there and then they say, oh, we're gonna have to call somebody else. Right?

18:49

You might you're like, what? But they're following their protocol. And the other thing is is a lot maybe BLS units, and they have what's called a, fly car or tiered system, where if they get there, then somebody's gonna come in maybe a suburban like vehicle who's a paramedic and started providing that care. So I could do this talk even on larger and other skill sets, but my point is communication is key and understanding each other's scope of practice is very important, which is why the Katie has even integrated interprofessional practice and interprofessional education, requiring students to work with other health care professionals to start having an understanding about their areas and their abilities and where ours meet merge, especially in emergency care, where it's like can be life or death situations is important for everyone to understand. So what are my takeaways hopefully from this?

19:54

Again, know the types of response systems. K? Is it the ambulance service? Is it BLS or ALS when they respond? Not just and, also, obviously, if you're having them stand by at at an event or a game, is it fire?

20:10

In other words, does your fire department run your EMS, or is it a separate agency in some places that happens? The tiered response, which I already mentioned, that may bring a paramedic to that scene. So and then what what are the credentials within your local? In other words, an EMT. Can they manage a supraglottic airway like a king airway or an iGel?

20:39

If I put that in as an athletic trainer, are they able to transport that? Or if I start that IV with fluid running, can they transport it? Prior planning is gonna prevent that poor performance and better outcomes for our patients. So, hopefully, you get an idea of we do have overlap. We need to work together.

21:01

It's not everybody staying their own lane. Next year on the EMS side, when sometimes you get a paramedic that might be overzealous and just, it's my patient now. Leave me alone. But prior planning and knowing who they're working with usually will get rid of that. So I'm pretty sure I hit what I was trying to hit in the time frame.

21:30

So happy to answer any questions.

21:33

Yep. Eric, I I was spot on. I think the you know, you talk about the the, stay in your lane. The one thing you definitely have to stay in your lane, and using that I think you gave that great analogy on using the roundabouts. And and sometimes you don't know what to do and people you know, you know what you can do, but you don't necessarily other people may not know what to do.

21:55

And that word becomes problematic. I think the the when for your skill side is understand your skill, know your skill, stay within that's the way you do stay in your lane. You're not doing things outside your scope of practice. And make sure you have that def get that well defined. And, you know, I know for you, me, you know, other you know, who are who have dual credentialed, that can that does get it can get kinda clunky at times.

22:25

And, well, you can do this. You know, I had a, as example, when I was I was on a, ride once, and I was covering the for the ambulance service, covering a game that had athletic trainers there. And they were like, okay. Well, bring over to where they knew I was I'd already done the pregame meeting with them and stuff. But midway through the game, we have athlete who had a, shoulder dislocation, and they're thinking, okay.

22:51

Come over. I can reduce it. I'm like, nope. Can't do that. We're not it's not within the protocol.

22:56

And I'm like, you know, so if we do, we're gonna have to transport the person. We don't we're not we're not permitted to do that. And, so luckily, they're they were able to reduce it and instead of having to put in a unit, which made paperwork nice for us and, you know, but, also, we're not having an unnecessary you know, you can it it had a good outcome. But, again, risk understanding the roles are critical. Just going finding what they do is so much good for the hand off, for every every aspect of the care, the precare, the hand off, the the understanding when they roll in.

23:30

But also, you mentioned that, if if they know who you are, then that communication, oh, hey. So and so. And now, like, I've done this now for 30 I'm in Baton Rouge, and I work with Acadian. I work with, East Baton Rouge EMS. And even other groups that I don't I do occasional.

23:48

And then you do that as well going out to Arizona. I was in, Alec you know, Tuscaloosa last week for an event with the EMS and, like, they I don't work with all of them, but they do the main ones, and it just it flows. I mean, it's so easy. They know what we do. I know what they do.

24:05

And, yeah, I like to say it's like in peanut butter. You know, if you I love peanut butter and it's really good and and, best best as it can get.

24:12

So and that like, the the joint reduction thing, yes. We can do it. And in most states, most EMS providers cannot unless there's lack of a pulse. But, ironically, my role on the task force that you mentioned is because the wilderness paramedic will be being added to their scope of practice, joint reductions across the body. And I was brought in as a subject matter expert, to also develop the teaching of that.

24:41

So in the future, there may be medics out there that can help you with that. But, again, that's understanding what's going on.

24:47

It it medicine's evolving, especially in emergency care. I mean, it's the delivery of care. You're seeing the the strain is on lack of access to or limited availability for staffing. So this is pushing this out as well. I think from the athletic training perspective, from that side of it is, and I think for other perspectives, just because you can doesn't mean you should.

25:09

And that gets back into the whole training. You have to know that you know what you know. And if you don't know it and not there's a difference of being confident and being competent. And, you know, it's like, you know, old pilots and bold pilots. I I've had I've had a pilot tell me that once.

