hello this lecture is going to cover chapter 24 a team approach to health care and we also talk about some als assist items in this chapter as well so assisting the higher level of care from advanced life support it's a very quick uh chapter we've only got about 25 or so slides to get through so we'll move through these relatively quickly you're a critical member of the emergency health care team so once you've finished this course you you obtain your emt certification um you're now a member of a healthcare team you eventually will get a job somewhere you'll work with with your team by working as a team emergency health care providers can improve patient and provider safety and deliver better emergency care essentially we can't do this by ourselves it takes takes a group we all have to work together so we're going to discuss some of these topics about how to work together properly work as a team as you go forth in your career community paramedicine and mobile integrated healthcare teams may be the best example of the team concept of what we call a continuum of care this is a new relatively new uh thought in the in the ems and emergency medical services community paramedicine and mobile integrated health care what these two things are is essentially what we've done since the inception of ems is we respond to 9-1-1 calls we show up at somebody's house we fix their emergent problem we transport them to the hospital after that we kind of you know our team the whole team concept kind of ends at that point we pass them off we transfer care to the hospital and we're done we go back and we start start over again what community paramedicine mobile integrated health care are essentially once we transfer care over to the hospital we could then swing around come full circle with this and and follow that patient's care all the way back to their house and ensure that that patient uh gets home safely ensures that that patient has the medications that they need they have the ability to take those medications essentially we would go out and we'd check up on them there are a few fire departments around central ohio that are uh that are testing out this concept of community paramedicine but essentially what that is is usually an emt or a paramedic who who goes out on their own or maybe in small groups and checks up on those on those patients that have called in to for our services so essentially if if someone were to go to the hospital they'd be diagnosed with congestive heart failure now they require the use of of lasix or medication that takes fluid off of their heart we would then ensure that that person has their appropriate medications when they get home because what we find a lot of times is these patients for whatever reason they can't get their medications they can't afford them they don't have a way to go to the pharmacy to get them then we end up going through this whole cycle again of of them having to call 9-1-1 us having to transport them back to the hospital and put an increased burden on on the hospital when all that person really needed was someone to just go pick up their medications for them that's what a compute community paramedic or someone who works in mobile integrated healthcare that would be their responsibility so again it's being a good team member not only to our teams in in ems world but in our larger healthcare team which is us emergency room physicians nurses uh you know that whole group of of health care workers we were all a team um and and that's what we're seeing here with this community paramedicine push a couple different types of teams that we'll talk about um regular teams regular teams are emts that consistently interact with the the same partner same group uh over and over again so this would be if you get assigned to an ambulance if you get assigned to a squad and this would be your your squad mates your your partner or partners that you work with on a daily basis regular teams can function like a well-oiled machine this this happens quite frequently we'll uh you know throughout my career you know i've worked with worked with some really good regular teams um and we've been able to uh essentially know what each other are thinking and that's good because that makes our job more you know that makes our service more efficient uh we can if we know what each other are thinking we can be one or two steps ahead um with each other so regular teams are good they're positive if you can find yourself in a position where you can work with a regular team that's great that's a that's a benefit temporary teams or emts that work with partners with whom they do not regularly interact or may not even know temporary teams are in a case where if you work for a larger fire department a larger ems system and you have to be transferred around to different ambulances different stations whatever the case may be or you're working overtime or something like that you're working with people who you don't normally work with that brings about some challenges you don't know those people you don't have a personal relationship with them you certainly don't know what they're thinking when you go on runs when you go on on these emergency calls so that makes it a little bit more challenging so if you're working in a temporary team situation you might want to think about uh you know doing some training early on on your shift you know let's let's start to to work together early on so that we can overcome some of those barriers so different special teams that you know if you as you go on uh go forth in in your career you you may be interested in uh you know and joining different teams and and i think that's a positive thing i think that helps you to build and advance your career as you go about so something like tactical ems where you work with a swat team special events where you would work you know fairs and festivals and sporting events some fire departments and ems departments i know delaware county ems hasn't has an ems bike team so you know you you would uh work special events like festivals and fairs where you would be on a bicycle riding around in crowds and things you know taking care of ems needs so don't hesitate to join these specialized teams as you go as you go forth in your career because that can that can keep things interesting for you can can help you advance and learn as you go about so we'll talk