is part-time for about three years so we have a pretty large group today this as you all know this is in preparation for your actual skills day when you guys are going to come on site and actually get your hands on the equipment so this is meant to be interactive however we have a large group but feel free if you have questions um you know speak up raise your hand however you want to do it and uh we can talk through discuss this Amanda norin the program administrator our director is going to be assisting all also so if you have questions put them in the chat or feel free to interrupt me so all right there's Amanda signal I got you in chat for any questions um Amanda do you want to go through introductions everybody this is pretty a large group so I typically don't no that's all right we be all right at least the instructors introduced ourselves so all right I didn't but intentions were okay all right we got one more I'm about to m in never mind all right so just some of the uh things I want to point out first of all you need to have your camera on if you don't mind muting your mics unless you want to speaker ask a question I'd appreciate it so we can eliminate some of the background noise and again raise your hand if you have any any questions um and I should say make sure your background is free of any inappropriate items so should you conduct yourself as you were in a classroom again interact um there'll be some lessons at the end we actually get a scenario of a patience and then uh you guys will get a chance to participate in that so we're going to start with the basics here um when you guys practice your scenarios one of the first things we're going to talk about is PP or BSI however you were taught body substance isolation BSI or PPE personal protective equipment so that's a very minimal in the prehospital setting we're be wearing gloves a lot of protocols depending on your department we going to call for protective glasses at minimal and of course we'll upgrade when it's necessary think about n95 so we went through the pandemic these were a huge item something we probably should have been doing anyway for patients we suspected has type of respiratory infection Airborne droplets for example U but now it's pretty pretty routine excuse me if I have a patient that has uh some type of productive cough fever we need to have n95s if not even a gown and think about your tra trauma calls when you guys get to your trauma scenarios and another block we'll talk about when it's appropriate to wear a gown so seeing safety we always say right off the bat is by seeing save I got proper BSI or PPE so get that ingrained in your brain that's going to be pretty much every scenario going forward you're going to start out with my is my scene safe so let's talk about what scene safety means to us so keep in mind you to have your head on the swivel at all times you need to be aware of your surroundings we call that situational awareness as you know we can get into situations where things can escalate we can have a domestic call for example maybe we're on a crime scene for example ex Le and we'll talk about additional resources when those cases happen so even in a private residence setting you know something as simple as steps uneven terrain there's a lot of on on job injuries that occur even in uh what we consider a safe steam lighting machines animals if you've been in prehospital or if you've been in Ems for a while you you dealt with animals um we usually politely ask the pet owners to secure them in a room because sometimes that could be unpredictable we get into drugs weapons um think back to the crime scenes when you're responding to a call and say a stabbing or a shooting or something of that nature even something simple as domestic dispute with a physical assault we typically call for law enforcement or PD first and a lot of times we may stage a block away or half a block until the law enforcement officers can Ure the scene is safe and then also weapons on the person you know I've been cases personally when people were transported to the hospital and this was missed maybe a knife for example then we get into weather conditions bystanders family a lot of times family members rely on them for our history of the patient but they can also be an issue depending on what the scene is so again scene safety BSI there's some hazards here well this one's pretty obvious to me first thing I see here is a a gun a weapon if you encounter this that's when we asked law enforcement or PD to secure that weapon Force now we got drug paraphernalia we got someone here that's having some type of medical problem um secure the weapons secure the medications um and always think about seing safety here all right that's interesting so this dog has got the that's probably the pet owner unconscious unresponsive finding face down this dog is protecting this patient I suspect so another scenario we're likely going to encounter all right so bottle signs all this goes back to ABCs you guys probably had BLS or CPR at this point same same Concepts here we always fix the airway open the airway whether it's a head tilt tin lift modified jaw thrust and a trauma scenario assess breathing and C culation so Baseline Vital Signs here breathing rate scan the patient's chest otate lung sounds let's see what the respiratory rate is for an adult for example we'd like to see that in the range of 12 to 20 lung sounds and we'll have some videos for you guys to hear some adventitious lung sounds think about patients that have pulmonary edema or flu in the lungs congestive part failure or what about the asthma patient or the COPD patient who has wheezing and then pulse when we're sessing our ABCs s your patient conscious and alert we're going to reach up while we're assessing the airway and breathing we can just grab a radio pulse and really really quickly what I'm doing here is checking to see if the pulse is first of all intact is it strong or is it weak or thready is it really fast is it really slow is it regular or irregular that's where the rate Rhythm and quality come in and then while you're there think about skin conditions you're already touching the patient is skin hot to the touch for example another Vital sign to think about is checking a temperature is this patient presenting with let's say pale cool clany skin or indications of shock for example and of course pupes and I want to demonstrate this on a mannequin here shortly how to take a base Baseline bottle signs and of course we'll show you guys when you actually come here on SES you're going to get a chance to practice on each other osting blood pressures and also palpating blood pressure capillary refill reach down there squeeze the nail bed let's see if there's any delay which would be an indication of poor circulation and then finally three lead and even 12 lead placement and yes EMT Basics your scope of practice includes obtaining the four lead and also a 12 lead now you're not able to interpret the 12 lead but you guys can transmit these 12 leavs to the ER and that Cal lab can get activated right away even if you don't have ALS on scene and we'll demonstrate what that looks like so I think this might be the point where I need to do that first of all let me let me demonstrate or play these videos for adventitious SL sounds and then I'm going to demonstrate on the mannequin taking bottle signs where to otate lung sounds and those other Vital Signs we talked about so this one should be okay this is where so man I was expecting these to play they should play um because they actually sound really good with the headphones I was impressed When Brad had played them before I we yeah if we can't get them to play we can uh maybe over a break we can figure out why they're not playing okay all right let me toggle back over to the mannequin I'll show you what I'm talking about for bottle side next all right so obviously you guys are going to have a blood pressure cuff you're going to have a stethoscope one of the other tools you guys can use and this is important for our respiratory emergencies as a pul Sox place this on the finger of your patient ideally you want to use the opposite extrity if I'm taking a blood pressure on the right side for example I tend to use the other finger to get an accurate pole sock so pole socks you like to see 94% or better uh but that depends on your patient you know if they have some type of respiratory disease like COPD for example a lot of times we'll just ask that patient you know what's what's your Baseline what's normal for you and that that'll dictate how the patient's doing blood pressure in this case I'm going to use the right arm on the mannequin key to this is having the appropriate size cup we got a regular size adult for this mannequin we do have a pediatric size typically and also a large blood pressure cup so obviously I'm not going to get accurate numbers on a mannequin but I'll least show you what it looks like so one of the keys here when taking a blood pressure and also osting lung sounds is is your finger placement on the diaphrag so as I'm taking a blood pressure we're in the AC area and then we Pump It Up basically until the pulse you here it's he the pulse rates and that's why we keep our thumbs off of the diaphragm because if the you can actually pick up on your own pulse here and that's why we teach two finger techniques so we increase the pressure and basically inflate the cuff you'll see I got this tighten down right for tight Pump It Up keep in mind I'm listening all right when the pulse goes away or I no longer hear it I'm going to pump it up about another 10 or so and then I'm going to slowly release the air out of this now nice and slow and then when we hear that pulse come back or that throbbing in the diaphragm basically that's going to be our systolic number and systolic dust means the blood pressure when the heart is Contracting and then when it disappears that's going to be our diastolic and that represents the heart at rest so you got two numbers there a diastolic I got a pulo and now I want to osculate Long sounds so typically two fingers ask your patient to take a deep breath listen here here now the base of lungs on each side as well then got our pole socks like I talked about some of your other votel signs don't forget about taking a temperature this is the traditional thermometer here this would go under the tongue we um some of the other ones might be some type of scanning infrared device um even at the department I worked at we had stickers which weren't very accurate but if a patient had an extremely high temperature we can at least pick up on that and we talked about skin conditions your patient is going to present flushed and very hot to the touch you can suspect a fever in that case and another thing I got here is a pin light for checking pupils just one of our Baseline neuro exams when we're checking level of Consciousness and we're thinking about any neurological problems such as uh let's say a stroke let's talk about uh hemorrhagic Strokes or maybe head injuries in a trauma scenario we're looking to see if the pupils are equal and round and reactive to light we call that Pearl and then finally I have a glucometer here which you guys will get a chance to practice this but you're going to check patients blood sugars typically I just do that with everybody that way we don't miss anything simple think about your patients that present altered and sometimes a diabetic episode can look very similar to a stroke and vice versa so you want to make sure we're checking blood sugar with anybody altered if not everybody and that's something we can easily fix so let bring the camera back to me and we'll talk about some of the adventitious lung sounds and hopefully I get those videos to play because think that would help you guys and you can do this on your own too just if you just searched YouTube for lung sounds you're going to get the same thing so some of the things we talked about pulmonary edema excuse me get that out of there um rails if you hear crackles or rails a lot of times we use these terms interchangeably but this is indicates fluid basically in a lower airway Alvi and then broni and the broni just kind of a way to help memorize this and the higher up in the airway we got fluid in those main branches of the Bron ey so rails and the Tails think lower airway fine crackles ronai more upper upper Airway both of them represent fluid but I can imagine the ronai is probably a more coarse maybe more wet sound and kind of makes me think of like patients with pneumonia for example the each case again is fluids and then we have wheezing which is pretty easy to hear actually that's one of the easier ones when I was a brand new EMC I was like I can pick up on wheezing in fact some patients we can hear that without even oscilating lung sounds audible wheezing from across the room for example then you have some patients that are so tight with an asthma attack that they're not even moving enough air to produce any weed and as soon as we give them a breathing treatment then the wheezing starts kicking in so don't be fooled by that so Baseline bottle signs very minimal guys Mak sure we're oscilating lung sounds and also we're going to get cavography which is coming up in a slideshow pretty soon irregular breathing patterns um this is what cavography would look like when we look our patients up and let me go ahead and grab one so I can show you what I'm talking about I'm we toggle back over to the mannequin and I'm going to place craphy on this patients with a nasal camulus this patient can get oxygen and also we can watch their camography the digital numbers and also the waveform camography which what you're seeing here basically in this little slideshow here are different examples of your regular breathing patterns that we can capture with cavography oops try it again toggle back so in this case imagine I've got this hooked up to oxygen this little orange connector right here basically this will hook right into your heart monitor and then here's a nasal canula that we would apply and you got a little little tube hanging out right here that's capturing any exhaled carbon dioxide now we can monitor that we tried to see or we're trying to get here a normal range would be 35 to 45 for cavography but again that could depend on your patients some patients with COPD might have have elevated CO2 and naturally retain CO2 because they have what we call a trapped airway disease pulses we talked about doing our ABCs and a lot of these things can be done simultaneously so why I'm assessing breathing I've already determined that my patient has a Pon Airway keep in mind if your patient can talk to you we can assume they have a payon Airway and then we grab their wrist I'm grabbing a radio pulse here and while I'm here I'm also assessing skin conditions again what's my rate Rhythm the quality of my pulse what if my CRT if I were to squeeze hey Jason yeah can you move the camera angle up just a little bit they can't see the capnography on the head there you go awesome that better okay thank you so if you could see it though basically I just put on a nasal canula here that has cavography that hooks into the heart monitor I'm grabbing a pulse and also assessing skin conditions and again if you suspect a fever don't forget to take that other bottle sign temperature and very important make sure we get a blood glucose on anybody especially if we suspect they're altered or disoriented or confused so we got different locations there I demonstrated a radio poles you got femoral pulses um in the central areas you got cded pulses if you had a patient with a cded pulse and say AB absent radial pulses then you can estimate their blood pressure is probably in a range of 60 at best so not good right if we have a good strong radio pulse and we're probably more in the ballpark of about 90 systolic at least and when we take vital signs on each other when you guys come here for your medical skills day we'll talk about that more detail for example otan blood pressure and also palpating blood pressure and when you do your full assessments especially in trauma there'll be detecting a p pulse that on top of the foot to see if we have good pulse motor Century in the extremities pupils I kind of hit on this already we want to see pupils equal round and reactive to light some of the emergencies you may encounter in the field are going to be we talk about the hemorrhagic stroke or the head injury patient who may have a blown pupil which means one of them's dilated or they're unequal in size um another one you may encounter is going to be your opioid overdose think about your patients that have pinpoint pupils that's kind of one of our our indications for potential opioid so don't leave that bottle sign out and now we're at EKG placement so so I got the mannequin set up here you'll see some stickers on the chest I'm going to show you the lead placements you guys will get a chance to practice when you get actually get here but begin with we typically take an underline EKG with just these four here if you look at these they're color coded and they're also labeled so right arm I put one here for the arm left arm here and then we can I'm putting these on the extremities with the intention of doing a 12 lead EKG now you can put these Lin leads or these uh these four leads on the trunk of the patients but typically when I take a 12 lead I try to use the extremities now sometimes that can be a problem sometimes if our patient is triming or if they move a lot it does cause what we call artifacts your 12 Le kgs are very sensitive to any movements and I may have to modify that bring it up to the trunk but I was basically I was trained by a bunch of firefighters and there's a lot of different uh ways to learn this one but this other one I Learned was white right smoke over fire and then the green ones basically your grounds it goes on the opposite way but again they're labeled right arm left arm left leg and so forth now looks like I forgot to get the 12 lead out so let me grab you the 12 lead cables now I got a bunch of wires here 12 lead what that means to us we're taking a look at the heart from 12 different camera angles if you can imagine that except we're looking at the conduction or the electric activity of the heart itself so if I go back to original four lead that we put on we're going to plug in our 12 leads cables and I put the stickers on here kind of demonstrate where these go so V1 if you were to palpate the clavical area and come down you're on the second intercostal we'll come down to three and four and then we'll put V1 on the other side of the breast bone we'll put V2 typically we skip V3 and go to V4 which is going to be mid clavicle and then will backtrack and put B3 between two and four and then five and six are on the fifth intercostals so all those are hooked up we ask for patients to please not move again these are very delicate some very sensitive to artifacts and then we press a button to capture the 12 leads so you guys will get the chance to practice that and everybody I said we're going to transmit these to the ER if we suspect a cardiac events you guys can get the ball rolling on the ER the doctors can receive these EKGs and they can call we we would consider a stimul alerts and they can actually get this patient straight to the cath lab once we arrive with the patient so that's that's a be of the technology today so 12 Le kgs medications as I mentioned cardiac events basically patients that we suspect are having chest pain associated with a cardiac event now there's a lot of reasons to have chest pain but if you can imagine a middle-aged patient perhaps with a history of some type of cardiac disease may or may not have it let's say your textbook patient with the chest pressure they complain of that radiation to the jaw or shoulder maybe they complain of being nauseous or very sweaty we call that dieresis or dtic and also they tell you okay well my doctor gave me this nitroglycerin and I used one of these for EMS AR know it's getting no relief so here's our patients that needs nitroglycerin so let me grab those tablets I