The Triple Threat!

Show Notes

The triple threat!

The EMS Show, EMS Avenger and the EMS Lighthouse Project Podcast assembled in Southern Oregon to share our experiences from the State of Jefferson EMS conference and talk a little shop.

What is The EMS Show?

Casual but important Discussions about EMS.

speaker-0: What do you get when you combine a world-class EMS physician and medical director... I speak pretty good English for a guy from Detroit. ...with an EMS veteran and all-around nice guy? Well, that's the dumbest thing I've ever heard. ⁓ that's so good. ⁓ my god. You get the EMS show. it into the people. Here's your host, Dr. Ritu Sani and Mike Verkest. Hey everybody, welcome to the EMS show, the ultimate crossover episode featuring Jimmy Apple, the EMS Avenger and of course, Dr. Jeff Jarvis from the EMS Lighthouse Project. Welcome to the EMS Avenger podcast, the ultimate crossover between the EMS show and the EMS Lighthouse Project. That's fair enough. We are all sitting here together in Southern Oregon. We've all been here at the State of Jefferson EMS Conference.

speaker-1: I I like- ⁓

speaker-0: ⁓ which is one of our favorite places to go. You've been here a couple of times. You've been here every time I've been here. This is the 15th or 16th conference. I've been here for everyone. And I think I'm probably, cause I'm old. Yeah, that's right. Wait a minute. I know by the way, I've been doing this a lot longer than you, at least the doctor. So let me, let me just say something real quick. They spent

speaker-1: You're all You're older than me. Yes, older than me.

speaker-0: greater than an hour doing the same shtick in front of the entire general audience today. Then they were probably so relieved because Jimmy Wynn closed them all out. Yes. And they could finally, you know, be done with that. But yes, somebody's always older. You've all been doing it a long time. We get it. Is there statistical significance to the age at this point? Does it really matter? Or is it just

speaker-1: He's older than me. That's what matters to me. Yes, no, it doesn't.

speaker-0: think you're old. Yeah. think we did this math yesterday. We've already forgotten. Which is how old we are. We both have forgotten. So for those of you who've been sleeping under a rock, you guys know Dr. Jeff Jarvis, EMS medical director, my boss actually, which is a whole other story. of course, Dr. Ratusani. His former boss. My former boss. And we're supposed to do a handoff episode where

speaker-1: Not not much Correct.

speaker-0: My former medical director, we do a little thing. It's a ceremonial thing. And then he pushes me off, but we talked about that when that first happened, but it's kind of old news now.

speaker-1: I would just want to say thank you for your contributions to improving the care in Fort Worth.

speaker-0: ⁓ that's very nice. Well, we did. certainly, we certainly miss him in. It's in my house. it's all, it's all. That's like, ⁓ I don't know if you heard that story, but I lived with him for a few months, but anyway, so anyway, beautiful weather down here in Southern Oregon. ⁓ I had the honor of, so this is about my 12th and 13th time. So I'm not far behind you. Yeah. ⁓ cause I was looking at Facebook memories popped up today and.

speaker-1: That's right. Yeah.

speaker-0: Well, there was one from 12 years ago. So I know it's been at least 12. ⁓ but yeah, had a, I love coming here because this is where I, this is where I grew up in EMS. We're having the secret Dr. Pepper handoff going on right here. ⁓ this place is, ⁓ this is like my home, home area. And so I love being able to come back here, and, talking to the people. like old home week. Get to see a lot of my people that I went to EMT school with.

speaker-1: my lovely wife.

speaker-0: I see like Erin Elder every single year we come here and she was sat right behind me in EMT school and you know, we're all getting old now. I'm also seeing a lot of my coworkers that I used to work with with getting total knee replacements and neck fusions and hip replacement, knee replacement, replacement, flex more. Jimmy, we're getting old buddy. Yeah. I mean,

speaker-1: Primiturally, I might add, this job ages you.

speaker-0: Yeah, I have high cholesterol. It's weird to even hear myself say that. I have high cholesterol.

speaker-1: Yeah, start talking about drugs we're on. And I'll tell you what, that conversation is a whole lot different than when I had the what drugs I'm on conversation 40 years ago. Yeah. Slightly different. Slightly different. Yeah.