25:27

You know, we're not we're gonna stay on the ground. A bold pilot may wanna do that, but that older pilot wants to go home and that is being very, thoughtful in their in their deliberate actions. So, yeah, just having that I think the the chart you gave, something you could do for your respective practice act is simply add another 5th column, and you have the AT, and you start stacking down the education training, we've I've done that here in Louisiana. And it really provides a really clean, picture for what what we can do and what what we do do, where there is overlap, and where there is some uniqueness there to, better appreciate where we can we can bridge the gap to make everybody's jobs a lot easier.

26:13

Yeah. And that really understanding that overlap is important in the emergency care for the transport. Because if we have skills advanced of EMS and that unit can't transport them, that's delaying definitive care for our patient. So that's why that understanding ahead of times. It more I think

26:33

the one, like, you and I talked about is just on, like, you know, core rectal, heat exertional heat stroke. And and, you know, when you're riding a unit, they're not putting they don't have the ability to cool. And especially if you're by yourself, it's not. So you have to have that. This is where I'll get this example of where practice drives another practice, so to speak.

26:54

So when, we had some we've updated our laws several years ago to other not just practice act, but other laws where we're acquiring, schools to have, be doing best practices with heat exertional heat illness, having a immersion tub, have monitoring wet bulb, etcetera. And the EMS unit I that I was working with, they're one of their they're a multistate, organization. And I was talking with their their, quality quality improvement coordinator manager in our region. And I said, hey. Look.

27:31

This is what we're doing now. He says, really? He's like, oh, well, by that time they're going through every 2 year, their protocol updates and reviews. And I get a phone call. You know?

27:40

It's like, hey. I need you I need to get some, pictures from you for how to do what happens for exertional heat stroke with the tub use. I'm like, yeah. I can get that to you. I'm like, well, I need it by tomorrow because they're doing a it's a it's a rapid update, and they're making it as a recommendation.

27:57

And for their they didn't make it as a policy change, but as a standard practice, but they were recognizing that, hey. If they come on-site to a school that has this, it's now a mandate for them. They need to they need to consider the cool first transport second. And so that was something that was very impactful. Sure enough, it it moved in it moved in very fast.

28:20

So these are things where we can work through making recommendations, not necessarily a mandate in terms of another issue of from a policy standpoint. But it does start to move the move that move that needle in a better direction.

28:33

To that exact point in Kentucky, actually, the the new twenty, 24 state protocols for EMS, actually updated to if you have heat, hypothermia patient that you do need to stay and cool them and do rectal thermometry. And, like, our ambulance services now have rectal thermometers on them. And as long as all the cooling capabilities are present or if not, you divert to, like, going to Buc ee's and grabbing a bunch of ice if it's close by. That is actually we went to step further in the state. The state protocol was actually changed, so then that filters down to all the local agencies because it's in the, state protocol, which, again, is a good change.

29:23

And this coming May, we're having a a Tufts meeting, and I have our state EMS medical director who's my medical director, happens to be medical director for Cobb County, who will be there. But one of the things they're talking about for the EMS and sports med folks is staying and playing and making sure people know the state protocol and the AT protocol. So We

29:50

don't have any quest right now, but I do have one if you could just elaborate one question before we where we sign off is thinking about a a medical protocol versus a medical guideline, like a delivery of care guideline. And you're I think we're starting to see that more, especially in EMS. They're moving to guidelines simply because they have limited they're having we have mentioned earlier, they have limited, human resources. So they're having to evolve those units probably more than they have to make those decisions, and we're seeing that in the field, like you mentioned, like the the paramedic practitioner that push. These are things that are evolving.

30:31

So if you could just elaborate for a second on what that looks like and what maybe, advantage and one primary disadvantage and advantage of each of those.

30:42

So it is evolving, and it's that they are a health care provider, and it's about your ability to clinically reason based on the best evidence out there to make a decision that's in the best interest of the patient. And, this hyperfocus that had been forever in EMS, and some of us in here can remember it's still fairly vaguely in in AT about you gotta do this skill. You can only do these skills this way, and you do it for this condition. Well, what happens when I can do a certain skill for one condition? So I can do a blood glucose stick if I think it's diabetes.

31:26

But if they're hypoglycemic and can't, you know, it doesn't make sense. So even the, national registry exams for EMS have changed to go to critical thinking and analysis and applying, you know, a reasoned out, you know, differential diagnosis and developing a care plan based on that. So the advantages to that are there are a lot of patients that are what EMS sometimes refers to as freak out flyers. They're constantly calling, and maybe they've tripped and fell again, and we have to go and help them get up. And so we go, we have to help them get up, and then we're called again.

32:17

Well, what they're implementing now, like, with community paramedics is they go on that call, but then the community paramedics starts back the next day and does a walk through of the house and looks for trip and fall hazards and makes recommendations. Why? To prevent the frequency of that occurring, which reduces the strain and and cause. So there are benefits to that. The same with the diabetic patient that's constantly calling because they're not able We the community paramedic is out there and says, why haven't you been to your doc?