actually grabb some of these medications for you here's what you typically see memorize these dosages while you're thinking about it if you're taking notes Here point 4 milligrams nitroglycerin and the route is sublingual meaning we're going to put this under the tongue again this is a conscious patients able to maintain the airway we wouldn't give anybody anything orally unless they were conscious and able to maintain an airway so we just tell those patients all right first of all let's see what the indications are well chest pain we talked about what about con indications we do need to make sure there are a couple things uh we check first of all first of all this patient needs to have a decent blood pressure you know 100 systolic or better because this medication will lower your blood pressure it dilates the coronary arteries and your blood system and basically that's going to cause the blood pressure to drop naturally another or indication to think about with these are Ed medications if your patient has has certain Ed medications within 24 to 48 hours because they can lower your blood pressure we do not want to give them nitri Lin and also consider oxygen for your patients so in the old days if anybody just said chest pain they would always get oxygen at least nasal canula maybe two or four liters and that would depend on your protocol these days there's some controversy about oxygen free radical Theory we won't get into that but I will say if your patient is hypoxic meaning they have a low Cole socks or they're showing indications of shortness breath I would not hesitate to put them on oxygen um in the short term with the patient we're probably not going to cause any issues there so again remember nitroglycerin point4 milligrams suspected cardiac events make sure they have a decent blood pressure and we rolled out any Ed medications within 24 to 48 hours we're going to give these to a total of three each time we're going to check that blood pressure very important check your votal sign and then make sure they're ready for the next dose okay some other medications let me go grab the epinephrine um I'm probably going to demonstrate for you guys today the O2 tank and assembly while I'm on this slide because that's something you're GNA actually get a chance to practice when you get here at least I can show you what it looks like on the camera so one second we backtrack a little bit here because I forgot to mention the aspirin anytime you're treating the patient for suspected cardiac event or chest pain we Ty give them the dosage of aspirin too so a normal dose usually is 324 milligrams these are baby aspirin normally because they're table because we don't have water NE necessary to give our patients in the back of in the ambulance um but something you want to think about with any medication first of all or allergies but for aspirin specifically make sure your patients don't have any active bleeding such as GI bleeds and uh I see a question here so yes to answer that question as long as the blood pressures remains above 100 systolic typically we can give Nitro up to three Doses and also baby aspin 324 milligrams this helps thin the blood basically and then we talked about how the nitr glycerin dilates the coronary arteries with the idea being to reduce the stress on the hearts maybe open up that artery to the damaged area of the heart how many of you know let see how many do you know you know how to give and why would you I'm sorry it just disappeared on me sorry I'm try to read your question there how many do you know to give and why would you give more than one so basically idea is if you give one and the patient still presents with chest pain then we need to keep giving a second or potentially third as long as they present with chest pain now occasionally I've seen patients they get one nitroglycerin and they get a huge relief out of it it doesn't happen very often but they could theoretically have resolved all their chest pain and then we would stop and of course the blood pressure gets too low we would stop there too that answer your question so up three doses check those cont indications and as long as they present with chest pain yes we're going to give up the three Doses and get them to the hospital get that 12 lead if you guys really want to and pressure Proctors when you guys do your or boards and also when you do your scenarios up here don't forget even as ENT we can order that 12 lead we can obtain that 12 lead and transmit that 12 lead to the receiving facility and I would be impressed so here some EMS do that all right oxygen I'm gonna pull the camera down to the other side here and I'm going to demonstrate assembling O2 regulator to an O2 tank in the steps to do so and then we'll come back to these medications so let me set my camera up here remember Amanda said if you need to pin me to this make it larger you can do so so the equipment I have here obviously is an O2 tank I have an O2 regulator I have an O2 key so one of the first steps we'll take here is I want to crack this tank just temporarily to purge out any debris so that quick nice little quick Purge if you look at your O2 regulator you see you got two pro and you got two holes you're to line them up with on the stem of the O2 bottle hand tight is good enough now I'm going to open the tank up all the way we'll check to see how much oygen we have in the tank and also here I'm looking to see or he for any leaks and let's just say in this case I'm using nasal canula on that chest pain patient we talked about we'll plug in the nasal canula and remember your flow rates for nasal Cano could be anywhere from two to six liters per minutes and then we have a non breather for those who need more oxygen let's say those who are having a respiratory distress episode with asthma COPD or CHF they're breathing let's say 28 times per minute very labored adventitious L sounds that we talked about that patient may be a candidate for a non breather in that case I'm going to dial this into about 15 liters per minute I think natural registry would say minimal 10 but typically in the field we give them all 15 liters with this so so this is a skill you guys will get the chance to practice um when you look at the regulator you'll see you have a little red area in fact this one happens to be right there at 500 uh as far as the oxygen content and we would normally swap these outs we get below 500 bring you guys back to me any questions feel free to speak up right now while I'm working on this camera stuff like I said you guys will get a chance to practice get your hands on the O2 tank we'll go through a assembly applying a non breather nasal canula and also cavography all right bringing you back to me some of the other things that uh medication wise that you're going to be doing it's in your scope of practice I mentioned the pinpoint pupils a few minutes ago for the suspected opioid overdose you can imagine your p unconscious and responsive agonal breathing or very little breathing um and then also the pinpoint pupils and maybe even indications of drug paraphernalia um Narcan 2 milligrams internasal which means we're going to give this into the nostril if you can see this I've got what's called an atomizer attached to my Naran vial so this gives it a nice little M spray kind of like a nasal spray and one cc in each nostril and surprisingly this works very well inter nasal um for advanced providers we do have an IV route for Naran which is a much lower dose so what we're trying to do there is restore respiratory drive and that's it um a lot of times if we get over zelis with an Aran we can create what's called uh immediate withdrawal your patient now becomes combative now your patient is projectile vomiting now we have a nightmare in the back of our truck so when I teach this I usually emphasize to the students I'm giving you incremental doses enough to get the respiratory drive back and personally I don't care if they wake back up necessarily long as I present that patient to the hospital with decent bottle signs and a good respiratory drive so we're watching their lung sounds we're monitoring their pole socks and their kinography and if you need to give add additional doses you can do so with medical control AB all memorize this dose 2 and a half milligrams in a vial of AOL and I think I got one of those somewhere here let me go grab that one for you I thought I had one out let me show you the te piece here oh it's in my hand so here's a vile two and half milligrams of butall I'm gonna open up this T piece here and at the base we're just going to twist off the top we'll dump the medication in here screw this back on hook this up to our O2 tank minute approximately just enough to create a nice little mist and now we have a tpce so for our patients that have wheezing or Bronco constriction asthma COPD for example um assuming they have no allergies to this medication we can give this 2 and a half milligrams of etherol and this is via nebulizer so I think there's a slide coming up we'll talk about the five rights but just know that anytime you give a medication to any patients um make sure we ask about any potential allergies medications and also with this one if your Paia is not able to hold this in their mouth we do have a mask device that would use and live this T piece so this will sit under what looks like a non breather essentially but it's a mask designed for breathing treatments for those who can't hold this up for people it in their mouth all right so activated charcoal think about poisonings overdose ingesting poisons um I'll be honest with you this this hardly ever gets used in the pre hospital setting uh I've always had activated charcoal in my units but after 28 years I have never given this so my best advice to you as an em student is if you suspect some type of poisoning especially with these kids I always call Poison Control and they can direct you usually with uh you know what type of interventions you may need and some cases um I actually had them tell me well your patient is probably okay they don't even need to be transported so they are a resource for you as well as medical control when you need to figure out this patient needs activated charcoal all right another one I see on here is or glucose we talked about that in the bot signs how important it is to take a blood sugar on anybody especially anyone that's altered um if your patient is having a diabetic episode or hypoglycemia let's say they're confused disoriented they may present sweaty or deretic we test our blood sugar let's say it's in the 30s or 40s however the patient is still conscious enough to maintain their Airway that's the key to giving anything orally and that goes for oil glucose or instant glucose as well so this one apparently doesn't taste well um a lot of patients actually dread this you would think it would be like cake icing but apparently it's not even though this one says it's a great flavor so this would just go basically you put it in the cheek of the patient always explain to the patient what you're doing especially if they first time they're going to be confused anyway if you can imagine that this can present a challenge so getting this on board this will get their blood sugar up usually will reassess their blood sugar and if it is indeed a hypoglycemic episode you can expect your patient to come around in a few minutes and then keep in mind this is kind of a quick fix too so these patients will need to eat something with some substance so it's not unusual for your patients to come around become what we call alert oriented to person place and time 80 times three and legally they can refuse transport very common with diabetics they've been through this times the last thing they want to do is go to the hospital um but what I typically do is I watch them eat a sandwich peanut butter and jelly sandwich or something to keep that blood sugar up because ours is a quick fix and last thing I want to do is leave and have to come back in about 30 minutes when that patient's blood sugar bottomed out again so all right how we doing on questions man are you taking care that looks like thank you yeah I got it thank you as promised memorize these your patients rights this is for any medication I have a question go ahead um I believe my computer cut out whenever you gave the dosage of oral glucose okay yeah so what is it 15 grams I'm trying to remember that dosage off the top of my head let's see yeah yep 15 to 30 okay it's a range of 15 to 30 per the nrmt guidelines uh each each one of those little things there is 15 grams we usually just give the one the whole thing yep okay thank you yep if you get them to take it um like I said some some patients hate the taste of this I've never actually tried one but this one is it's horrible it's bad and orang is orange is no better than the Cherry just saying okay I what that Alexis and you just give the one nor I mean normally yes um it will take probably about five minutes for that to for you to even see any uh effects of that medication working so like when you recheck their sugar if it's not above the threshold that it's supposed to be above for your protocols you may have to give more um hopefully if you did what you were supposed to do in the beginning with those additional resources and you called the the medics in hopefully they're on scene by the time you have given that and it's working and if it's not working they're going to start a line and give some more powerful sugar through an IV but okay thanks yep yeah the key there Alexis is make sure your patient is a able to maintain the airway and so we got to catch you got to catch them in the right time in a sweet spot if they deteriorate to the point where they're all altered then we would have to rely on Advanced dmts and Medics to establish an IV and get the dextrose IV and that'll wake them up almost instantaneously all right so oral glucose 15 grams in that tube for a dosage and here's your patient rights um six rights and I think there's some additional ones these days too so right patient right time right route right dose right medication right documentation um these are things you want to kind of mental check anytime to give a medication to any patients and also be thinking about conations that's the key especially with that Nitric glycerin we talked about you know the blood pressure the edms for example oxygen okay we kind of went through that already here's the uh the tank I already explained um dosages 1 to 15 liters nasal canula I typically teach two two six lers and then of course the non breather I typically just pour it in 15 lers per minute you thinking about that trauma patient that living signs of shock or you thinking about that patient that has uh severe respiratory distress with a low pole socks or adventitious lung sounds you know give them some oxygen if they need it all right so one of the controversies with giving too much oxygen we talked about free radical I touched on on that but one of the other things is what we call a hypoxic drive or knocking out the patient's respiratory drive so if you're thinking about a COPD patients who naturally has carbon dioxide retention now you and I as healthy people with with no respiratory problem we kind of use that CO2 the chemo receptors in our body detects CO2 levels to stimulate respiratory drive now those with with respiratory disease like COPD they're naturally used to elevated entitle CO2 or CO2 levels so the theory is if you give them too much oxygen their body is going to mistake that for okay I've got too much oxygen I need to slow down my breathing which is not what I want to do to the patient that's having a hard time breathing already so that's the idea behind the hypoxic drive so my understanding then this this has to be over a certain amount of time a period of time usually in the prehospital setting if you're in a Metro Atlanta for example we're pretty close to hospitals um I haven't personally encountered this but it's something to be mindful of when you're giving oxygen to COPD or osma patients so indications again hypoxemia I just means low oxygen in the blood system remember we're using that pulo probe I demonstrated kind of help us now keep in mind that's just one tool um this is kind of a pet peeve of mine when I see ENT or paramedics included who throw a patient on the pulseox and this patient is exhibiting respiratory distress and if the pulseox reads good they're like okay we don't need to give them oxygen no that's not the case if your patient is exhibiting signs of respiratory distress we need to treat that there's a couple reasons why oxygen could give or the pul off could give you a false reading one is going to be if they have coal extremities another could be nail polish and then think about Co poisoning a patient that has Co poisoning is going to give you a normal pulse op reading and we know those patients need oxygen so it's one it's a tool put your clinical presentation together and if they eat oxygen give it to them don't withhold it all right routes we talked about already nasal canula the N breather are probably the most common you see the flow rates here uh again H breather says 10 to 15 so minimal 10 with that one if not 15 and then also when you guys practice your bag valve Mass ventilations with your patients that are agonal or not breathing we call it apnic we also hook them up to 15 lers per minutes for a supplemental oxygen device OB be AOL is a bronco dilator for those who are wheezing or trying to open up those tiny sacks in the lower airway the alioli you call it remember the dosage two and a half milligrams and we're given this via nebulizer here's your flow 6 to 10 lers per minutes indications wheezing or bronos spasms con indications obviously an allergy D uol and then some relative convocations now let me talk about this tapic cardia I'll just tell you right now if you're having a hard time breathing and you're hypoxic and especially if you've already used your meter dose prior to EMS arrival your heart rate is going to be fast so take this one with a grain of salt the concern here is Abol does stimulate your hearts so we do need to watch these patients especially those with cardiac disease or middle AG or older and we would put them on a heart monitor because we do know Abol increases your heart rate also your force of contraction so that's why that relative convocation is in there and another one double Aster CHF so I'm G to ask you guys let's see if you guys are the experts what could be a problem with Bronco dilation for a patient who has pulmonary edema or CHF does anybody know no ideas what was the question okay think about a patient that has fluid on their lungs pulmonary edema what could potentially go wrong if we gave them a Bronco dilator and let's say opened up the Ali or dilated Airway I see Emily raised a hand Emily what do you think so in congested heart failure failure and Pulmonary there's fluid that are sitting in those passageways right so if you're giving AOL that's going to open them up which could force more fluid in there you go the idea you're 100% right Emily so the idea the theory is if we open up those Airways those Alvi and we now flooded the Alvi which inhibits your O2 CO2 exchange so that's why there's an aset there I just want you to be aware of that um again I'm going to follow that up with if your patient needs oxygen or if they need a breeding treatments um they then give it if you're on the fence about what to do guess what we're going to call medical control anyway you guys are going to need to call medical control and get orders for these medications so run it by the ER give them your full assessments V signs and then see how they would advise you to proceed if you're ever on the fence or sure not sure what to do with the medications side effects uh typically headaches and I should have mentioned that with the nitroglycerin because many patients hate nitroglycerin because it gives you a pretty bad headache usually when you dilate those blood vessels it kind of reminds me of being severely dehydrated that that lingering headache you get from dehydration is probably what they feel like when