speaker-0: I had the opportunity to talk on a couple of, well, it's basically ⁓ two topics. I did a sort of BLS airway and really, because there's a huge BLS EMT EMR component of responders here and it's very rural, right? ⁓ And we'll see rural stuff, we'll see suburban stuff, but there are some folks that are in my class that it's 50 minutes to the next person's going to get there, right? So we were talking about getting resources to a scene early for help. That's 50 minutes, right? And so ⁓ it's an interesting, diverse group of folks. So we talked a lot about just sort of like fundamental BLS airway stuff and really ⁓ bag valve mask. And then we found out the same. Is he picking up from there? I picked him up from the airport. What are you talking about? For have the same exact topic. Yeah. Like an hour later. so. who wore it better? Well.

speaker-1: Damn.

speaker-0: What we did was we did, we made it into a part one and a part two and a part two. so, he focused on like the basics and talked about like medical patients and cardiac arrest. And then I did a trauma scenario and then talked about proper DLS airway technique. And you're talking about the H-bombs. Hypotension. Hyperventilation. Exactly.

speaker-1: talking. hyperventilation.

speaker-0: but really putting it on, because what happens in the real world? What did you tell me in the car the other day about like new guys shows up? yeah. Well, yeah. So it's like, he was the story of like the EMTs doing their first ride along, right? And we want them to have a great experience. So they come out and we just happened to catch something good and we're like, Hey, why don't you bag?

speaker-1: new guy. The most complex skill we do.

speaker-0: Right. And so we talked about it. I talked about it. The physiologic impact of all of that overbagging. Yeah.

speaker-1: So I'm convinced that we not only don't bag well, like form a good seal, I don't know that we can teach that. Now you can do it one on one off, but at a system level, particularly at a system the size of ours, 1600 clinicians, the vast majority of whom don't touch patients very often, they're firefighters on engines. I don't know that we can. So I have a very unique solution on ⁓ how to handle this. Just don't even try shove a superglottic in and bag through that. Oh, we can do for sure. They can put superglottics in.

speaker-0: I think you've managed one part of the multipart system.

speaker-1: What you do with the bag? Oh, that's a whole different-

speaker-0: Right. I agree 100%. And I've actually been saying this a lot over the last couple of months and advocating. mean, once you've established your couple of breaths that you actually are able to ventilate and ⁓ that. ⁓

speaker-1: You're just seeing the rise and fall of the chest, of course. That's the only way to do it. Right. No other way.

speaker-0: Right. Cause chest fell correlates so well to adequate tidal volume, but that you should just not waste time and just put the supraglottic airway as an adjunct unit of itself. Okay. So we sucked at bagging and because of that, one thing that we can do to make it easier is drop an eye gel immediately. So we are not playing the mass game.

speaker-1: Yes. Yes. Yes. Now we're still bad at the other part too, which is what do do with the bag? How big bag? How fast should you squeeze it? Right.

speaker-0: I mean, if you look at Spate's cold, all the work he's done, why is intubating a head injured, why is it bad? Because it gives you the exact tool that's perfect for over ventilation.

speaker-1: That's one reason. I think there are other reasons why it can be bad because we do it poorly. We don't adequately prepare our patients for pre-oxygenated and then we, it'll fuck our ass. absolutely. Yep, yep. Don't have any H-bombs. That's okay. I got some.

speaker-0: Set them up for the H-bomb. Go back because you might have had this conversation. You're like, just drop an eye gel.

speaker-1: Yeah, well, super cool.

speaker-0: Superlatic. Sorry. I guess not everybody uses. What? Okay.

speaker-1: No, we don't need that. Not for any particular reason. Eye gels are fine.

speaker-0: cardiac arrest. mean, you can't do that in a head injured patient. person with a dad, you can't just drop a superglutton.

speaker-1: can do what in a head injury. Well, you can, particularly when you like do it right, like say with medicines.

speaker-0: Yeah. So Joe, no, but that's not the same as just dropping. And somebody taught me that when you're going to use medicines, you should do a bunch of shit before you use enough.