about some different uh types of groups dependent independent inner tip in excuse me interdependent groups dependent groups each individual is told what to do and and how to do it by his or her supervisor or group leader so a dependent group essentially the way you can think about this is they depend on their supervisor or group leader to tell them what to do you know this isn't necessarily ideal we certainly want and and the push has has been over the last few years to allow us as emts to think on our own to not just do exactly as we're told but there is certain situations where a dependent group is necessary where you have to do exactly as you're told and it's certainly if you're doing something that's out of your comfort zone and you need a supervisor or group leader to tell you exactly how to proceed that would be you know a strong case for a dependent group on the flip side under uh independent groups independent groups are where each individual is responsible for his or her own area so they're responsible for they they get a set of essentially a set of of tasks or mission or missions and and then that person tackles those tasks however they they see fit and they're responsible for that healthcare providers who work interdependently are functioning as a true team so interdependently would be working in both of these different types of groups so there may be groups who are being told exactly what to do and ones that are responsible for their own their own area working together as a true team effective team performance some some basic ideas and thoughts of effective team performance we all work under a shared goal right we have a we're we're a mission oriented team a mission oriented team means that we have uh we have a mission to complete and we're all working towards completion of that mission so if you're working in a team as long as you are doing something that's productive towards that goal you're going to be an effective team an effective team member effective teams have clear roles and responsibilities they have clear roles and responsibilities so they know what to do and they know how to do it uh effective teams are diverse with the competent skill sets diversity is is uh is very good for effective team performance this way you have folks with different skill sets with different backgrounds and that that all helps in in that team performance effective teams collaborate and communicate they work together they come up with ideas they they you know deconstruct these ideas and figure out what works and what doesn't work um certainly with communication communication is incredibly important particularly closed-loop communication that's a uh the essentially the the definition of closed-loop communication is where i met i i give an order or i give you an idea in or or a dosage or um something that you know needs to be done and you repeat that back to me so that i know exactly what you're doing and you know exactly what you're supposed to be doing effective teams are supportive and they have coordinated leadership so certainly a team cannot cannot work properly cannot be effective without a good supportive coordinated leader communication and team dynamics fostered from crew resource management and team situational awareness this uh i i shared a video um on the google classroom um and and it's a video from uh from a former um uh nasa astronaut um and this video talks uh amongst a number of things about uh essentially crew resource management and the situational awareness um of a team uh and these videos are are i think they're they're really neat it's really neat to see from the perspective of a nasa astronaut um a little bit more about this this thought of t of crew resource management and what this means what crew resource management is is essentially using your uh abilities and your skills to let the team know when something's going wrong uh the this all came out of the the aviation the airline industry what what they found was happening was when a pilot and a co-pilot in the past when they worked you know the same aircraft the pilot was in charge the pilot was in command they what they say went and there was always a there was always a an inability of the of the crew member of the co-pilot to speak up and and and say something when when something wasn't going right so this happened to actually cause quite a few um airline crashes quite a few aviation incidents um that caused the you know the death of many many passengers um in many aircraft uh because of the fact the simple fact that a co-pilot did not feel enabled and empowered to speak up and say that something was wrong because there was always this thought of the captain's in charge the captain the captain knows what needs to be done and they're in charge and i can't question their their authority so the aviation industry uh took a step back and and you you hear you'll hear the the mike mullen the videos that i shared with you you'll hear him talk a little bit about this but the aviation industry took a step back and said hey why can't that co-pilot speak up why can't they challenge that captain and they shouldn't do so in a disrespectful way but if there's certainly something that comes about that that co-pilot feels necessary to to bring up to the captain they should not fear bringing that information up so how does this apply to you this applies to you because if you're working with a teammate even if that teammate is of high higher level of care like a paramedic it is okay for you to to probe this person a little bit to alert them and you'll see this is what this pace acronym stands for for crew resource management probe them a little bit meaning uh you know question respectfully question what's going on hey i just noticed that you wanted me to place this person on on two liters per minute of oxygen on a on a non-rebreather mask is that is that what you wanted you know that's probing that's saying you know i don't think that's right so i'm going to ask to double check alerting that person is saying hey i don't think this is right you know it's not it's you know it's no longer questioning it challenging it again saying i don't think you know this i don't think this person needs to be on two liters per minute i think they need to be on 15 liters per minute so challenging them with what you think is the right answer and that's important and