we dilate those blood vessels so same thing for the uh aerol irritability you know that's them just kind of being you know hyperactive Restless because of the stimulants we talked about on the heart I of course tach cardia and maybe even palpitations which is a nice fancy word for increased or fast heart rates any questions about AOL here's a meter do one your patient likely has one of these maybe they've used this a couple times before they activated n one because they were getting no relief um bronos spasm wheezing same conations we already talked about same side effects just a different route and a different dose what should I use so I showed you the T piece that one on the bottom right was the one I had and I told you also there were a mask if you see the teddy bear there if you guys can see that image you can see the base is hooked up to a mask and then this is more ideal for those who probably aren't in good enough shape to sit there and hold the mouthpiece in so a lot of times I'll just use the face piece right off the bat and then you see another device down here to the bottom left do anybody recognize what that is [Music] um CPAP CPAP yes CPAP is in your scope of practice for EMT Basics at least here in Georgia so when do we give CPAP anybody know or who's a candidate for seatpad Wonder a lot of times people use it um at night who have sleep apena yeah absolutely uh sleep at me as one think about a respiratory emergency that you may encounter in a field as an entt all right I see some answers on here CHF is correct and also COPD did you know going back to that fluid displacement with the Bronco dilator CPAP which stands for continuous positive airway pressure and ours A simple again these are not ventilators or bypass these are continuous positive airway pressure we're going to hook these up to oxygen device the same O2 tank I showed you guys we're going to dial in the pressure and the corresponding liters per minutes and the idea is we're going to display some of that fluid off the Alvi to allow O2 CO2 exchange to take place and these things actually they do wonders for a patient before we had CPAP ALS units could give a diuretic or Lasix or water pill and typically that would take a long time to be effective we would never get to see the immediate results patients that are on CPAP it turns them around so quickly now indications receip P let me talk about that before I forget again conscious and alerts a able to maintain an airway and also they need to have a decent blood pressure CPAP actually affects your preload on your heart we call it which could lower your blood pressure so think about your nitroglycerin range 90 to 100 or better probably the same thing for a CPAP and that'll depend on your protocol but yes COPD is another example those patients that had the expiratory wheezing from empyema COPD actually benefit from CPAP too and some protocols may have even call for it for asthma although I haven't routinely done that for asthma patients we'll show you this device when you guys get here for skills medical skills and you get a chance to see how we dial in the pressure so just so you know you have to adjust the pressure we usually start at the 5 millimet I think it is I always forget the unit me the metric for the uh the pressure but we'll start at five corresponding O2 flow might be like six liters per minute and then we do what's called titrate to effect which means we increase it as needed until our patient gets released so what's that look like in better respiratory Maybe improv pole socks maybe better lung sounds um and skin color you know we know the patients that are hypoxic can start out pale and it can show signs of cyanosis so all those things we're watching um to see if that patient improves now sometimes they a little claustrophobic you have to get your patient acclimated acclimated to the mask um maybe start start out slowly put on their face let them hold on their face where you can assist them to do so you may have to coach them a little bit it is a little awkward um when you get a chance to do your clinical ride put one of these on yourself so you can get a idea what this feels like it's not I can see how a patient could be kind of scared of this claustrophobic and it's not exactly comfortable but necessary all right I mentioned conations already blood pressure conscious alert able to maintain Airway um we already talked about COPD and also CHF which usually presents with the pulmonary edema or clinal LS now did you know that you can give a breeding treatment in conjunction with the Seth or at the same time absolutely we could hook up a one of those nebulizers that I demonstrated before straight to this BiPAP or excuse me CPAP not BiPAP CPAP and in some cases you may have two oxygen devices some of them you can use one oxygen device and just amp up the liters per minute so just deps of what you have there and don't forget camography when you guys place a patient on cpad place that camography that nasal canula Style camography on first because once I get a nice seal of the cpad Mask I don't want to break that seal which leaves me the entitle CO2 we said the range write this down 35 to 45 is what we like to see for a normal person and anything less than 35 means they may be hyperventilating or respiratory alkalosis if you can imagine a patient hyperventilating they're blowing off excess CO2 therefore their entitle CO2 reading is going to be low and then vice versa for those who are not breathing effectively hypoventilation think about your opioid crisis or overdose patient we talked about that's not breathing if they are breathing they're very agonal or slow now that patient cannot blow off and title CO2 or CO2 therefore those numbers are going to read higher than 45 oh boy a video I really wish I could figure this video stuff out all right they're probably going to talk through I got some slides here to kind of demonstrate so we talked about the digital numbers 35 or 45 but also we look at the waveform so the very top one shows you a normal waveform cavography and I'll try to use my little cursor here to demonstrate so we're at the Baseline zero as a patient exhales remember they're getting they're all looing the CO2 we'll see that kind of go up increase sharply and eventually Plateau outs now let's look at the asthma patients see the shark fin as they exhale or try to ridel of the excess CO2 because of the trapped air in the alvioli we get a different waveform here and it looks just like a shark fin that might be an indication of some type of Bronco constriction for example and then the other two slides were just simply showing hypoventilation and hyperventilation so I showed you the canular one you have an inline CO2 here this one's for your Advanced Airways if the patient were to get an igel um it's one example of what we call blind insertion area device we would just hook that straight to the tube hook it up to our Monitor and monitor the capnography that way cpath remember I said continuous positive airway pressure not the same as BiPAP where you might have two pressures one on inhalation and exhalation typically see this with mechanical ventilators if you're on a um Critical Care units or maybe do inter facility transports um you're going to see mechanical ventilators a lot of times patients will be taking from um ICU to other facilities um and then we'll that is including your curriculum in the ENT day um I don't have one of those machines here demonstrated but I think we have some slides and videos for you for that all right or glucose came back here it is 15 grams po Place between the gums and the cheek again this is for low blood sugar does anybody know what the normal range should be for blood sugar for the typical adult 8120 c120 your protocol May read patients that are symptomatic less than 60 was probably in would probably be a candidates for or glucose again we got to catch them while they're still alert enough to maintain an airway side effects vomiting I guess this stuff is pretty nasty um pediatric dose is 0.5 to1 grams per kilograms pretty much any pediatric medications you're going to give are going to be weight dependent so we have to work on converting weight to kilogram if you're not already used to doing that and then we have other resources such as hand heavy and even brazzo tape we use for drug dosages look God now let's say we have the diabetic patient same one let's say their blood sugar is in the 40s let's say they are altered to the point where they are not a candidate for anything oral against the glucose well you guys can't start an IB right but what can you do glucagon it's basically a shot into what we call an IM route intramuscular um again severe hypoglycemia this needs to be for patients adult patients of Pediatrics greater than two years old cond indications um I don't even know what in the world that is increased risk in blood pressure hypers sensity to the drug which would be pretty much all of them I'm not sure what that term is guys so um what I'll say about glucagon it's not GNA be as fast acting as maybe the insta glucose and especially not as fast acting is given NEOS IV routes uh these patients simply get transported because it might take 15 or 20 minutes uh for this glucagon so it Taps into your gly glycogen excuse me um and basically gets the blood sugar elevated that way aspirin every said 324 milligrams maybe aspirin that are table indications onset of chest pain if you suspect as cardiac and major cond indications again make sure they don't have any bleeding particularly any GI bleeding because these are blood thinners we can exacerbate these type of bleeding side effects could cause bleeding GI bleeds epigastric distress Nomine and heartburn so again chest pains aspirin and if the blood pressure is good no Ed cond indications nitroglycerin point4 milligrams of the three doses Tain that 12 Le transmit it to the hospital activated coal this is 25 to 50 gram for all ages again consult medical control or even better Poison Control if you're considering charcoal so if you're wondering what's going on here charcoal as you know is a very natural absorbance we basically just putting this into the stomach to absorb the poisons is the idea Comm vacations would be unable to follow commands or protect their Airway which goes for anything or NRC glycerin 04 milligrams every 3 to five up to three Doses and now we don't give this to Pediatrics uh chest pain conations again can't emphasize this enough hypotension hogia any type of bleeding and Ed meds in the last 24 to 48 hours and always prompt your patience because they might forget about the ED medication so we always ask our patients in a sample history about their signs and symptoms allergies any medical history or medications rather for M and inferent history last oil taking events leading up to my point is don't just assume because we asked them if they had any medications that they haven't taken any Ed meds so I usually prompt my patients and us that as a followup question hey just to confirm you haven't had any Ed meds you know last 24 to 48 hours because we can be detrimental to these patients if we give them nitroglycerin the cause of blood pressure the body Ms would you have a spray version too same dosage point4 basically just spray this under the tongue um my most of my experience has been with the tablets personally same indications same cond indications epinephrine 3 milligrams I am intramuscular all right when would you guys give someone epinephrine when they're coding that's true and it would be in a national scope for advanced EMTs but what about an EMT reaction allergic reaction all right um tell me what epinephrine does for allergic reaction I'm pretty sure it works as like an anti-histamine uh blamin and lucites to reverse the signs of a multistem anaphylaxis Okay so so you mentioned multi-stem so by definition an aaxis to us means two more body systems affective we could have a respiratory problem like the wheezing or Strider where the airway is shutting down literally we can have skin conditions like the hives ticaria and then cardiovascular could be lower blood pressure they're going in the shock as their blood pressure is bottoming out so what does epinephrine do we know epinephrine is adrenaline essentially what does that what does Dr do your heart increases your heart rate increases your force of contractions and also the added benefit we call this a beta effect is Bronco dilation so we're knocking out a lot of stuff at once with the epinephrine and again this is your anaphylactic patients you may see patients that have allergic reactions they may not progress to a true anaphylactic reaction they may just present with hives maybe some of those leaking capillaries that you talked about abouts um and in those cases we may just give them breed and treatments and if the Medics are there um they might just give them some vadr and usually they're okay so we're watching for that one who says first of all hey I've had allergic reaction in the past and if they tell me they had a breathing tube put in them I'm all ears I'm listening to this patient because I'm thinking this is could this is what could potentially happen this patient if I don't give them the epinephrine um see I look for the blood pressure look for the Bible science the hypoxia the wheezing ticaria and intramuscular 3 milligrams is your dosage for an epip pin go ahead you should still give a um a person like if they're having an allergic reaction like with hives or something you should still give them an epip pin yes yes we're gonna give them an epip pin If U if they're showing signs of anaphylaxis so um so like more specific like hives on like the face or like around the the neck not well not just I'm not focused on the hives alone but what I'm worried about here is the ones that have the low blood pressure those that show signs or signs of shock think about the in addition to the hive think about the pale cool clamy skin which we know indicates poor skin conditions a low blood pressure so and if I got wheezing and erary on top of that then it's a slam dunk case hey this is this is headed towards Anais or even if you suspect they're going to head that way you guys can still go ahead and give them this this epine just memorized those uh we'll talk about it when you guys get here but we're going to introduce this into uh typically the thigh muscle we'll show you how to do that um the slide already shows it but I had an epip pin here this is a trainer version so basically you're going to hold it this way we don't put our thumb over this I've actually seen some healthcare providers actually stick their cell with the needle so we have to be careful so like this into the thigh and it's got a little spring action that injects the medication you're going to hold it there for a few seconds until it finishes injecting the meds remove this and like any Sharps it needs to go into appropriate Sharps container and then we can massage that into the muscle and then reassess any critical patients you guys have especially this antic one you need to reassess every five minutes keep an eye on those lung sounds too because we know that can be part of your anaphylactic reaction as well as a low blood pressure and then as you can imagine side effects again Restless headache trimers U even dis rmia which is a a term for irregular heartbeat in some cases so though these patients on the heart monitor because you could get some irritability in the conduction system of the hearts you guys good on the epip pin that any questions about that one just remember it's got the alpha effects which is increased heart rate increased blood pressure and the beta effects and the way we teach this to help us memorize is beta 2 we have two bmbs that's how we put the two together beta 2 is going to be Bronco dilation so we a lot of benefits from NE Naran we talked about this um adult dosage again this is for opioid overdoses look for that pinpoint pupil in your scenarios and that's usually going to be your best indication for your patient is comos or maybe drug paraphernalia um slow agonal breathing hypoxia um you may have to assist their ventilations you may have to start bagging these p Pati until we can get this Naran on board so we'll demonstrating you guys get here how to use Airway ad juns placement of the airway junk how to measure which one to use um because typically these patients going to have some type of Airway obstruction and the number one cause is usually your tongue you may get the patient with snoring respiration that's because their tongue is is blocking their Airway so we have to fix that going back to ABCs you know Elevate head tilt chin lift if there's no trauma involved if we need to put an airway adjunct or let say an Opa or Fingal Airway if they'll take it we'll use that and back the patient if they have a gag reflex intact meaning they won't accept an airway we may have to use a nasal trumpet um and then we'll back these patients until we get the Narcan on board and then hopefully when the Narcan kicks in which usually happens within a few minutes we get the respiratory drive back 04 to 2 milligrams we talked about inasal you see the atomizer on that little syringe there that's what I was trying to show you it creates a little M like a nasal spray if you will we typically divide the dose up and put one cc in one nostril one cc in the other and inasal works pretty well I mean I was kind of surprised the first time I did this internally because I've been used to doing IVs for a long time um but this I mean it's just as effective as an IV all right I guess you guys get a 20 minute break for snack time so um let's let's take a little break here come back in about 15 minutes you guys need to go uh use your restroom or whatever you need to do and maybe I can start setting up for the next session okay so I got 11:20 um let's make it 15 minutes and if you guys have any questions I'm just going to stick around and I can answer those in chat or we can talk here okay f yes you mentioned very early on in the lecture about oral boards are our oral boards our final inperson skills day I know there's been a few things that have meant the same thing and they've just been worded different so it confused me just a little bit Yeah so basically or board is is before you actually do any skills testing usually that's your last step before you're clear to do clinical rotations or your clinical internships so uh it's it's a test it's going to be virtual with one of the instructors where they give you a medical scenario usually on a slideshow with your patient presentation and you just kind of run through your assessment and verbalize your treatments and then and you come for your skills date testing which is typically U after you done your skills of practice days you'll actually do some scenarios with a partner on site and one of our locations okay so we're supposed to do our old oral boards before our skills Chase no oral boards before clinicals so that's after um so I think the process would be you're in your I think you do your finals get your instructions uh for or boards and then when you pass your or boards and then the last step for you guys are going to be your clinical internship so skills days will come before or Bo for you okay so the skills days if you're confused about that obviously you're doing the virtual preps first both medical and Trauma very important to get the virtual preps done first and then you guys will do the actual medical Skills Practice day that's a full day for medical and you'll do another one which is a full day for trauma and then lastly you'll do a skills testing day or we test the students uh in scenarios okay I have the personally next week and weekend I have all three one the other so then after I do the skills testing day uh that Day falls on a Sunday would I just contact my instructor next week to do my oral boards or I don't think you have to con that let me think about that because I've finished all my chapters and pretty much marked everything off and I don't remember seeing a section to like do that so I'm just confused on how I need to do it I understand so