speaker-1: You absolutely. So I'm separating this out, cardiac arrest and non-cardiac arrest. When you are dealing with the cardiac arrest patient, I think that's one of the challenges. You have to make a mask seal on 100 % of those patients. Just drop the supra-glottic bag. If you have a patient you're trying to prepare, say for intubation, pre-oxygenate, mask seal is incredibly important. The easiest thing to do is just use BiPAP. particularly with a ventilator that has essentially some version of SINB so that as you give your paralytic, eventually they're going to stop breathing and they don't just turn off, right? Their tidal volume drops, becomes erratic. The vent will pick that up and then start spontaneously delivering breaths. One-one situation.

speaker-0: Okay, but not everyone's got fancy dental.

speaker-1: This is true and we don't have fancy ventilators on every call. That's true. So you could use the poor men's which is you go ahead and do a mask seal. You're still back to the mask seal but now you have limited it to your most highly skilled clinicians which is a smaller number and I'm certainly talking for my ⁓ system. 1600 people you don't have to teach that to. ⁓ But yes the conversation that I was talking about was cardiac arrest.

speaker-0: I just didn't follow completely. I, you know, I'm more. Yeah. It's talked about earlier when we're all sitting at lunch and something, the point that I think we need to really acknowledge is that we keep making these decisions between cardiac arrest and between a drug assisted intubation to RSI or DSI. Those are actually two entirely different types of intubation that had very little to do with each other. Competency in one does not necessarily extend to competency in the other. They are this entirely different skill set. ⁓ yeah, I mean, I could not agree more with that. And, and, and I think it's even stratified even a little bit more when you start talking about RSA, right? So a rapid sequence airway where we're, we're, we're just planning on using all the medications. Anyway, so RSA, ⁓ or delayed sequence intubation, right? Like, so it stratifies that even bit further. And even those have different right, you got to know when we're going to do RSA versus when we're going to just sort of bail to RSA or go with RSA versus performing the whole DSI. So

speaker-1: Absolutely.

speaker-0: But if we think about it that way, well, all of my department's intubations are like two thirds of them, three quarters of them. Cardiac arrest? Cardiac arrest. our people won't get to do that skill anymore. So you're just, you just want to take away intubation is what you're saying? No, you want to take away intubation. He was like, is a proposition. He's provoking. Which is good. But it's an argument we hear, right? ⁓

speaker-1: No, What you're saying Dr. Sani is that it's more about you than it is about your patient. Is that the argument you want to make? I'm happy to get the media here. That'll look really good on the front. Yes. Dr. Sani, local EMS medical director, says, it's okay if we hurt our patients, but it's good for us.

speaker-0: How can we get good at innovation if we don't innovate? That's the question, right?

speaker-1: You might feel a little bit better about seeing that on the front page, but I would argue you're still gonna end up on the wrong side of the-

speaker-0: sure on the wrong side. Well, I'm definitely in the wrong side of argument. But, but I think, I think this is not an uncommon argument that I yeah, it's like, if you take, if you move to like a, like a superglottic first or superglottic only or superglottic in your cardiac arrest cases, then you're really

speaker-1: I might have even made the argument.

speaker-0: talking about taking this skill that's already low frequency and making it even lower frequency. think Jimmy's point that, you know, doing an intubation in a cardiac arrest and doing a drug assisted airway management are different skills. But the mechanics of the... The laryndoscopy. The laryndoscopy. The laryndoscopy is same. And what we do know is you need reps on it to do that. That being said, I think...

speaker-1: Yeah.

speaker-0: I'm going to sacrifice my performance with one patient so that I think I might be better in a little while. It's pretty taut with this poor argument. And really when your frequency may be only three, four times a year, that's not really going to make you more.

speaker-1: Yeah. You also end up with making what is just on its face a really unethical argument.

speaker-0: It is an unsound medical proposition. mean, generally speaking, think this is actually a very EMS centric argument that we have to innovate in order to get good at this.

speaker-1: Fair, but let's talk about say open appendectomies or cholecystectomies. 30 years ago, 40, I don't know when we started doing this, let's say 40 years ago, if you needed your gallbladder out, it was open. It's stem to stern baby, and that sucker comes out.