then emergency the last element of that pace mnemonic stands for uh when you need to essentially alert your teammates that there's an emergency at hand now my example of giving you the the two liters per minute versus 15 liters per minute we would never get to necessarily to the emergency phase unless that patient started to decline but this you know again we're i'm kind of molding this into into an emt's life as far as how crew resource management applies to them certainly an aviation emergency would mean you know declaring a mayday declaring an emergency of the aircraft so you know a little bit different from the aviation perspective but from from the emt perspective uh certainly you can apply these crew resource management principles to your job um you know i encourage you to look up some more information about crew resource management it is um it is a neat concept to think about as you go go forth in your career all right so let's talk about transfer of patient care i know we've talked a lot about this throughout the course so far but just kind of to wrap everything up transfers introduce the possibility of patient care errors those patient care errors would would come from a lack of credible information that's transferred so if you don't transfer good information to uh to the the the provider that's now going to take over patient care they may come into this with with a false idea of the situation so transfer of care needs to to have good uh you know almost up-to-date and comprehensive information that you have you need to tell the whole story and tell the important parts about the story to that to that provider that's taking over some general guidelines for a smooth transfer uninterrupted critical care so if cpr is being performed cpr needs to continue we need to not stop cpr so that you can give your transfer of care report you certainly need to continue cpr with minimal interference respectful interaction um be respectful of your peers if if you're transferring to a nurse um you need to be respectful of their knowledge um and that's important that enter that respectful interaction is important uh if you if you start off uh in a disrespectful tone or you're disrespectful to that that nurse or that doctor they're immediately going to discredit anything that you have to say common priorities and and this isn't excuse me common priorities common language or common system this is all important because we all want to be on the same page so if if you if you find that the airway is a priority that this patient you know their airway is declining that should that should be a common priority between you and a nurse a nurse should have that same exact priority airway breathing circulation abcs so you need to ensure to communicate those common priorities and we use that we do that by by using common language common language meaning um you know uh approved medical terminology you don't want to use anything that you've made up or that that you and your your partner uses you know some some terms and other things that aren't aren't approved so certainly using a common language helps to alleviate any transfer of patient care issues all right so let's talk about bls and als providers working together it's quite possible that you will work side by side with an als provider certainly if you go towards fire based ems i know that some of the ems private ambulance companies and ems only organizations do have uh you know paramedic trucks with only paramedics on them and then you know emt squads with only emts on them but in a lot of cases a lot of certainly firebase dms you're going to notice that you you may be working with a higher level of care you may be working with someone with a paramedic or with an advanced emt understand that bls and als cannot exist without each other we need we need each other to operate properly so bls efforts must continue throughout the continuum of care you must continue the efforts that that you are providing um even though als is there you can't just stop you know if you if you work on a bls only truck uh you know two emts and you call for als care they're still going to need your help so that those efforts that you're you're providing airway breathing circulation you know chest compressions bagging them with the bvm those are all bls responsibilities and those need to continue what may be a paramedic-only skill in your ems system may be common for an emt to perform in another one of these cases that come up is is innovation you know innovation used to be in ohio an emt skill it's no longer um and that's and that's uh no longer a skill that's approved uh as a as an emt provider in in the state of ohio but other states may still have that in there so you know there's there's different uh skill sets based on location so keep that in mind um and certainly uh different protocols that different agencies and different areas of the state use so just be be aware of that as you're working with bls and als that if you're working um interagency if you're working with different agencies uh you may come in contact with one of these issues where um you know the skill that you're performing is a paramedic only skill in their system so just understand that because you're going to have to go you're going to have to you know cross that across that bridge essentially assisting with als skills assisting follows a four-step process patient preparation equipment performing the procedure and continuing the care so you're going to assist als skills you're going to follow these these four steps patient prep preparation what do you need to do to assist in preparing the patient for the als skill so if this is a iv uh you know intravenous uh they're starting an iv you need to prepare that patient you need to ensure that you are are prepping the site you need to ensure that they have the proper equipment what type of angio cath do they need do they need a a saline bag set up do they need a saline lock set up performing the procedure what help do they need during that procedure what help you know do they need any assistance as they're actually inserting that that iv and then continuing care you know what different types of things do you need to look for on the way to the hospital you can assist that that paramedic by keeping an eye on that iv to ensure that it remains uh patent so let's talk about assisting with