32:51

What is it? You you don't have a car, so you can't go to regular appointments even at the local clinic or your doc. You know? Can we give them in some cities and things, you can give them an UberPass or other things so they can get to those appointments so they don't have the diabetic emergencies. So those are the good things on.

33:12

Right? One other example that's a little bit morbid, AEMTs and EMTs now can we cannot pronounce that, but we can call for an order to stop resuscitation or other efforts for medical futility by providing a whole bunch, and then we have to wait for a paramedic to arrive or the coroner to pronounce it. Paramedics can pronounce death, which they also not not just in the obvious signs like decapitation or that. I'm talking about you've been on scene doing CPR for the high quality for 30, 40 minutes. So there are good sides to this.

33:51

Right? The downside comes when somebody is using that medical judgment, and the the question always comes up from the naysayers is what if they choose the wrong plan? What if they choose the wrong treatment? Right? You have your differential.

34:08

You choose this. It could be the other. Well, the answer to that in EMS and the side that we're on because of wilderness medicine, we're out there 4, 5 hours out, and we may not have communication. Right? So if we're without communication, we've gotta do what we think is in the best interest, and sometimes that outcome may not be what you want.

34:35

And there is a great post recently by, by, I think think it was the army doc on Twitter. He said he always challenges his residents to think about the situation when they're reflecting, you know, afterwards and after action review about what would you have done based on the resources and the information you had at the time, not what you know now. So and and and don't be as harsh because of that. But those are the downsides, and people start worrying about, are you educated enough to make those those treatment decisions, etcetera. The other thing in EMS, the other counterargument is is most of the time, unless you're in a very specialized, like, wilderness men, you can call for a medical consult.

35:28

I have the numbers of my our team medical director for a special operations unit and then our agency medical director. I can call him anytime, any day. I have a question on patient. I don't care if it's 2 in the morning. Well, we'll answer or Jeff won't answer.

35:45

So, hopefully, I

35:49

Yeah. I think you're seeing that. Like, I mean, that's a great exam I mean, explanation of that. And and, I think I know I've saw I've seen this here is with paramedics, they started doing you may have heard in your area called TIP or treat in place

36:02

Yeah.

36:03

Protocols. And they started this it was very narrow window. It but it's once they've gotten a few things right and they're getting the and they're getting into, telemedicine because then those cases are actually getting on video call with with their with medical direction and doing a face to face call. And I just wanna have the technology. They put a very strong buffers in so then they can gradually they'll start expanding that.

36:30

But, also, telemedicine having the units that are you know, you can have remote or austere conditions. You have satellite. You can plug video. They can do all the diagnos basically, a briefcase and a bigger briefcase. And you can do all the things there, that you need, that cost money to have that.

36:49

But it's available for that to do, critical decisions with with assistance.

36:55

Yeah. And and you're right. And that's what a lot of community paramedicine paramedics are doing is is the things you're describing. So it's becoming common. And in the wilderness, like, we carry in stuff.

37:06

I could do, 3 lead, and as soon as the new device comes out, it'll have both, temperature probe and 12 lead. And the things about this big, it goes there, and then it just goes to my phone so I can see all their vital signs and everything as you're hauling them up a cliff or whatever. We have capnography, like, when we talked in one of our previous talks. You really putting an airway down, you should be doing capnography. If the device is literally that length and it clips onto the side and connects to the tube.

37:41

It's battery operated, and I get not only cap numbers, but waveform cap on that thing. So the the technology is there. It's just if you know where to find

37:53

it. Oh, yeah. Yep. And you have resources. And, again, it's just evolving.

37:57

But you

37:58

know communication like we just talked about. Yep. Knowing what each other has and what each other's using, and you learn things and and it advances both fields.

38:07

Yeah. So, you know, the last thing I'll I'll mention on that, you know, it's working a lot with EMS. It also provides the justification to go if you're having difficulty with getting a resort and you're pairing in with EMS, like protocols or guidelines, it's more apt to say, okay. They're gonna make that recommendation that your like, your school or setting your hand is, oh, yeah. You need to buy this because we need to do this.

38:32

We need to get off-site. We need that increased collaboration just becomes more it it's, they have access to resources, simplistic not simplicity in care, but in more the higher efficiency in care. Because EMS is trying to do their their job, and it's to get on-site and get off as soon as possible. And those are noncritical and critical conditions. So that, again, increased collaboration.

38:60

You've mentioned this already, Eric, already. I mean, you discussed it already today and is that, it's paramount for this entire discussion, not just interdisciplinary discussion, interdisciplinary care. Don't work in don't work in a silo and be be willing to get to that you wanna find the roundhouse when you can to collaborate. So great. Thank you again, Eric.

39:25

I think we're wrapping a little bit over time a little bit. But, again, thank you, again. Fantastic presentation on a very timely topic, for everyone. And, again, thanks very much, and we'll be following up soon with other, presentations we have.

39:41

Thank you.

39:42

Great. Thank you,