you finished all 41 chapters you done with your final um I believe so are those the medical and Trauma exams um the final actually be at the end that'll be um like it sounds the final exam for everything and I think that's when you start getting instructions um okay for the next phase I think that's when it'll come into play for you after you're final I would ask Amanda she say she's on the phone right now with the states um I'm actually gonna log on to my account real quick and see if I can find a a little chapter for that see if maybe I just skimmed over it okay yeah check your EMT checklist and it pretty much lays out the progression of the course for you too you can probably find the answer in there for [Music] okay I see it it for me it is called a final clearance exam there you go final clearance exam it's going to ask you a series of questions it's kind of an honorary system where you say okay I've got this done I got my invations turned in I've got it's basically a checklist of questions to see if you're ready for the next phase um and after you take your final you'll get instructions for a drug screen you guys will get uh once you get your drug screen results back then we give you in instructions for the or board so all that information will come to you eventually okay awesome would it be smart to maybe try and knock out the final exam next week before the skills testing or wait until after that's entirely up to you honestly I don't I don't think it makes a difference um I mean that's to me it's two different things U one is just the didactic stuff so you can work I've had some students knock out all 41 chapters and be ready for all this so what you whatever you're comfortable with this I think is the answer um and after the final all you have left is clinicals yeah you guys do your clinical rise 48 Hours um that's new requirement for EMTs in state of Georgia a lot of things have changed since 2023 so um your skills days you're you're going do a lot of skills a lot of Hands-On practice um that includes your skills testing day and then the last step of the program for you is your clinical rides hey Jason you know in the requirement it says you have to have 20 patient contacts and it's very specific as to Pediatric and geriatric and and when you do your rides and you don't get those specific um patient contacts do you just keep doing it until you just keep writing until you meet those requirements yes hopefully that's the exception but we've had a couple of cases because it's hard to meet the two pediatric minimum usually if we do have a student with an issue so yes the answer to the question would be we could uh schedule more rides and if needed we can do a clinical extension which will give you an extra 30 days to wrap that up with no fee okay so we we have a plan a backup plan if you will but yeah what Robert's referring to is you need five geriatric you need five adults and then minimal two pediatric now the good news is pediatric is all the way up to age 19 which I never think of an 18y Olds at pediatric but for the states that patient will qualify as a PE and it's all about strategy you know the services you ride with you know you probably want to mix it up get your inner facility transport get that volume of 20 patient contacts and maybe a n one service here or there or maybe even non-emergency Transport service that has a contract with Children Healthcare Atlanta I saw a students the other day I think they did Central EMS they must have a contract because they did P transports all day that's the most P I've ever seen when I was doing audits so um strategically pick your med units I guess is the answer and Amanda clarified for those who are asking um also about the or boards it says you'll sign up your old boards after your drug screen comes back so final instructions for a drug screen takes about three three to five business days for us to get your results for the drug screen and then we'll send you instructions uh for signing up for the or board and then once you're successful with the or boards then we let you loose for clinicals how long does it take to get a um instructor to your oral board typically how long does it take to get to oral boards registered yes like with an instructor um that's a good question I don't know you have to look at the calendar and see what the availability looks like um yeah when you get to that point I think you're just you're going to sign up on your student website portal for the or boards and you have to take what availability shows so I I don't know what that schedule looks like without looking at it man is trying to help me through the videos here let's see as far as videos are you using the PowerPoint version well e for for for e e this e e all right guys I think I might have figured out the videos so I'm going to backtrack here we'll go to those Lum sounds and I'll pick back up with the other video so let's see let's see how this goes [Music] could you guys hear that all right thank thank [Music] you sorry about the ads e what about that one did the audio come through for that one no any audio in this video we're going to talk about crackles and whether it's fine crackles or coarse crackles I want you to think fluid in the Airways when you hear crackles and your lung sounds the cause of crackles can be from basically any sort of fluid or mucus that built up in the Airways and you hear that crackly sound as the air passes through that fluid or mucus filled area in the lungs you can hear these in all different spots usually in the bases could you guys hear that all right so that was the crackles fine crackles rails again indications of flu and lungs let me play the wheezing one for I think that one's important I'm have to click a lot of buttons to make this work so bear with me if you see your state you can register online to vote right now it only takes 2 minutes in this video we're going to review the expiratory wheezing lung sound typically expiratory wheezing indicates some form of COPD asthma allergic reactions anaphylaxis uh some form of a respiratory disease that is anywhere from mild to severe you're going to hear wheezing when you exhale and even when you inhale depending on the person's condition but typically speaking if it's on both exhalation and inhalation you have a more severe breathing problem that you're dealing with exory wheezing alone in and of itself can often indicate just a mild Airway problem and uh something that's usually uh either self- resolves or uh prescribed medications will handle [Music] the [Music] refer to in children because it's more commonly seen in them they can produce it with uh conditions like Airway obstructions or CW epiglottitis and the key thing to remember with aerous lung sound is that it's going to require medical intervention often times on the quicker end of things [Laughter] all right that were the lung sounds I wanted you to hear so weing that last point was probably important too so I added the Strider in there so like they said in the video um upper respiratory issue usually associated with Pediatrics think of C you know is one of the emergencies we get a lot of times respiratory problems in fall with these kids so if you imagine a kid their their Airway is already narrow the windpipe for example um so any type of inflammation or swelling is really going to drastically affect the kids so the high-pitch whistling you're thinking upper Airway and then for an EMT basic you know obviously oxygen you can get the patient tolerate oxygen you may have to do a blowby technique where we hold the non breather mask in front of the patient or have the parent you doing so and maybe even humidified oxygen to help reduce some of the swelling But ultimately the paramedics around to give this patients was called reaby which is another form of medication given via nebulizer all right so Chris you have a question yeah I was just curious um you know when it comes to oscilating you know lung sounds and and the heart and all that and and our equipment like our stethoscope I've seen these digital stethos go become a lot more popular especially in the ER where I've been working and and shadowing some of the doctors um how do you what do you think of of is it necessary the extra expense all of that you know I've heard some people say as an EMT because you work in kind of chaotic environments that it can really help and isolate sounds and stuff but do you think it's really necessary to spend any kind of extra money on that kind of gear yeah I personally I've never used once I can't really speak on the behalf um the exception is I've had a couple of students that had some type of hearing impairments and I've seen those students actually purchase those so perhaps I could benefit from one now after you know 28 has been effective so I never actually used one I saw a student or two come through with one and I was kind of fascinated by it so um how much money are we talking about for these things I I mean anywhere between like 250 and $400 $500 just depending on which brand you go with and which you know some have like a digital readout where it will show you um you know vital vitals right there on the stethoscope itself so it just it kind of depends um but yeah like in the ER especially I've seen I've seen the doctors and some of the nurses using it a lot my personal opinion is as an EMT or even a paramedic in a prehospital setting I I think just a regular stethoscope and blood pressure are are adequate for what we do those doctors you know that specialize maybe respiratory therapists and whoever they uh they're U I can see them having a need more so than us so we're down to the basics basically in other words we may talk about or we might teach you about oscilating heart tones for example and that that case I'd have to have some special equipment to even recognize a normal heart Zone in a chaos prehospital environment all we're trying to catch up on here is the obvious ones you know the wheezing The Strider which you can hear from across the room usually and the pulman and edema and I think that would be enough so I would encourage everybody to go buy one unless you have some type of hearing issue all right so let me pick up where we left off I think there was another video I'm G try to get back to I'm curious to see what that cadar video has to say let's spe this back up let's see if I can make this work want something you pursue it and with via the pursuit for your pigment is just the same it's time you found a hi I'm Mark from ACLS certification Institute and in today's video presentation we're going to talk about entitle capnography and how we use it in ACLS and especially during a cardiac arrest now what is entitled capnography well it's a quantitative measurement of a patient's exhaled CO2 which is the byproduct of cellular metabolism I kind of think of it like the exhaust in a car right fill the car up with gas the motor uses the gas and then kicks out exhaust if you get a notice from your emission center like I just got I'm going to take my van in and have the Miss Center check my exhaust and by evaluating the exhaust they can see if there's a problem with the motor this is exactly what we're using entitle CO2 for in ACS remember the cells are going to use this oxygen create this CO2 but I still have to have adequate cardiac output a working pump to pump that CO2 all the way back to the lungs so it can be exhaled and measured now usually in the field I'm using end tile to tweak my ventilator I'm using it for respiratory and Pulmonary status remember a normal end title is between 35 and 45 and I could look at those numbers and adjust my ventilator accordingly to keep them within a normal range however in ACLS and in a cardiac arrest I'm using entitle not necessarily for the pulmonary or respiratory status but to look at the function of the pump the function of the heart it can also help determine the effectiveness of the chest compressions I'm doing if the heart fails now before we get into these numbers let's take a quick look at a capnography waveform and Define the parts in the waveform now remember we're talking about the patient's exhaled CO2 so this upward inflection we're seeing here first is the patient exhaling they're blowing off CO2 so the patient starts to Exhale they're starting to blow off CO2 and we can see this waveform start to rise then it plateaus it levels off and where ends and drops is the beginning of the patient's next inspiratory effort so where are we actually getting this end tile number from well it's the end title remember that one breath of air the amount of air that a patient takes in during one breath is called a title volume whether they take the breath in or we're giving them the breath that's the tital volume the amount of air that's going in during one breath now the patient's going to Exhale all this tidle volume and we can see that they're exhaling the title volume exhaling the title viome it ends they begin to take a breath so this is their n tial exhalation and that's where we're getting that number from that's the amount of exhaled CO2 during that one exhaled breath or exhaled end of tyline now moving horizontally from left to right when we're looking at this waveform that's a measurement of Time how fast is the patient breathing now to demonstrate this let's say the patient's respiratory rate goes from 20 to 50 now you can see how the waveform has become shorter because the patient is taking less time to Exhale so again moving from left to right horizontally that's a measurement of time we're looking at the patient's respiratory rate and all this upward deflection is exhalation by the [Music] patient now during a cardiac arrest it's our goal to achieve an entitle reading of Le least 10 or above 10 mm of mercury if during chest compressions you notice that your ential reading is at 10 or below we need to improve the chest compressions we're doing another great benefit to continuous ential monitoring during a cardiac arrest is to assess for the return of spontaneous circulation so you work in your full arrest you're working your full arrest suddenly your end tile spikes to over 40 boom baby we have lift off yep assess your patient we may have just had a return to spontaneous circulation remember this CO2 has been building up in the body but we've had poor profusion because we're only providing chest compressions suddenly the heart begins to beat on its own it rapidly pumps all the CO2 back to the lungs and we can read that on our end tile and that's what caused the rapid increase in our end tile reading now if your patient has had a return of spontaneous circulation we're going to adjust our ventilations to achieve an end tile between 35 and 40 that's our target range we're trying to hit another great benefit to continuous end tile monitoring during an arrest and especially in the intubated patient is Breath by breath monitoring of that et2 placement if we're bagging the patient and subtly our end tile goes from 30 to zero reassess the tube we may have just popped out our endot tral tube remember that pulse a symmetry can take 30 seconds up to a minute to adjust their saturation may still be fine but your entitle waveform is going to drop right off a cliff as soon as that endot tral tube pops out so quick review why do we like antile in the fullest one assessing the quality of our chest compressions two to determine a return of spontaneous circulation in the patient and three Breath by breath assessment and confirmation of the placement of that endal traill too [Music] so let's take a look at how are we going to set up our inline entitle capnography now usually it's done with an adapter one side's going to fit on the endot tral tube just like this the other side will fit onto the ambo bag then there's an adapter that's going to slide onto this and go back to your monitor so it can pick up and give you your reading now let's have some fun with capnography for a moment I've got this hooked up to an endot tral tube and I'm I'm going to breathe through this tube and I'm going to create a waveform on the monitor I want you to look at the waveform while I'm breathing through this tube now first I'm just going to breathe regular as regular as I can then I'm going to start breathing fast then I'm going to hold my breath now when I hold my breath look at what happens to the capnography waveform but then look what happens to my pulse oxymetry reading okay here we go [Music] [Music] [Music] [Music] [Music] so you don't have quantitative entitle capnography well we can still use one of these guys a colorometric detector which is just a fancy paper that changes color when it detects exhaled CO2 remember out of the package they're purple and when it detects CO2 it'll change color to gold or yellow so remember gold is golden now remember the colorometric detector is not 100% to verify endot tral tube placement it is 100% for detecting exhaled CO2 so I'm working a coat up on the floor respond to a full arrest and I intubate the patient I place a colorometric detector in between the ET tube and the amboo bag and it stays purple and someone says hey your tube's not good I know my tube was good one I saw the tube pass through the vocal cords I had absent epigastric sounds good bilateral chest rise good equal lung sounds so my et2 placement was fine a couple minutes into the code while performing quality chest compressions administering epinephrine and running the code suddenly it changed color from purple to Gold what just happened the patient had a spontaneous return of circulation so remember this is not 100% for2 placement just for the presence of exhaled CO2 so let's see if we can get this to detect my exhaled CO2 and change color so we remove it from the package don't eat that and you can see it's purple so I'm going to Exhale through it and you can see the paper is now changing gold changing gold in color it's detecting the exhale CO2 and changing color remember gold is golden now if you're a nurse in the ER working in the ER and you know you have a cardiac arrest coming in get your entitle capnography handy and get that on the patient as soon as they hit the door again why do we use Untitled capnography in ACLS one to assess the overall profusion status of the patient two to assess how well are we doing our chest compressions three an ongoing Breath by breath assessment of a confirmed Advanced Airway hope you enjoyed today's lecture on entitle cavography I'm Mark for ACLS certification institute.com remember to all right so keing takeway there obviously he got into the advanced Airway stuff um but do pick up on that and that sudden spike in entitled CO2 during a card arrest could be an indication of H Rost for return of spontaneous circulation so that's something you guys um can do something about so all right let me find my PowerPoint we'll pick back up what we left off any questions about cavography before we move on I think he did a wonderful job explaining that I was interesting how he maintained his Co socks all the way up until he passed out going back to what I said P Sox is just one tool don't rely on those numbers solely um it's U it's just one to tool belt so all right one second to get your PowerPoint back up let's see where we're at BL Cod ask for charcoal all right cardiac or risk management you guys will have a little little station we set up for this one where you actually run through um level Consciousness calling for an AED for example assessing for a pulse and unconscious patient we're going to teach this back typically when we say ABCs for those in Cardiac Arrest it's going to be cab with emphasis on compression so we'll check for AC cred pulse we'll look listen and feel for any breathing simultaneously and we'll start our chest compression soon the patient is pulseless and adnic and then once the second rescue arrives with an ad then whoever is taking a lead in the scenario basically operates the AED and then hands off chest compressions um to the second rescuer so again compressions chest compressions if you don't do anything probably the best best thing you can do for your your patient are chest compressions now we have mechanical