advanced airways endotracheal innovation is the insertion of a tube into the into the trachea to maintain and protect the airway so just so you guys are aware the difference between what you as an emt in the state of ohio can do and what a paramedic can do one of the differences is in tracheal intubation and just you clear up clear on that the tubes that you guys can can insert are essentially supraglottic or rescue airways the eye gel the king airway those do not pass into the trachea those are not past the vocal cords and are are not inserted directly into the trachea so that's the difference that's what an uh a paramedic can do they can do an endotracheal innovation which is using a laryngoscope to actually insert a tube down into into their trachea so what can you do to help them insert that advanced airway you can help prepare the the patient so we talk about pre-oxygenation and apnea oxygenation so prior to them inserting that that uh uh inserting that into tracheal tube the patient's going to need to have a you know as good of an oxygen level as we can because there's going to be a few seconds there where we're not breathing for them as we're inserting that tube into the airway so pre-oxygenating them with a bvm is something that you can do to help prep that patient for that procedure so what are some of the equipment that you can gather for uh for a paramedic ppe you can gather you know ensure that they have gloves if they need a mask if they need eye protection all of those things are important suction unit with a rigid and non-rigid catheter so you can have the suction unit ready in case there's any excessive fluids in the mouth trachea you can suction you can help them with the suctioning the laryngoscope handle and blade i'll show you i'm sure you guys have already seen these in class but we'll show them to you again the lorenzo scope handle and blade mcgill forceps in case there's any sort of airway obstruction that needs removed you can have those ready certainly getting the uh the endotracheal tube itself those come in different sizes and they usually come in in uh whole and half sizes so you know four four and a half five five and a half for example um so asking the the paramedic hey what size e.t tube or endotracheal tube do you want so that you can have that prepared for them and then a style that an or a tube introducer that is the uh the the wire essentially that's inserted into the endotracheal tube to stiffen it up um so that it's it's easier to pass uh during that procedure so that's another piece of equipment that you could assemble for for the paramedic some more equipment water solid soluble lubricant a 10 milliliter syringe that is used to inflate the cuff of the endotracheal tube so you can have that that 10 milliliter syringe ready to go confirmation devices those include capnography um there's many different confirmation devices but generally now with capnography the most important thing for you to have ready is that capnography that fits on the end of the et tube and i'll show you guys one of those in class as well commercial et tube securing device there are devices that are placed around placed in and around the patient's mouth and head in order to secure that tube so we can get one of those out as well and then alternate airway management devices so having that secondary rescue airway ready the igel or the king airway whatever your your agency is using that would be important to have ready as well in case the paramedic is having trouble inserting the the endotracheal tube all right performing the procedure during this procedure uh bvm pre-oxygenation again uh i've already talked about that evaluate for airway difficulties manipulate the patient attempt innovation confirm innovation and correct issues this is all again this is all what the paramedic's going to be doing so what steps out of this process can you help with bvm pre-oxygenation is one you can evaluate for airway difficulties you can have the patient open their mouth and stick their tongue out and see how much space is is available there you could certainly help manipulate the patient sometimes we place a patient in what's called the sniffing position where their head is is is gently extended back so that's something that you can help with as well then you can certainly confirm intubation as well by helping the the paramedic to listen to lung sounds and then assisting with attaching that capnography as far as continuing care what can you do with that et tube as you go on certainly you can uh monitor the co2 the capnography levels you can monitor the sp02 the pulse oximetry reading if if either of those numbers is is inaccurate you know is or excuse me is abnormal um that then you can certainly alert the paramedic increasing resistance when ventilating so you're probably going to be ventilating this patient so after the paramedic inserts the endotracheal tube you will then take over the with the bvm and you'll be ventilating them so if you notice an increased resistance you can alert the paramedic of that other physical signs of poor ventilation or perfusion so the patient's skin is cyanotic those types of things improper positioning or dislodgement of the et tube if you happen to notice that the et tube becomes dislodged or moves around a lot you could certainly alert the paramedic of that as well so that's some continuing care options or items that you you may be uh responsible for after the the paramedic has performed the endotracheal innovation all right so let's talk through vascular access and what you're going to help with with with vascular access vascular access is a procedure that gains access to a patient's circulatory system to inject or remove fluids medications or blood products patient preparation what can you do i've already talked about a few of these things but you can position the patient properly have them lying on the cot with their arm extended you can explain the procedure to the patient hey we're going to insert a an intravenous line into your into your arm so that we can provide you with medications you can ensure that the patient's comfortable and calm some of the equipment that may be necessary again ppe properly sized bag or syringe of the iv solution so that's up to the paramedic do they need a syringe of iv solution for a for a normal saline lock or do they need a a bag of of solution