speaker-0: I've had her appendix out in 1998. It was open.

speaker-1: Scar starts around her knee, ends around her shoulder, slight exaggeration. But the technical skill is substantially different. So when I had my gallbladder out, it was a couple of punctures and it was done essentially robotically. I mean, there's a human driving the wands, but surgeons made this argument. Well, how am I going to be good at these open surgeries if I'm doing the minimally invasive? But the minimally invasive was much better for patients.

speaker-0: a little wee bit.

speaker-1: Who's it about? Is it about us or is it about the patient? We also used to intubate people after you called the code. This was a pretty common problem. Certainly when I was a paramedic student, would work and arrest, stop the arrest, there's a line. And that's unethical. And thankfully we recognize that and stop that.

speaker-0: Sure. Get your rep in. actually a famous case within the last couple of years. department got in trouble because they were actually inviting people to the scene. Yes, they were. intubate after they called it. ⁓ The way we normally would

speaker-1: why we can't have nice things.

speaker-0: The way we normally wouldn't want to do this for paramedics is they would go somewhere where there is a medical justification for the intubation and then they assist or perform the intubation such as in an OR for shadowing people around the hospital. just say we're going to invade this person because we want to get this person a rep. know that technically can't even do that with an ID. Like CMS doesn't consider an ID to be justifiable if you're establishing the ID just for utility.

speaker-1: Or certainly they're like, hey, knock yourself out, but we ain't paying for it. Right.

speaker-0: You know, I used to have a guy that, ⁓ and this is the one I knew about, but I'm sure there were more. And just like the blue angels sit around a table and they go through the.

speaker-1: That is

speaker-0: up, smoke gun a little bit more. They're going through their entire routine. Sitting at the office desk, right? It's like our Formula One drivers do too. Just like the Formula One drivers do. so I think, I mean, that counts as a rep, doesn't it, Jimmy? I mean, if you had an innovation log, sure, absolutely.

speaker-1: intubational. So the importance is the law.

speaker-0: I mean, I had to maintain a lot of my innovations. you do? Yeah. Oh, is that a weird Georgia thing? It's a system thing.

speaker-1: But it seems like it's not really the piece of paper that's improving your confidence.

speaker-0: No, the paper's not improving my confidence. Would that count for you in that and saying I've set up my mental model. I've got a 68 year old cardiac arrest. Whatever I've I've got max BVM going. I'm taking care of my patient. We're getting ready to go. I got my backup airways ready to go. Like you're going through all the steps. Like in my mind, as good as

speaker-1: He's guessing,

speaker-0: But this brings up, this is an interesting and it's sort of a little side thing because it also ties into checklists a little bit. We seem to think that we are somehow different and as cool as and both not as cool as other things. And I'll use aviation as an example. you're talking about the highest of high performers in the aviation world who use visualization as a technique to gain reps. Well, people would say, did, Jimmy made a face when you looked at that. That's got me thinking maybe that is a unique and reasonable technique for preparation for these high, high acuity cases, like a septic patient and just sort of going through the mental high-performance athletes. do the exact same thing. If I made a face there, it was because I actually loved the concept. No, no, no. When he was saying that, I was thinking, man, why? are you not actually doing that? I think that's great. Like when we talk about checklists, You know, when we talk about checklists and, and, and EMS, we still often hear back, well, I should know it's my job. know how to do your job. Who do you think do the blue angels ever take off without a checklist? I doubt that they do. So you've got the people who are the highest of highest performers in the highest field, right? Aviation, astronauts, ⁓ high stakes, highest of highest stakes.

speaker-1: definition of the right stuff.

speaker-0: And then we're like, well, we're just the EMS people. There's nothing higher stakes in the person's life that you're dealing with. These are all, we tend to not give us credit, our own credit for the states we're dealing with. And if you have in the high, that kind of high stakes issue, I think using the same techniques and tools makes a lot of sense, which is why I think, yeah, we should be looking at aviation. But I love this idea of sort of visualization and doing sort of almost dieted meditation, you know, of a, a, ⁓ of a critical incident. know, the other, the other thing I often say when, when I have a medic say, well, I should know how to do my job. I'll say there's a pilot. Now there's a commercial pilot and you have to how to do their job. yeah, of course they do. So the next time you fly on a plane, just stop into the cockpit. Cause I always ask for a car, car on Delta. Okay. You know, didn't know they were still doing that. ⁓ yeah. I got one the other day. Okay.