CPR devices now in the fuels and they those machines are absolutely wonderful um not not to mention they do very effective chest compressions we don't have to worry about swapping every two minutes for fatigue but it also frees up your hands now you got you know with limited Personnel I can get other things taken care of whether that's IV access drugs or some other things so so let's see compressions first What is the compression breath to uh chest compression to uh respiration ratio so for BLS we always teach 30 to2 for kids that could change depend on whether you have one rescuer or two Rescuers so with kids we'll start out with 30 to two 30 compressions two ventilations and then when help arise or if you have two people forming CPR we'll change that ratio to 50 compressions to two ventilations adults 30 to2 throughout throughout and the only exception of what adult is going to be once you do have an advanced Airway place then just continuous chest compressions or asy synness there's no more 30 to2 ratio it's just let the mechanical CPR or manual CPR go after Advanced Airway placements here's the machines I was talking about the one I'm familiar with is the Lucas one in the middle you see it's got a little plunger there who's a candidate for it obviously in in Cardiac Arrest but if they can fit inside this device and also if the plunger can reach their chest if you're thinking about smaller patients then they are a candidate for mechanical CPR anybody else we're back to Old School chest compressions mainly swap every two minutes or every five seconds these these come with old plates um normally we use a long spine board as of a hard surface to do chest compressions and even lay person CPR or a citizen may be told to bring a patient to the floor to create that surface the mechanical CPR devices have their own little plate there so you may not have to put one back forward unless you just need a way to facilitate moving them to the stret Pediatrics are people to so some of the things to take in consideration with PE first of all are Vital sign as you know kids have a faster heart rate they breathe faster everything is different and you can see a breakdown here with the B Signs what expectrum ranges are I mentioned handy earlier as a resource that's kind of a way to get the estimated weight for our patients that are pediatric because remember when I said a lot of the medications we give the Peds are based on their weight in kilograms um Hy has an app where you just plug in the patients approximate age going to spit out normal vital signs for you and also the drugs we mentioned braso tape we get into ACLS and Pals if that point in your career that's another resource that basically measures the the size or the length of the patient thinking about infant and then wherever it lands in the color code system they'll give you your dosages equipment sizes and your arranges for bides Pediatric assessment triangle you guys have probably read about this uh at this point as you know could be challenging to get a good good assessment on a kid imagine a 12-month-old with a respiratory problem who's screaming who's extremely irritable they are not going to let you come up there and put their hands all over them if you're lucky what the parents help may be distracted and you may be able to get some lung sounds or maybe a pull socks but the Pediatric assessment triangle typically is when be done from across the room that General appearance for example they're the work of breathing are they struggling to breathe circul what their skin conditions look like from across the room are they nice pink and dry or they are they modeled indicating some type of blood pressure or circulation issue and then appearance are they responding appropriately are they drowsy head bobbing all those things are kind of built into the phri assessment triangle and then we use tick or tick LS basically for appearance tone good muscle tone are they interacting with you appropriately they should be scar they should be crying consolability um look or gaze and then speech whether it's a strong cry or for able to talk work of breathing you're looking for nasal flaring substernal retractions inter Rec costal retractions those are all indications of respirator stress posturing and again lung cells and then finally circulation skin color Now we move on to deliveries OB call um complications most of your labor and delivery calls if you do deliver in the field most of them are going to be normal we do have some exceptions so I've seen some prolapse cords I've actually seen a breach U where we had to actually just basically just go faster to the hospital isn't much we can do in the field but the good news is um normally it's just facilitating the delivery the key here is you got to figure out you have time to get to the hospital so if you have something that's imminent meaning if the patient uh the baby's crowning or the head is protruding then we know we're going have to stay on scene get our kit together and then when you guys come up here for your medical skills today we'll have a little scenario we practice with our mannequin going through the steps of delivery so that's facilitating the delivery preventing explosive deliveries that's going to be suction in the airway correct manner drying stimulating the baby taking abgar scores after one minute and after five minute cutting the cord for example and we'll run you through those steps prolapse cord I mentioned U this is a potential emergency here you could have a nucle cord for example where the emical cord is wrapped around the baby's neck if you're able to do so just simply remove it if you have a prolapse cord and the baby has not delivered yet this might be a case where we have to separate the vaginal wall left hand two fingers to keep the pressure off the forward so we do not impede circulation and then transport the patient in the knee chest position also to help take some pressure off the cord and get them to the ER quickly for emergency c section and we'll talk about some of those emergencies um if it's not imminent in other words like most of our obgy and calls we probably have some time you think about a first pregnancy it probably takes a long time for that delivery to occur so what we're going to do to me time is obviously take care of the mother we're going to get Baseline bottle signs we're going to do supportive care for the parents and then we're going also going to measure contractions we want to know how long these contractions are lasting the duration of the contractions the intensity to contractions and uh get a history find out sample history is key here we want to know if there's any complications with this patient have they had any pre-existing conditions like gestational diabetes preclampsia which is hypertens associated with third trimester pregnancies um have they had any um prenatal care for example and are they high risk so that's probably the bulk of the work we're going to do with our patients there and again supportive care to the hospital all right so some problems you could encounter during an OBGYN call one of them is G going be called placenta preia the placenta presents typically this presents with bright red blood not necessarily a lot of pain and then the other one is going to be abruptio placenta where the placenta separates from the uterine wall this one you can expect a lot of pain abdominal pain that is and then also dark you know bleeding so we're talking about vaginal bleeding here um we may not know what we're dealing with here but these are a couple ones that you may see particular with third trimester pregnancies and abdominal pain so always ask about any vaginal bleed abgar so I said after a delivery we're going to take an abgar score at one minute and five minutes so here's what the abar abar score represents so a for appearance skin color it's not unusual for a patient to have some peripheral cyanosis or discoloration of bluing but after five minutes usually that clears up and healthy baby pulse want that to be in the range of 60 to 100 or excuse me better than 100 for the best outcome so if you're wondering the score is going to be 0 one two two are the best categories for a total of 10 there so pulse rate if that pulse rate is less than 60 and this patient is exhibiting sinosis or signs of poror profusion keep in mind we're have to do chest compressions on this patient even if they do have a pulse and that's specific the Pediatrics next category is Grimace you know are they uh are they responding to cry or excuse me stimulation or they crying grimacing in their face activity to me that's like muscle tone movements and then finally respiratory efforts you know are they breathing um are they only gasping or do they have a strong cry so if these patients are not breathing effectively this is another case where we may have to assist ventilations with the BBM and supplemental oxygen all right I don't think that's a video but it's a demonstration of the mannequin like I said we'll get to practice this on skills day patient assessment so when you guys come for your skills days we typically start you off with individual skills we practice the O2 assembly for example we'll practice uh run through the medications how to administer those medic ations uh we'll run through a a station where you get to do oral Airway adjunct nasal fral Airways assisting ventilations with oxygen and then after lunch we incorporate all these skills into scenarios so this is an important part right here how do we do a patient assessment we already said in the very beginning we always do BSI is my scen safe you're going to start doing this for the rest of the time now um next question is going to be how many patients do I have always thinking about additional resources because if I have a multi casualy incident obviously I'm going to need more units and routes and being a basic truck you guys just just be in the habit of call for ALS backup anyway um nature vness noi or mechanism injury that's going be that depends on whether you have a medical scenario or trauma scenario I mentioned additional resources already consider seaspine if there's a traumatic event or we suspect there's some trauma or maybe a medical call that led to trauma you need to Le at least verbalize while you're being tested hey I'm taking c-spine in consideration whether you take it or not is up to you general impression that's basically how the patient presents to you um mental status check your patient's level of Consciousness just like we do in CPR if they're alert and seem confused ask him some baseline questions do you know who you are do you know what year it is you know um where you're at um person place and time that would be a0 time three and then the fourth one if you hear a times 4 just means they recall the events keep in mind you could have a patient that's alert or times three that may not recall having a diabetic episode or maybe had a seizure prior to arrival and those patients still legally are able to make decisions for theirself the C is for chief complaints always ask your patient patients explain to me you know what's going on today don't put any words in her mouth keep these open in the questions think about the chest pain patient just ask them how would you describe the pain don't say is it sharp or is it dull because I don't want to lead them in any direction and then finally and probably the most important aspect of this are your ABCs here's where we're going to fix any problems with the airway any problems with the breathing we're going to fix that right there on the spot before we move on so for example snoring respirations com toes think about the opioid overd nose I might put an airway ad jump in there temporarily then I'll move on to breathing if I need oxygen I'll give them nonre breather or if they need to be assisted of ventilations I'm going to do that right there before I move on and then finally circulation um if there's any uncontrolled bleeding this is where that needs to be taken care of before you move on to any other part of your assessment guys the primary assessment is where it's at if you have any problems with Airway breathing ulation you need to mitigate that first and then of course take care of any life-threatening events whether that's uncontrolled bleeding or some scenarios might give you a trauma case could be maybe a gunshot wound to the chest or stabbing where they need what's called an inclusive dressing um there's a lot of different things you could uh you can encounter that are life-threatening and finally you need to make a transport decision so depending on how your patient presents if they're critical obviously we need to get them off the scene especially those scenarios even those chest pains are very time sensitive Strokes another good example are very time sensitive and then um once you call for your transport decision then you finish up your sample ask your opqs questions get your Baseline bottle signs if you haven't already done so don't forget about blood glucose please thr that pulse off on them don't forget about the heart monitor you guys can hook them up to the monitor now so let's see what's going on there and then at the very end of the scenario I you guys will give a report to the receiving faciliity we'll practice patient care reports as well you guys still good with me any questions thank you um this goes back to app and Glasco Coma Scale probably want to know this Glasco Coma Scale GCS or Glasco Coma Scale is typically used in trauma scenarios um you're looking at your eye response whether it's spontaneous response to verbal commands response to pain we give them a score based on that and that one is a total of or best C best score was four next is verbal response whether they're oriented confused inappropriate or in incomprehensible sounds or no response and the last category is going to be motor response base commands localizes to pain uh draws from Pain you got flexion of pain or extension of pain which is kind of like posturing of the body with the extremities um and you put that score together the best case scenario would be a score of 15 and interestingly enough a person with no pulse and not breathing is still going to have a minimal of a three if you look at that scoring criteria here's the 04 I talked about about person place and time and then event would be the fourth leg of that and your um trauma scenarios be conscious of some potential medical event that may have leted up the trauma I've been on calls where patients had a diabetic episode maybe they had a seizure and in some cases even a cardiac arrest that led to a really nasty NVC or a motor vehicle crash so you have to investigate some cases when things aren't add enough check that blood sugar get those Baseline bottle signs stroke assessment if your patient presents with signs of a stroke and here we're using the fast acronym facial Dro arm drift any type of speech issue and then the last one is going to be time um time is important to the hospital because they depending on when they were seen normal last there's a window of treatment there they have to be within I think four hours three hours I can't remember exactly the protocol at the hospital but um that's one of the first questions they're going to ask you when you deler a stroke patient and when was they seen normal or when were they seen normal last that dictates what treatments they may or may not get so always always always anybody is altered especially if they present with a facial droop slurge speech anything you're suspecting a stroke first of all make sure you get a blood sugar let's don't be silly and misdiagnosed this as a stroke when it was simply a diabetic episode that we can easily fix but if we rolled out a low blood sugar and we're suspecting stroke very important you need to do some form of stroke assessments whether it's the fast one or if you're familiar with it Cincinnati prehospital Stroke Scale which are very very similar in nature it's just the Cincinnati prehospital Hospital we're going to have them smiling smile real big ask them to hold their arms out in front of them close their eyes we're looking for arm drift there and then we'll ask the patient to repeat this phrase you can't teach an old do new tricks and then we're looking for speech problems there what can you do about a stroke absolutely nothing um basically supportive care consider of oxygen and get them to the appropriate facility in a timely fashion so going back to that patient assessment slide where we talked about calling for immediate trans sport definitely get this patient off the scene as quickly as possible because time is probably the most important aspect of a stroke and then recognizing stroke same goes for your chest pains so sample history I mentioned already you're getting your signs and symptoms we're always asking a patient about allergies and don't forget about those five patient rights or six patient rights we talked about for any medication administration ask your patient what they're currently taking don't forget the prompt about Ed meds if you're treating the cardiac events any past history last oral intake and also events leading up to the presence so next op CST this is perfect questions in your medical scenarios particularly for your chest pains difficulty breathings Donal pains things of that nature we want to know the onset of the event to me that means was it a rapid onset or this something that's kind of been developing over time provocation um does anything make it better or worse for example the chest pain patient if they say when I walk or exert myself my chest pain gets more excruciating that might be a clue or the CHF patient with flu in their lungs if they say I have to prop myself up with multiple pillows even sleep at night or if they say when I lie down my I have increased respiratory distress that kind of Falls in a provocation quality or or the provocation category and then quality remember what I said ask them to describe their pain if they have any pain make them describe it in their own words ask about any radiation of that pain in other words ises that pain move anywhere does it move to the jaw does it move to the shoulder if it's abdominal pain does it radiate to the back there there all hints that we can use and in severity ask your patient on a scale of 1 to 10 10 being the worst pain you ever experienced how would you rate this pain pain now we can engage our patient students especially those chest pains remember we're going to give those ones nitroglycerin after I give them nitroglycerin I take their Vital sign again I want to ask them are you getting any relief from the nitroglycerin that might be an indication that they're having a true cardiac event if they get some relief and then lastly we got time to me time is the duration of the vent overall so sample op CST you guys need to know these and you're going to use these when we practice patient care scenarios for both medical and Trauma and in the bottom there you can see some tips here aeiou tips is an acronym for different causes of alter mental status the A's run through alcohol intoxication acidoses ammonia um to me that makes me think of a renal failure patient with high levels ammonia AR rymus meaning irregular heartbeat maybe it's a cardiac events or some type of fast heart rate for example that's called an ultral status we got e for electrolytes um endocrine for like the diabetic episode and of course epilepsy for seizures ey for infection think about sepsis a person who has septic shock is going to be altered and also have signs of low blood pressure or shock and a leaking capillaries we talked about overdose um that's an obvious one opioid overdose for example um oxygen or lack of oxygen uremia blood in the urine tee or temperature whether they have a a fever trauma or some type of thy and deficiency if you're not sure what I'm talking about patients that particularly diabetics that are Mal nourished or if they're alcoholics cannot metabolize blood glucose without thyon in fact our old protocols used to be anytime we gave dextrose we give them thyon prior to that it's basically a