for uh for a drip and we'll talk about both of those in class i'll show you i'll show the process of of spiking a bag iv tubing and rip set so uh uh the iv2 this should act that should actually be drip set iv tubing and drip set i will um i'll talk to you guys about uh about the iv tubing and setting up the drip set when we get into class how to how to properly insert that iv tubing in the the drip set into the bag of of saline solution or the medication skin prep pads already talked about that so you get alcohol pads out and get the site cleaned and ready to go adhesive tape uh gauze oops excuse me gauze commercial iv securing system which is usually a tegaderm and an iv pigtail catheter so all of those things those equipment again i'm going to show you those in class to show you how to set up properly set up for for this procedure and then if and then we need to to differentiate between iv and io access so if it's iv access they need a venus constricting ban or a tourniquet and then if it's if it's a and that's an iv tourniquet a little elastic band not the tourniquet that we place on somebody who's bleeding and then we need an iv catheter and those come in different gauges 16 18 20 gauge some examples if it's io access or intraosseous access that's where the paramedic is going to be drilling into the patient's bone i know i've talked about that to you guys before but io access is where they're going to drill into the patient's bone for access for vascular access for that procedure instead of the iv catheter you would need an i o needle and then a mechanical i o driver or insertion device and that's essentially like a little drill um that they use to uh to drill the needle into the into the bone all right spiking the bag again i'm going to kind of roll through this a little quickly because this is something we're just going to show you in the lab but essentially you're going to remove a little rubber cap or pigtail on the end of the iv bag you're going to take the spike which comes with the the drip the drip set and you're going to spike that into that bag into that where that pigtail came off going to squeeze and release the drip chamber until it's full again i know this doesn't make a lot of sense to you as i'm just reading it to you but we'll show you this in person you'll get a chance to practice this you're going to unclaim the tubing and you're going to let the flow fluid flow until the air bubbles are removed from the line check that drip chamber to make sure it's only half filled and then you hang the bag up um at that point you can attach the drip set to the fluid bag and you're going to fill the drip chamber halfway by squeezing it flush or bleed the tube to remove any of it of the air bubbles you want to make sure that there's no air bubbles in that in that tubing again you guys will see that in person when we get to class as far as performing the procedure during the performance of the procedure stabilize the patient's limbs a lot of times when we when we are starting an iv the pain response from the patient is to to pull their arm back especially if they're semi-conscious or unconscious a lot of times their arm kind of pulls back as we as we insert the catheter you may be tasked with holding that patient's arm stabilizing it can certainly provide comfort to the patient as that procedure is taking place as far as continuing uh care for for vascular access you can observe the access site for swelling bleeding discoloration or leaking and and all of those are signs of what we call iv infiltration so essentially the catheter has made its way out of the vessel and now the fluid that we are administering to them is just being uh essentially distributed throughout the the interstitial tissue and space around that that vessel and that causes swelling some bleeding discoloration all right so um uh troubleshooting team conflicts um one of the things that that we do want to talk about when we you know discuss you guys helping paramedics with with procedures you working with other emts and you working as a team we want to ensure that the patient always comes first if there's any sort of argument that happens you're going to have to you're going to have to just work through that argument you're going to have to ensure that that patient comes first so regardless of what the argument is about you're going to treat the patient first and then afterwards after the call happens we're going to discuss this in a respectful manner you know again afterwards back at the station whatever the case may be do not engage do not engage in conflict if somebody and this this goes for for patients and co-workers you know if somebody challenges you uh you know uh disrespectfully or or with any sort of uh violence or anger don't engage keep your cool keep your distance keep your cool um separate the person from the issue so a lot of times it happens your partner gets frustrated you've taken 15 runs that day you're tired you're a little you're a little fatigued you know they have a little bit of compassion fatigue they don't want to help um you know in someone's time of need because of of you know some of the issues that they have going on it happens we're all human beings separate the person from the issue so maybe it's your turn even though that person may be in charge of that run maybe you recognize that they're having some issues separate that person from the issue tell your partner hey you know what go go out and grab something from the medic go ahead and grab you know some equipment from the medic i'm gonna i'm gonna take over the questioning in the house from now you know for now that separates them from that from that issue um and then and then finally choose your battles uh you know choose your battles wisely if it's not worth fighting don't fight for it especially in the moment uh you know you can you can deal with things afterwards you can deal with any issues that might come up after the fact in a respectful calm manner let everybody cool down let everybody calm down don't fight those battles that just just aren't worth fighting all right so just a handful of review questions here i've pulled out a couple questions that weren't very helpful so uh we've got a handful here but we'll get through them uh and then that will wrap up chapter 41. which of the following is a characteristic of a regular team and you can