speaker-1: You know,

speaker-0: Um, I guess I said right on that, but, um, uh, and say, Hey, I know I trust you. You are a pilot. You are a professional. Don't worry about checklists. Yeah. You'd say you just shut up and fly. Do your job. Don't worry about checklists.

speaker-1: Right. So my brother-in-law is, he was a B-52 pilot and then flew, ⁓ retired as a captain for American Airlines. we were...

speaker-0: I heard has wifi now. Calculations re- Bite me. Okay, alright.

speaker-1: Try getting a direct out of here. So we're flying around in his private plane. And I'm like, hey Howard, ⁓ I got a question. So we're going along single engine plane that we're flying. If the engine quits, what are you going to do? He said, well, this is really easy. I'm going to take out this checklist and I'm going to hand it to you and you're going to read it to me. like, Howard, we are plummeting to the ground. You need to do some of that pilot shit, Howard. You don't have time to do a checklist. And he said, Jeff, I don't have time not to do a checklist because I one mistake and we're screwed. So I just love that.

speaker-0: It's like the famous quote from, I think it's from John Wooden that said it. You don't have time to do it right. When will you have time to do it again?

speaker-1: Yeah, yeah, it's great.

speaker-0: So anyway, that was a nice little adventure off into... ⁓

speaker-1: What are the odds that we would talk?

speaker-0: about airway. Yeah. know, one of the other things I talked about, I would love to get your guys' thoughts on is again, for the specific audience that's been here, BLS primarily with a few intermediates or advanced what you, know, ⁓ we talked about winning the call in that first five minutes when there is no one coming and it's just BLS. And so I had a really great discussion.

speaker-1: RULE

speaker-0: With no slides by the way, because the AV system broke broke again I didn't have a guy on a ladder in the middle of my friend Yeah, trying to trying to fix that but you know ⁓ You know, there's a couple of key points that we hit on and like as to why Things go sideways and and it's usually not a big old giant crisis that occurs that derails It's a series of these little tiny little dominoes of early decisions that get made or don't get made that really start to veer us off into bad lands. And so one of the things that we talked about was, was really having sort of a system of how they're sort of ⁓ keeping an eye on the scene, how they're managing the initial assessment of theirs, which I have personally seen now with this group, but in a system where

speaker-1: Yeah.

speaker-0: It was, you know, volunteer, very low call volume. ⁓ They put the new people out where they never run calls. And then, so when they get one, they're not quite ready for action. Even though they thought they were, they took the class, man, they're ready and they got the stuff on and they look the part, but they couldn't even manage to around an O2 tank when the stress was happening to them. So we talked about. getting that initial survey done, managing those immediate life threats. And then one of the things that we talked about was communication within each other on the scene. And then also when the help finally does get there. And we talked about the importance of a structured handoff. And so we use the example of the S bar, right? Situation, background, assessment, recommendation. And we talked about it in the first part of the

speaker-1: not to be confused with foobar which are

speaker-0: what the AV system was most of the time here. ⁓ but just, we love Stata Jefferson, but there wasn't maybe challenges. Just saying that in multiple different, in multiple different, it was the college stuff, whatever it is the bane of every conference. Yeah. Absolutely. We're not singling anybody out, but, ⁓ we talked about the telephone game, right? And if you think of all the opportunities there is to miss something or to miscommunicate something that we've done or we want to do. ⁓ and I feel like for the feedback that I got from the people in the class was that was probably the most, ⁓ important part that they took away from the talk was a structured handoff report. So, cause you know, think of all the opportunities for, if we talk about a BLS arrival on scene, they do some stuff, ALS gets there. They got to tell us what they did. Right. So we take in what they did and then now we have to do what we're going to do. And then we got to go tell our story and hopefully we remember all the stuff that they did before. So I can remember to tell this, add it to the stuff that I did and then give it to the next person, right? The nurse. And then the nurse has got to it to the doctor. Like there's a ton of opportunity for there to be a problem that affects the patient somewhere. So you, you're right. You can't overestimate or over-emphasize the importance.