vitamin I can't remember if it's B1 or B12 I get those mixed up in my head um insulin again your diabetics be conscious if they're wearing an insulin pump if they're having a low blood sugar episode or hyposmia because may have to dis may have to stop the pump there psychiatric and then poisoning they what I said call Poison Control if you need guidance on these poisoning patients and then finally set s is for strokes seizures Syncopy space occup occupying lesions this would be like a brain lesion shunts malfunction that patient has uh like a ventral shunt into the brain um where they're getting increased inoc cranial pressure and then sah I think is subaco hemorrage would would to me is just a some type of brain bleed so aoi tips things to consider for anybody that's altered here's another one um I wasn't familiar with this one till I read this slideshow the first time move stupid from a metabolic oxygen vascular going add to those bleeds we talked about including hemorrhagic strokes syrin and the diabetic episode seizures trauma emia psych psychiatric infectious Pepsis and then drugs and alcohol medical patient assessments uh we're looking at some of the potential abdominal pain emergencies that you're likely going to encounter owner when you guys do a Hands-On assessment on these medical patients and for those that are presenting with abdominal pain we're going to teach you to palpate all four quadrants you're put your hands over the stomach you're going to push in if the patient tells you they have pain in a certain quadrant we usually work away from the pain first so palpate the other quadrants first and work our way towards the pain um some things we're looking for there are first of all the aconine turd for tenderness evisceration which would be like some type of traumatic event where the abdominal organs are exposed rigidity if you push down the stomach and you feel it feels rigid or hard then it might be an indication of some type of internal bleeding and of course you could have some distension where the belly just kind of blows up there so other things you could find here and this would be a really bad case pulsating masses if you feel a pulsating Mass when you're assessing someone's abdominal pain we're thinking about an aortic aneurysm here or a AAA for abdominal aortic aneurysm so what you got in there is essentially a large blister on a major artery it's likely leaking producing pain if that were to rupture that patient is likely going to bleed out within a matter of a few minutes so this is a true emergency we always want to transport these patients carefully um they talk about Murphy's Sign uh a sign of I think gallbladder attacks um I remember correctly this was the one where we have the patients hold their breath and they have it produces pain I can't remember how that one went to be honest with you MC Bernie's points this is the the point from top of the pelvic area if you can imagine your pelvic bone we call it the U um I say between the pelvis and the umbilical cord or excuse me your belly button umbilical cord about third of that distance is considered MC Bernie's point if you were a palpate there a patient with pentis would likely present with some pain with palpation and then also some tenderness there so and something else you may read about is rebound tenderness with these two meaning when you release the pressure from palpation that actually produces the pain versus pushing down or putting pressure with palpation and of course any abdominal pain we're always concious of anyone that could be potentially pregnant um the best way to address this in your patient assessment is just simply ask your patient you know is there any chance that you can be pregnant when was your last menstrual cycle and if they are pregnant we want to know how far along they are so here's a good rese source for you guys to use this was the the old psycho motor exam reports for the sheet we would use for uh skills testing I still like this sheet I still kind of use it for my my background when I teach patient assessments if you look at that you'll see exactly what we talked about BSI seems safe um next one's going to be u mean injury I having a hard time reading these but nature illness mechanism injury we're considering the number of patients we're calling for additional resources we're considering Seas fine then we jump into our primary assessment um well first of all level Consciousness cheap PLS um and then ABCs again Airway problems fix them breathing problems fix them circulation problems fix them before you move on to anything else then we get our history we get our Baseline bottle signs and we do our secondary exam which is the Hands-On assessment and please don't forget to otate Long sounds especially in these respiratory problems um listen to Long sounds you get at least U if not expose the chest palpate the chest with your chest chest pains you thinking about pedal edema you're assessing these patients where they have fluid uh any lower extremities um get all your Vital Signs including the blood glucose reassess every five minutes for patients that are critical and then every 15 for those who are more stable and don't forget to call for transport immediately when it's appropriate all right I think we're getting towards the end here we have a little case study where you guys are going to we're going to talk through this scenario together basically so you're dispatched to a local high school for a 42y old female with severe abdominal pain you're 15 minutes from a local hospital and you're one hour from a PCI capable facility and if you're wondering what that means percutaneous intervention or think cath lab for a potential cardiac patient let's see what we get so this is kind of how the or board is going to go for you guys you can get a little slide here that shows you how your patient's presenting um we do our scene size up as always scene safe proper BSI or PPE I'll run through my checklist all right how many patients do I have what's my nature of illness in this case we'll say abdominal pain I'll call for additional resources I need to alss and Route remember I'm in basic truck right now we never know what's going to happen with these abdominal pains and then I'll consider C fine well I would assume here that we don't have any trauma but we'll make sure that's not the case and we'll say we consider she's fine but I have no indications for see spine at this point then we keep moving so what would you do next can you guys tell me after a scene size up if you see if you refer to that sheet we had back there I don't know if you guys have a hard copy of it but what would be next on your list after I seen you size up about the pain pain level yeah we'll definitely get to that cheap complaint ask your patient describe that pain how would you describe your pain don't forget those OB curious questions onset provocation anything make it better or worse because that pain radiates I'm sorry somebody asking a question okay um severity ask him on scale of 1 to 10 how would you rate your pain most of them are going to say 10 so going say 12 and they're going to be out there okay and in time how long has this been been going on so yeah cheap complaint um what after chief complaint what else would you do Chris I see your hand up well we also just want to get like a you know a general assessment um you know what they look like what they sound like um their level of Consciousness and how they're reacting to um um and then you know you can start like you you were saying starting start asking questions and and getting a history okay yeah we should probably back up to the general impression so the slide kind of gives you your impression but if you were being tested you could say okay well how is my patient presented what is my general impression and that's when we would paint a picture basically of how your patient's presenting hopefully you guys will have live patients when I do this skills day I do a lot of the role plays I'll do for those that are conscious and alert I'll run through the chest pain that way you guys can interact with me and ask me all the appropriate questions so we got Scene size up we got uh general impression we got level of Consciousness we got te complaint out of the way what's up next ask the patient if they uh took any medication okay that that'll come up in Sample history yes um what's more important than anything else before we move on ABCs ABCs guys that's that's that's where it's at right there and this is what gets students in trouble and I'll give you a scenario where this was actually my National Registry uh psychomotor exam I had to retest National Registry a couple years ago because i' let mine expire many many years ago and I remember this scenario it was a gunshot wound for example to the truck chest and if the student did not check the back for an Exit Wounds they were going to be unsuccessful because they miss an opportunity to put an inclusive dressing on the back um so this just kind of drives home the point if you have an airway problem fix it if you need to add jumps throw it in there if you have a breathing problem if they need to assist their ventilations with the BVM do it then they just need oxygen on breather throw it on then before you move on and course circulation checking poles rate Rhythm and quality skin conditions and while you're there be thinking about if this is a trauma episode is there any uncontrolled bleeding because we want to fix that before we move on to any other part of your assessment so primary assessment AB C's all right what after now anything after this I don't care what order it comes in but what are some other things now somebody already mentioned op T and Sample what else would you want to ask in patiency I was gonna say get a first set of vitols absolutely let get some based on Vital sign so Alexis if you're in charge of this patient what vital would you want order uh definitely a blood pressure in case it's a dissection okay we'll definitely get a blood pressure what else can we do um get a heart rate on them okay we'll get a pulse rate check their O2 everything definitely a 12 or four four lead 12 lead all you may be proud I was going to trick you guys in that monitor thing so yeah we get to Baseline B sign well pressure pulse rates sure we'll throw PSE socks on her just to see what's going on um respiratory rates um while we're at respirator what do you want to do with your stethoscope I just pretty much gave that away check for L sounds I it may seem silly it's AAL pain why am I messing with lung sound so I'm just telling you guys it's probably a good practice to osculate lung sounds on all of your patients you'll be surprised I've been fooled before uh I think I've missed a spontaneous Numa one time because I assumed it was something unrelated to breathing so kind like the blood glucose thing just do it do it all right so we got Bas on B sign blood pressure pulse rate I heard pulse Ops respiratory rate and I heard monitor good job throw that patient on a heart monitor even abdominal pain calls for a heart monitor um what if this is that AAA patient that I talked about you never know Jay did you have something for us oh yeah I was just going to say we should also probably uh make a transport decision uh figure out if we want to do the secondary assessment in the back of the ambulance Jay is right and that slipped my mind after we do our primary assessment and we checked our ABCs that's probably when we need to make a call for a transport and I will say abdominal pain even though this patient might have normal vital signs I would just go ahead and call for immediate transport because you never know what you're dealing with dominal pains are complicated especially a female this childbearing age um same thing for Respiratory stress chest pains and especially strokes and of course traumas we know we're going to get those off the scene quickly so yeah thank you very good points call for immediate transport all right so someone else run me through Ops what would that sound like for this abdominal pain patients onset you would ask when the pain started like how long she's been having pain okay so onset and time A lot of times get kind of confusing um so yeah onset like I said I always think about onset is it you know was it a sudden onset that just kind of hit you out of nowhere like a kidney stone might present or have you've been dealing with abominal pain for several days and it's kind of increasing getting worse and U so yeah onset is one of them what's next I heard I think yeah um soor I think someone else already speaking out don't do that you would ask if there's any movements or conditions in which the pain would get worse or there any positions that make them more or less comfortable yeah provocation do anything make this better or worse you know there might be clues for us to use down the road so um for abdominal pains um typically palpation is one of our biggest ones there when we palpate to four quadrants of the abdomen we're looking to see if they have any isolated pain think about that pentis patient you know it might be isolated to the right lower quadrant for example so there you go um what's after provocation the quality so you could ask the patiently uh rate your pain on a scale of 1 to 10 one being you're perfectly fine and 10 being the worst pain you've ever felt in your entire life okay that would fall under severity but that is correct um for Quality I'd ask them how how would they describe the pain um and to say keep it open any questions don't don't lead them in any direction don't say hey are you having sharp dominal pain because they're going to say yes so um quality of pain and then I think I heard somebody mention radiation already so we'll throw that out there does that pain move anywhere um think about a kidney stone that usually presents with flank pain in the in the back area um and I've experienced this personally so I'll never forget it that pain moves towards the groin and you can feel the whole process as that stone moves to the urr to the groin um very very painful ever since I had that episode I've been very very very generous with pain meds since uh since that to these patients so so radiation we mentioned severity yes ask on scale 1 10 how do you rate this pain on scale of 1 10 and we document that and that's very important for our chest pains too um and in time I think we already mentioned that how long has this event been going on when did it start in other words all right somebody run me through sample I need to know what each of the um what's the word I'm look for what do sample stand for let's start there signs and symptoms all right allergies allergies medical history um pained last in last out and event P would be uh past medical history yeah so signs and symptoms medications uh I even call it pertinent medical history I don't even know every little detail just the pertinent stuff you know um and then last oral intake like you said why why do we care about their last oral intake um um could possibly maybe if like a diabetic time8 something yeah that's actually a good one too yeah if your patient has a low blood sugar and they're on insulin they probably didn't eat so that's one example what's another one you guys could think of why I know about last intake anation poison I hear some good ones out there I heard I think I heard anaphylaxis too um what that patient was allergic to nuts they didn't realize they got nut bread here we are anaphylaxis and then yeah poisoning ingestion of poisons is one I like both those answers um what's that sorry Contra indications for medications you would consider giving okay um I was going to say like peptic ulcers and things like that usually when they've eaten it kind of Smooths out some of that pain maybe just little H that was kind of farfetch but and then the hospital is going to want to know too if these patients are going to be getting surgery um they want to know naturally if there's anything on their stomach all right those are all good examples last Orient take and invents leading up to um can you think of a reason why the event leading up to is pertinent to um think of examples of a patient found unconscious unresponded we don't know what happens I mean I think definitely events leading up that would help you point maybe to a potential medical condition like if you come across someone who's unconscious and you find out that they've been doing strenuous activities fairly recently that may point to a potential cardiac issue sure or right helps you with the nature of the illness or what might have caused the [Music] problem yeah if it was a trauma you you know if the if the event leading up to it was a trauma you're going to have a different kind of assessment um of of what might have happened what kind of internal injury might there might be versus like an illness yeah and always be conscious guys make sure that there was a medical event that make sure there was not a medical event that preceded the traumatic event like we talked about the seizures diabetics and then the cardiac arrest all right all good answers let me see where this is going 42y old female sitting up right at the desk I'd say she's conscious and alert I imagine she's tracking EMS as they arrive we ask her about her she complain already she says I have severe abdominal pain we'll go through opst and while you're interviewing your patients and here's where your bedside mayor comes in I would come in and say hi I'm Jason I'm with RC Health Services um what's going on today and I'm getting a lot of stuff right there first of all I'm checking their level of Consciousness I can see if this patient is alert oriented if they seem confused I might dig a little deeper and ask them some baseline questions like okay you know where you're at right now do you know what year it is do you know who the present is and we can kind of assess their L that way and while I'm there I'll just say okay if they're speaking to me clearly I know they have a pton Airway so I just checked off two boxes right there next I'm scanning their chest I'm looking to see how they're breathing I'm also taking lung sounds I'm throwing that pole socks on all this is kind of happening simultaneously in the Real Worlds and um and like I said always always otate lung sounds and while I'm all meanwhile I'm grabbing a radial pulse and all this is happening within 30 seconds while I'm talking in the spaceship I just want to know if that pulse is there you know with the quality of it rate res quality and again skin conditions are they hot to the touch for example um and then we've done basically our ABCs in about 30 seconds so we've already made a decision based on that whether we're going to call for immediate transport so what do you think immediate transport for this patient or you want to stay and finish your assessment it's kind of tricky because ABCs are intact there always Payton I'll say she's breathing 16 times per minute non- labored adequat lung sound clear she's got a good strong radio PS at a rate of we'll say 100 do we call for a load and go or do we stay I would say if the if it's abdominal pain and it's severe enough um you want to get her moving to the hospital because you don't know what's going on in there um there could be internal bleeding some kind of an organ issue you know appendicitis you know a rupture so you want to get her moving absolutely so don't be fooled by the ABCs being attack or even normal Baseline Vital Signs so yeah I agree with that we don't know what's going on in that belly um what if it is something that's uh ultimately need surgery so like I said you guys can you can be be very aggressive with calling for immediate transport there's no harm no faou what if you're wrong then nothing happens right what if you're wrong and you stay on scene too long then that's going to be a problem so be aggressive with that call for immediate transport and you can't mess up all right we went through Ops te sample already so I think we can keep moving um you can can I ask a question Jason so you know given the information that you you just gave us um you know I I personally