pause the video and read through those and the answer here for number one is b members consistently interact with the same partner so remember a regular team is one where the members are consistently interacting interacting with the same partner or group of partners number two essential elements of a group that people must share include so essential elements that of a group that people must share include focusing on individual goals placing an emphasis on one way of accomplishing a task working with a set of shared values or promoting a personal identity and the answer there for number two is c working with a set of shared values remember if you're working in a group of people an essential element would be working with a set of shared values you know using the values of the group not individual things so promoting a personal identity it's not about personal things when we're working in a group it's about the the group and the group's mission so again focusing on individual goals no be focusing on the group goals number three members of an interdependent group and you can go ahead and pause the video and read through those and the answer for number three is d interdependent groups work together with shared responsibilities accountability and a common goal so interdependent groups work together it's a shared responsibility number four when a team member speaks you should repeat the message back to him or her this is an example of closed-loop communication a clear message constructive intervention or courtesy i mentioned this one briefly the answer number four when a team member speaks you should repeat the message back to him or her is called closed loop communication so for for its answer is a closed loop communication closed loop communication is is very helpful so that orders and and you know recommendations are understood clearly number five a team leader helps individual team members work together is often defined by policy procedure or statute or c or excuse me nc provides coordination oversight centralized decision making and support for the team or d all of the above the answer for number five a team leader is d all of the above they help individual team members to work together that's a certainly a responsibility of a team leader they're often defined by policy procedure of statute a lot of times uh organizations hold the team leaders you know the the lieutenants the captains the officers they hold them uh to to maintain and and follow and ensure that the subordinates are following policy procedures statute so that's that's usually what a team leader is is responsible for and then they certainly provide coordination oversight and centralized decision making uh and support for the team that's one of their biggest responsibilities is supporting their team all right number seven as you ventilate an intubated patient which of the following observations would cause you to immediately alert the team member ventilation is creating equal chest rise the patient's cyanosis is disappearing the oxygen saturation level is now at 94 percent where the bvm is offering more resistance so if we break these down which when would we alert the team leader the ventilate the answer to this one is d the bvm is offering more resistance and that's because d is the only one of these things that's essentially a bad thing right we don't need to alert the team member when the procedure is working properly so if ventilating is ventilation is creating an equal chest rise that's good we want to see that cyanosis is disappearing good we want to see that we're expecting that the oxygen saturation is now at 94 percent which is you know uh on the lower end of normal but it's still relatively normal oxygen saturation so that's that's good we're not alerting the team member about that but if a bvm is offering more resistance that is something that we want to alert them because now there may be a problem with that uh with that innovation with that endotracheal tube all right number eight you are assisting the paramedic with vascular access when you spike the iv bag it is important for you to use which technique sterile clean aseptic or reduction and the answer for eight is a it's important for you to use a sterile technique again we want to make sure that everything is clean and again we will we will show you this uh when we get into class when we get into the lab uh the sterile technique all right and finally number 10 your partner is working a 48-hour shift and has had little sleep he disagrees with you over how to position the patient and how you should drive to the hospital which of the following should you do you can pause the video there and read through those options all right and the answer for number 10 is a follow your partner's orders and discuss the call after the patient has been dropped off at the hospital so again we don't want to confront your partner about their behavior in front of the patient it's going to make the patient very concerned and they're they're going to be concerned that they're not receiving you know proper care in that moment so you certainly wouldn't want to confront them in front of the patient tell your partner he sure does not know what they're talking about that's a little disrespectful you're not sure where they're coming from um at this point so you don't want to necessarily confront them with that at you know in front of the patient at this moment ask the patient who he or she she thinks is correct obviously that's an incred an incorrect response there we're not going to let the patient be the judge of of what treatment needs needs performed for them so you're going to follow the partner's orders especially if your partner's you know is in charge of the run they have more unless that order is dangerous right if they've ordered something and you know it's incorrect it's not a matter of what you think is right versus what they think is right it's flat out incorrect or dangerous order you know that's when you wouldn't actually follow those orders but otherwise you're going to follow their order and you're going to resolve the conflict after you've transferred patient care let cooler heads as it says here at the bottom let cooler heads prevail all right and that is all for chapter 41 um and that's our last chapter of the book as always i appreciate you guys attention and we'll see you in the lab