would have asked questions I I wasn't really sure about the severity of the pain and I guess I would have asked more questions like you know did she have internal bleeding like when she went to the bathroom and stuff like that because to me if it was just severe pain you know do in your experience do many people you know call the call a um you know an e EMT or paramedic versus going to a hospital or going to the doctor or doing something so if I was sitting at my desk and my stomach hurt really really bad you know I don't know I I guess if somebody thought I'm going to call an ambulance may maybe that pain would be severe enough but but is it your experience with that kind of symptom you know wouldn't you want to ask more questions because you if the person is ambulatory wouldn't they go to the hospital or somebody take them to the hospital was that s so what's your experience all right so you're G get pretty much all the Spectrum you're going to get some people that are stable and they have some irritation in their stomach and they're just going to call number one regardless of what happened so you can't even count on um that so but I I'll go back to what I said before because there's so many things can be going on internally with abdominal pain um I would just play the safe card and yes you're right I'm gonna ask some more questions yeah and here's the key when I say get off the scene Robert 10 minutes I just mean 10 minutes or less so you'll have time to get your sample curious to you don't get any wrong and yes you can be into a little deeper but that's the difference between a testing scenario and what happens in the real world in the real world I may stay on scene longer but if I were an NT student testing and I got dominal pain I would assume the worst case scenario and just call for me to transport so that you're successful on the actual skills testing days so it's it's a judgment call in the real world though um any other questions that was your initial assessment um I I did join that question about what is BBS CTA okay BBS stands for bilateral breast sounds and CTA would mean clear to all Fields so sorry I should explain that um when you're oscilating lung sounds we're checking for clear and equal bilaterally meaning both sides are clear and don't forget that your trauma when you guys do your trauma ones we'll get you some chest injuries penetrated injuries um you definitely want to be checking those lung sounds because if you have absent diminished lung sounds with a sucking chest room for example uh that patient is critical and there we have we have to take immediate measures or else that patient will die for example an inclusive addressing yeah BBS B brush sound CTA clear all Fields so that's that's how we document it in our patient care reports we use a lot of acronyms if you haven't figured that out yet all right so I think I already quizzed yall on what bottle signs to give we got the blood pressure we got the pulse rate respiratory rate we threw a pulseox in there we got a blood glucose if you're patient think about appendicitis they could have a little fever too so don't forget about the other Vital sign um oh what you think about that I didn't see that coming 96 over 40 we consider that okay for her or does that make you nervous we're gonna be nervous because those are low numbers yeah it's that's far from baseline or at least what on paper for the rest of the class what do you think a normal Baseline V sign would look like for her assuming she had no hypertension 70 to 120 yeah 12 120 I mean a nice beautiful textbook number 120 over 80 most people aren't there I'll tell you that right now but uh if we get anything less than 140 over 90 we consider them in a decent blood pressure but 96 over 40 that that gets my attention a little bit so let's see where this is going I feel like he's a little hypotensive for some reason uh oh heart rate's 120 well you know what your heart does when the blood pressure is low it starts beating faster to compensate respir I told you 16 but they're actually 26 that's a little fast I mean a normal range to what 12 to 20 for the uh typical adults she's breathing a little fast we call that teia just a medical term for fast breathing but I see her L sounds are okay her B Sox is 95% that's better than 94 so we're okay right no not necessarily don't forget that demonstration that guy passing out in that captain video um vles are equal reactive so we kind of roll out any type of Overdose maybe we could roll out some type of internal bleeding maybe some type of hemorrhage although this Pati is presenting abdominal pain so I don't think any of that's going to apply here but peoples are good what glucose you guys okay with that number is that okay I think it's a good number it's not any signs of any hyper hypoglycemia all right we're good we're in the normal range for bu glucose um okay treatments what do you guys want to do for this patient J maybe yeah start start with the nasal canula maybe for the hypoxia maybe move up to a non-rebreather okay keep breathing a little faster pseo is okay but I I'm okay with some supportive oxygen here nasal Cula um sure em you have any ideas maybe just help her get in a position of comfort on on your stretcher it's an easy thing but it does make a difference yeah it's the little things we neglect to transport position and comfort whatever that means for that patient with abdominal pain somebody's got an open mic so please be careful with your mic um that's basically it for you guys maybe consider nasal canula get some baseline vitals transport position Comfort to the appropriate facility and I think in the beginning they gave us two options they gave us a local ER and they gave us a PCI facility I think it was 20 or 30 minutes away any thoughts on that hospital was uh 30 minutes away and the PCI was a little bit further I believe yeah PCI was a lot further travel we had a local ER that was around the corner I imagine um uh I think for this I think maybe it would be better if we just take them to the local hospital first and if they need further treatment they can get an if to take them to that more uh I guess well equipped to facility but they would probably need Medical Care Now versus than waiting for later okay yes one one thing I'd consider maybe when I get into my Hands-On assessment and I poate the admin what if I found that full stage Mass um this would be a little outlier here but if I did and we suspected an aortic dissection but was called aism would that change your mind about facility transports yes I probably elect for a trauma facility in that case or somewhere that ultimately can get surgery so providing your patient is stable you know the only time that we would want to go to the closest hospital versus a specialty care facility one of them is going to be Cardiac Arrest it's kind of a natural there um there's only one exception to Cardiac Arrest if we got that patient back where we got a Ros back then it does make more sense to get them to a PCI facility because ultimately they get better treatments but if they remain in arrest and I said we don't get any B Signs back and we'll take that patient to the closest hospital generally and the other one's going to be basically any Airway problems that we cannot mitigate or fix on scene those patients are going to go to the closer facility and then um okay Emily do you have something I see Emily and I see Chris with raised hands yeah so just out of curiosity with her vitals being where they are you've got um you know uh blow blood pressure high heart rate uh High respiratory rate O2 is dropping um should you start maybe considering shock or some kind of shock in this in this situation or and would that change uh your management or your treatment of the situation at all yeah so what I'm thinking about here and we don't have the skin conditions at least not yet if this patient had this blood pressure with increased heart rate let's say signs of shock whe that be pale cool and clamy skin then that might dictate where I take this patient he might ultimately go to um trauma or PCI versus a local ER let me see all right how often do we want to assess this patient would it be every five minutes if he considered her unstable there you go anybody unstable guys just just blurt out to us all right we're gonna recess every five minutes you're more stable patients every 15 is okay all right discussion all right I thought that assessment was going to get a little deeper I'd want to know about the palpating the abdomen if we found anything in the adomen remember that remember the turd the funny one we talked about tenderness miseration rigidity distension those are things we're thinking about we're thinking about pain with palpation whether it's isolated to any specific quadrant kind of know generally where your organs are right upper quadrant liver we've talked about pentis being localized to the right lower if it's later in the stage it's especially if it's ruptured um you got to spleen upper lefts and we talked about flank area for kidney stones those are the most common Els all right so documentation um this is the ugly elephant in the room nobody likes to document we all want to play we all want to get back there and work on our patients but at the after we deliver them to the hospital guess what we're doing we're sitting in the ER area and we're going to write these patient care reports um we're going to teach you guys and I think you guys already been through the homework assignment I assume chapter 10 where we introduce you to charts and also soak or you know examples of formats writing your patient care reports and your department will dictate that it may be in your standing medical orders for which one to use or how to write your patient care reports um so they're just breaking down chart for you cheap complaint history I'll say pertinent history your assessment that means putting your hands on the patient osting lung sounds palpating you know all that good stuff we talked about treatment you know what interventions you took and then transport how do you transport that patient for example I transported lights and Sirens to whatever facility is versus without lights and sirens and then soap is going to be subjective to me that's kind of like your opqrst question objective is going to be your Hands-On assessment and of course assessment um that's kind of weird objective to me is what you find and then your assessment is going to be your Hands-On assessment and then plan would just be what your treatment is and how you transported them and where you transported them to and we always document any changes around if your patient presents um Better or Worse we need to make documentation of that this is all about covering your butts guys at the end of the day what's going to happen is and I'm a big stickler for this when you guys do your clinical internships I'm not going to accept this one sentence patient has chest pain patient transported to the hospital Vital Signs O2 we need something little more like the homework assignment we gave you some examples we gave you some the templates to use um and here here's why it's important when you get you get called to court 10 years after the call you're not going to have any recollection usually so all you have is your patient care report in front of you and those Warriors would love to rip you the shreds been there been there guys I've been there's a witness for like a neck and back pain we're talking about a minor NBC minimal damage patient amatory neck and back pain naturally they're suing somebody that attorney had me up there and their job was to make me look stupid and all I had was a patient care report to refer back to I can't remember that call you how many neck and back pains I've ran in 28 years so it's all about liability it's all about protecting you and also the department you work for so so so Jason you know that that's what I do for a living in my real job right and so I defend doctors and hospitals and so you know a lot of times what will happen is that you know there could be an accident in the plane the uh the patient fell plane if fell and they said they had a traumatic brain injury and then years later we're going back and we're looking at the the medical records and we'll depose the EMT or the paramedics and particularly when you started talking about glass cooma scale and whether or so we we look and and uh scrutinize every single thing that you write um because we're trying to show that there's no causal relationship between what they're complaining about and and something that uh they may be suing either the hospital or the paramedic service for so you can you can back up what I'm saying basically uh how important it is to document document documents so we all hate doing it it's it's our least favorite aspect of this job I get that so but but so importance um nvcs less than ones usually um if if I get called the court it's usually DUI case or NBC or the person suing the other party or the insurance company so what you tell me Robert with your experience and I've asked lawyers this in the past because a lot of Pat will like to go to the hospital in the ambulance and and the theory is if they can rack up a lot of bills it would help their case is there any truth to that so oftentimes what we see is that um you know people automatically depending on how bad they're hurt think about hey I'm gonna end up in a lawsuit but a lot of times when the lawyers get involved and sometimes they get involved really really quickly um then they they don't want the patient saying you know I was fine you know they they want them and and so a lot of times they'll send them to different doctors that they know or chiropractors um but you know the thing is for EMTs and paramedics when we depose them and I probably deposed you know probably a thousand EMTs and paramedics over my career is the fact that by the time you get deposed on your record um you often don't have any recollection of that and so what makes you stupid looking is when you're trying to recall something and it's not correct or it's not consistent with what you wrote um and I'm not sure why EMTs or pyramed do that all the time it's not in the record it's nowhere in there where they're saying hey the patient said this or the patient said that but you know oftentimes it it you know I've seen pyramed and EMTs get sued as well um for the care and treatment like for instance you were talking about nitroglycerin and you give nitroglycerin and it was contraindicated and clearly that's in your training which is one of the reasons why this is helpful for me to go through this trading so when I'm looking at the records and thinking about what paramedics and EMTs do on a scene but yeah you'll you this is so important and I don't think anybody really appreciates how important this is because it's so scrutinized years later when you're deposed and then you might get called into court and you have to testify in trial so if you have a long enough career as an EMT in paramedic there's a pretty good chance that you're going to get to post absolutely um I've had multiple subpoenas coming away I don't necessarily have to sit for of those so I don't get thrown out before I get involved I had a couple of Sid cases where investigator got involved and called me as a witness too but um yeah it come with the territory guys and uh there are such thing as Good Samaritan laws that hold up in court for certain cases but uh if there's any negligence or breach of Duty that's going to fall back on you and your service um insurance I don't know much about I've always worked for the fire department so we had you know we had coverage but I know that our insurance options for paramedics as well just like you see for doctors and so forth well thanks for that Insight Robert it's nice to have a lawyer I always enjoy talking to the lawyers about these cases yeah I I was lead Tri counsel for Mattel and The Rock and play sleeper cases if you're familiar with that the babies about a 100 babies died in the Rock and sleeper cases and so SIDS is a completely different animals you know when the when the um when the EMTs and the paramedics come in and and particularly if they're trying to revive the baby and so there's a whole big documentation investigation that goes along with a with a baby ultimately dying from SIDS so the police officers will get involved very quickly and obviously the corners will get involved pretty quickly and so we've deposed a lot of EMTs in in paramedics on Sid cases and what I'm thinking about guys you know we thinking about additional resources if there's any type of crime or an abuse neglect you have a legal obligation notify the proper authorities um that means getting law enforcement involved on these sces and also notifying the Receiving Hospital usually I pull the doctor to the side get the social worker involved if needed and document the crap out of that one because you will be back in courts okay all right so that's my soap box for uh for documentation and how important it is uh I see a question here yeah hey Jason I was just going to say um I've uh had a lot a lot of experience working in a trucking company specifically in the safety and compliance department and I have dealt with a lot of legal cases depositions and all that um and I was just going to say when you mentioned you know does does getting put in an ambulance does that make a difference a lot of uh in a lot of cases perception matters hugely um and a lot of these cases are not going to make 98% of these cases are not going to make it to trial uh there's going to be a whole process leading up to that trial there's going to be uh you know subreg and and meeting and stuff and in those meetings where you're negotiating settlements every little thing that happens is going to be construed one way or another by one side and that's why it's so important like the do documentation is so important um every word you write in that document is going to be scrutinized and then also how you act on the scene um the um the complainant the victim whatever however you want to say say it they're going to have an assessment of you as a person and how you acted and that's going to make a huge difference in their aggressiveness in the case um and what their their legal team will be able to use against you so you always have to be conscious of what you're writing what you're saying and how you're acting um because you might not be thinking of it at the time but I guarantee you that person that's that you're talking to that's in their car that's in your you know in in the um in the stretcher there this is like like one of the worst moments of their lives and every that's happening is magnified a million times in their brain and they're going to be reliving it over and over and over again and the the worse you act on scene um the you know the less of the worst bedside manner you have that's going to that's going to come back uh big time against you and I've seen it a hundred times you might not think that that thing you said um makes a difference but it does also in positions and in these cases what happened after the case what happened during for you personally were you texting people about what you were doing were you taking pictures at the scene and distributing them to friends other co-workers I just saw a case where police officers were arresting somebody who was handicapped and one of the police officers was texting another officer joking about how they were going to have to use some special equipment to put this handicapped person uh to take them to the hospital or whatever and the one of the patient's family members took a picture of the cop texting that that's something that can also happen to you on scene so you just always have to be conscious just always pretend like you're being scrutinized because you are by one person or another even if you don't think you are that is so true in Public Safety in general for all aspects fire un us police um you're held on a different standard and your behavior and like you said bedside manner goes a long way guys even if it seems like something very you know simple to you this person in their eyes this is their worst day we have to treat them as if it's the worst day and I'll tell you good bedside manner goes so far the truth is guys you could be the worst EMS person out there but if you're passionate empathetic and show good side that bedside manner you're GNA get out of trouble most of the time and here's what I see all the time very experienced very salty paramedics and EMS can be included that know their job inside and out and probably the best person to have on that scene when they have a true emergency but they stay in trouble all the time because they're salty and their demeanor uh is perceived the wrong way so yeah good point very good point so I've been on both sides of that Spectrum so all right let me see what's else we got left here okay we're we're at the end here basically I'm giving you a glimpse of what you're going to see in the future so when you guys come for your skills days you're going to create a lab shift in P dab in this slide here we not expected to do this today but if you want to see how this works um click on lab let's see what happens next um basically you're going to run through these components your shift name for example if it's medical you know Medical Practice Day lab site it's going to default to that one we're going to Mark our time is 0 800 hours I'll be confused by that when you guys actually come here assume you're Eastern Standard time we usually start our classes at 9:00 however we have to document Z 800 In Piss stap because it only recognizes central time obviously we had that issue today so we all learned how important time zones can be um the duration is going to be eight hours you will be here for eight hours for that whole day um there's no exceptions that's a state requirement to keep you guys here captive for at least eight but don't worry we got plenty of stuff to do and we need all eight hours of it usually um the number of students is the one student filling it out I guess just put one pick the pick the date of the skills dates and then you'll click on create a shift and we'll talk about more detail when you guys come here for your skills day or practice day I'll have some documents to hand out to you guys where you see what skills you need to add that day and also be mindful that you will have to write patient care reports for each of these skills practice days and also your testing day matter of fact it's going to be three for each so get that template out and start working on patient care using chart or soap or documentation using chart or soap because I want this to be nailed down when we get you guys to your clinicals we're run into a lot of problems with this with students that are just taking shortcuts putting one or two words that's not going to cut it okay I'm trying to do you guys a favor ahead of time so when you do create or add your skills you can see down at the bottom of your lab shift there's a plus here for lab practice items will give you that sheet so you'll know which ones to add so that's a look at how to do so you click to go once you've added skill and then says You must change the evaluator to the appropriate evaluator so the fsab is going to default I think to student and because you're expected to do at least two instructor evaluations is also for pier you'll have to change the evaluator from to either of the instructor that day or a peer or co- student that day scroll to the bottom and you repeat this process over and overo for for each skill and there's a lot of skills you're going to be doing um you're expected to do all this documentation at home and not exact not in the classroom because it takes a it's going to take you several hours I'll be honest with you um like I said the state requirments and Georgia changed to 2024 you guys are lucky um I say that factiously but you're lucky enough to be the to get to add all these skills and do the extra clinical rides um which means a lot of time in fit dad that is the end of the presentation um this is supposed to be a 4our block so I'm G to stick around here if you guys have any questions about anything if you want to go back over any skills I just kind of gave you a brief introduction to some of the basic ones you will get a chance to get your hands on equipments um you guys get here is there anything else you could think of anything mindboggling today about meds interventions or even skills I see a question here what other equipment supplies would stay with the patients um I don't come on come on and talk to us I don't know if I understand that um premise of that question sorry I lost yeah go ahead we were talking about uh she asked about uh the EKG cables like if you transfer patient over does do the cabl stay with the patient so we had a couple of us that answered that particular question so she now she's asking are there other equipment SL supplies that stay with the patient most of your expensive equipment is going to stay with your truck it's assigned to your truck and it stays with you the H the hospital or if you transfer if you're an EMT and you're going to transfer to a paramedic crew they're going to have their own equipment um but like things like stickers um some of the blood pressure like we'll use the blood pressure cuffs that are actually compatible with the hospitals around here so the blood pressure cuff will stay with the patient um if you've got the one that actually works with just the life pack 15 you'll keep those so you'll know because when you get onboarded at a certain agency they'll tell you this stays with the patient or this stays on the truck so you won't inadvertently pass off any equipment that you shouldn't have and something else you may think about Anda so think about patients that we do full sepine or full mobilization you may have to leave your long spine board in other equipment behind and then usually they stage that equipment once that patient has se spine has been cleared and next time we go back we'll go look for our equipment and and a traction splint comes to mind obviously when I put a traction splint on someone I'm not going to be able to remove that take it back with me so there there are a couple things I could think of that you'll have to leave behind yeah sometimes they have like um uh some of the hospitals they have like a spot where they'll put ambulance equipment if it was something like that like a traction splint or a backboard and you had to leave with the patient they'll put it in a pickup area so that that particular agency can pick up their equipment again exactly um yeah cables um yeah don't forget you 12 of these guys we every time we do a 12 lead it's we've been known to leave those on the patient accident you have to go back and retrieve that equipment later so and and CPR machines mechanical CPR devices when we first started using these the ER didn't even have them yet the first doctor that saw my Lucas device cussed me out and told me to get that piece of off the patient because they didn't know what it was now I can't get the things back because they're like this is nice we don't even have these yet and U I gotta beg to get my my Lucas device back usually I guess now most hospitals are equipped with it man is that true I think so I'm not I'm not exactly sure be quite honest the ones we transport to they all have Lucas good you have to fight to get it back okay all right all right um some of my ambulances that I work on don't even have a Lucas device all right all right I know she's smirking because she knows that I came from a county that had all this nice expensive equipment not to mention a power load stretcher system you know a nice Striker stair chair which would have been great you know 20 years ago when I had it back but it's too late for me now then you guys will have a chance anything else guys uh study the got a couple of questions in the chat there are we supposed to inspect clavicle stability when we talk about applying a c collar most definitely uh if you notice something is out of whack or it looks deformed there's crepitus uh note it there's obviously nothing you're going to do about it but note it before you're putting that collar on because you're going to relay that message to whoever you transport the patient to yeah document reason why you with tell the cat collar and your cover to okay uh let's see J says on mud skills testing days for the patient assessment exam does everyone get told a standard nature of illness or do we get presented different ones during the exam uh different scenarios so you take the lead and then we flop and your partner takes the lead so each have a different look at a different scenario that'd be too easy guys they can't give you the same one the whole right so things that think about for medical chest pain Strokes diabetic episodes anaphylaxis respiratory problems like cop study those meds those dosages um trauma events you're going to get your blunt force trauma head injuries chest injuries penetrating chest injuries are one of my favorites to talk about and test on um and then you know of course we'll practice sepine taking sepine multiplication seated patients and also suine KS even though none of us actually use these for sepine in the field anymore we still teach that still in the curriculum um my personal opinions are better suited for pelvic injuries Sor right all right anything else on here sandre yes are you I have my virt my um virtual trauma on tomorrow are you guys doing that one are you in aworth or stockridge I don't know what the schedule is yet I'm in I'm in uh I'm just in Georgia I'm in NE one of those just virtual so I'm sorry I'm sorry you said virtual I misunderstood um I don't know if I'm doing that one Amanda do you know the answer that question do we have a brad Brad's doing uh trauma tomorrow okay you have a different instructor tomorrow so um I think you guys will like Brad too he's a lot more loud he's louder than I am and uh he's also a firefighter paramedic with a lot of Knowledge and Skills so um I think you'll be happy so did you see my I enjoyed this the part I saw did you see my text where my um devices went out I did see that yeah so I miss like the so I don't want to hold anyone up so if if it's a thing where we're done and anybody do don't mind wouldn't mind recap a little bit over the past like 30 minutes before I came in because um when I brought my laptop in to having to do my updates I didn't think it was gonna take that long so I was viewing it all on my cell phone which got ready to die which it did die so I had to go to get a laptop it wasn't like go in the other room and get the laptop so I missed a lot of um a certain portion at least easily 30 or so minutes of something in there okay yeah I don't mind sticking around we can we can dismiss the other students and I'm I'm here till 5 o'clock whatever you need that's great I get paid by the hour I'm good I get it anybody else um I'm gonna clear you now Emily all right anybody else need to be cleared for to sign up for their inperson yeah so if you guys are at the point where you preach chapter 24 um if you already signed up for medicor or virtual we should have opened up registration for the other skills St but if you're not if that's not the case let us know so we can open up registration what what do you mean to be cleared what what is that basically we have to go on our end and just authorize you to register um but you'll use the same access code used for this class yeah you're good yeah oh okay I signed up for the skills day already I didn't know I need to do something different okay now you're good okay sorry to confuse you yeah these are for students that may have not been cleared and for some reason or another but you well initially initially we were only allowing you to sign up for prep days because they have they should be done before you go to your inperson because this is the foundation so that your inperson makes more sense so we had students who were skipping prep and just going and signing up for in person so we had limited to where you would just sign up for virtual and then you know when you have 3,000 students that gets to be a bit much so we switch to just approving all days um but there are some that still are missing that um clearance so so so C do you have to do like I so I'm done with everything except for the the final I guess and Chason and I talked I think yesterday or day before yesterday about submitting my shot records and stuff so do I have before I do trauma virtual do I have to do the medical skills first or can I go ahead and sign up for trauma virtual you can sign up for trauma virtual there's actually one tomorrow oh okay all right yeah most you guys do the virtuals before this the medical Skills Practice days you can do them however you need to but [Music] um in other words you don't have to do medical and then trauma you can just just make sure the virtuals come first before the actual Skills Practice pH and you're good okay Misha has a question about medication all right were you in the chat box here yeah what's it say concerning medications after checking right name doses person Etc probably referring to the patient rights if there's a discrepancy do we still administer like if the patient takes medication that's not in their name or not labeled oh this sounds like prescription medications that we're talking about here so confused whether we're referring to the medications we give the patient for our protocol or the patient's actual prescribed medications so do you see the button that's got a microphone Misha Michelle sorry there you go yeah talk us through this one I guess my I guess my question was um I guess for this instance it would be their prescription medications but we normally don't administer their actual medications but like say like if it was um asthma medication that they have like they have their own inhaler but maybe um they were using like their mom has asthma too so they're using their their mom's inhaler would we would we still um administer that or no so you're asking would we still administer our medications or use theirs so I guess what you're getting at is here there are some cases where EMTs can assist the patient with her own prescrib medications like the meter dose inhaler maybe NR cholin but if your question is if they're using a family members then absolutely not We're not gonna we're not going to do that so we would never encourage a patient to use a medication that's not prescribed to them um but if that patient needs a butol well guess what we have it we'll call medical control and if the patient meets the uh requirements and their congregations then we can do it does that make sense yes that makes sense okay I know what you're talking about patients are using other people's meds all the time maybe they ran out maybe they had a prescribed medication and the family member just happen to have one and they're using it too yeah that happens all the time all right and there was a student earlier in the session that made a comment about um he knows some paramedics who use icing versus glucose yes that's a that is a sugar however if the patient has some kind of reaction to that if it's expired and something goes wrong it's not in your protocol and it can come against you for not following your protocols or using the medication that you have on your ambulance yeah good good point it's going back to liability um guys 90% of this job is cover your butts okay I'll be honest with you um Leon yeah I just had a quick question so regarding CPAP I've heard things about PE values could you potentially talk about that a little bit because I don't think I don't I at least I didn't hear anything about that but I'm a little curious about it okay so he's referring to PE or positive in exory pressure is that what you're talking about um yes sir yeah so I the equipment we're going to use and the one we're going to demonstrate for your oxygen driven so pretty simple the mechanics are very simple you got a dial for the pressure and you got the corresponding oxygen Administration and liters per minute so that's really all we're worried about when you think about Peak you're thinking about more sophisticated equipment such as BiPAP or mechanical ventilators like in an ICU patient for example we have they have to keep that positive in expiratory pressure at a certain level to keep that Airway the way I look at it is it inflated um and that's really all I know to tell you about that so Amanda you have anything better than that I don't know what to say no I mean we don't go too in depth with it are you a medical student uh no I'm not but I was a I'm a Explorer with my local department for like three years now and I've heard a lot about it ever since they started talking about happen when I do stuff on patients yeah um I I know the basics of it's trying to keep your lva open and we usually have some kind of flowchart that we're going with we like five of Peep like Jason was saying five of Peep is seven uh liters of oxygen or eight of Peep is whatever the next level up is I don't have those memorized because like I said it there's a little cheat sheet that comes with uh every CPAP unit yeah okay thank you as long as you understand the concept the idea is just to keep the lvr light opens and somewhat pressurized even when the patient is exhaling uh to allow for that O2 CO2 exchange so it is a concept you you should understand but yeah our equipment is not sophisticated where we measure Peak all right and then you guys do CPAP on a patient make sure you turn the oxygen on um don't ask me how I know about that but if your patient acts like they're smothering to death you might want to listen to what they're trying to tell you um because at 3:00 am sometimes things get messed up and we might forget a step and oxygen is probably very important cpad all right a little bit Yeah candra you ended up coming out right around when he started talking about patient assessment correct was um not long after we came back from break because I still had the phone at that time and um around that time it was starting to try to die gotcha so where should I take you back to see see I didn't see any of that did the did the videos ever start working I finally got the videos figured out if you want I saw that already I just you know I saw that you saw give you idea where I was so we went through the meds we took a break and this is where you left yes okay so Cardiac Arrest we'll have an actual BL your heart I appreciate it I thought you G I thought you gonna speak on a couple of things here there okay so I'm mute now okay you me give me run through the slides okay for anybody else uh you guys are welcome to smiss yourselves here unless you have any questions if you do you're welcome to hang out you can if you want to see this again you're certainly welcome to do so um yeah go ahead I just had a personal question for Amanda about the skills days okay so I'm not sure they can do like a breakout room or anything um yeah I can't I can wait until the meeting is over or when this is no that's all right uh let's breakout room I just had to figure out how to make it work don't ask me I don't know what you're talking about breakout room so yeah break yeah you can do breakout rooms however I'm not the host of the meeting so I can't um but I will stop recording now and I'll catch up with you Ren um can we do it in like 30 minutes because I have a virtual meeting in two minutes that's starting yeah um you have my number right so I've been texting you yeah can you just call me whenever you can it doesn't have to be like in the next 30 minutes can be whenever so perfect perfect I can do that thank you'all so much yeah Leon if you don't have any questions you're free to go anybody else thank you guys for your participation today and making this less awkward for me this is not the format I'm comfortable with I like being face to face with you guys and I'm looking forward to the skills days where we actually come here and um I think that's when I do my best teaching so thank you for bearing with me in the technical problems and we'll see you guys in the near future let us know if you have