speaker-1: Told you it wouldn't. You stop, everybody. Yeah.

speaker-0: We, we practice when we do a handoff in the ED, we use 30 missed ⁓ and you have 30 seconds to go through this very, very specific list of what they want to know. You have to practice it. And if you don't get it right, there's going to be an email and you're going to hear about it. it, but in reality, it is, think so.

speaker-1: And you got to practice that.

speaker-0: important to actually follow that to the letter. It can go so wrong. There are some storytellers in EMS and they want to tell you a story when they hand that station off as a storyteller. As opposed to just providing a snapshot to what you're seeing, you know.

speaker-1: We were, this came up at a panel discussion at the Georgia. That's what I conference. No, we were ⁓ in Rome ⁓ and ⁓ the conversation is what would you like ⁓ the ER team was there and the medics were there. And the question was essentially, what do you want from each other? It was, it was great. And the, the field is like, I want you to hear what I'm saying.

speaker-2: system.

speaker-0: Hey, less fat.

speaker-1: because what I have to tell you about this patient is important. And the, so I want you to just stop and listen. What do you want? And typical trauma surgeons like get to the point because we got to do shit too. So I think both of those are very valid points. Figure out what you're going to say and practice it in your head before you open your mouth. Unlike what we're doing on this podcast. Because the order.

speaker-0: The EMS show, not Lighthouse by We don't have a teleprompter over there.

speaker-1: So the order that you say this in is also very important. ⁓ We have been, since medical students, trained to present a patient in a very structured way. you're in the ER, you have a couple of medical students, a couple of residents, they're all giving you reports at the same time, and you're doing your documentation. Yes, I'm following that. So you're following all of it.

speaker-0: somebody that form.

speaker-1: until somebody starts telling you going off script and giving you the same information in a different way. And I'm like, what? I can't follow this. I can't process it. When I'm doing terminations, if somebody does it in the script that I've given them, I'm following it. I got it exactly. But if they say, well, they're in VFib now, but you know, when we first got there, this was an unwitnessed arrest. And then we did an airway. And ⁓ by the way, the initial rhythm was this. Dude, can we just start over? I don't know what you just said.

speaker-0: Perfect example of this is when you go to a fast food restaurant and you give them your entire order. I used to do that. You're like, I'm just going to give them exactly what I want. want a double cheeseburger, no mayo, extra bacon, no garden. I want a large fries with three ketchups on the side. I want a Coke Zero and you know, exactly. this is to go. Do you want a cheeseburger and what did you?

speaker-1: And then like what button to push?

speaker-0: You know, you have taken away their ability to follow along because now you are off their script. Yeah. Yeah. That's good. So what's really interesting, you talking about the telephone game. No, didn't do it. in fact he was. But you were not paying attention because people were watching. Yes. But, I, know, working in the emergency department, ⁓ when I admit a person to the hospital,

speaker-1: What we want, but go ahead. Yes, I was triggered.

speaker-0: I put a flag on that chart and I keep a list. And I read the discharge summary of everybody, single patient I admit. And in the number of times that I read in the H &P or the discharge summary, something that I never said, but they're like, in the emergency department, this and this and this happened. Like there was a chart that I wrote that said none of those things. And we had a conversation.

speaker-1: Thank you And we had a conversation.

speaker-0: So I'm curious as we implement HDE here and our medics start to, I think one of the benefits is they start to see what's in the history that the emergency physician puts in and they'll be like, that's that, it?

speaker-1: Yeah. Nope. at all. Yeah.

speaker-0: Speaking of telephone, I had this conversation earlier with Bob Page and we were talking about how people learn in the field. And I started thinking about it and I was like, you know, our knowledge base is almost like you game telephone.

speaker-1: are

speaker-0: providers rarely have access to experts. That's becoming less of a problem in the social media age, but traditionally they never had, well.

speaker-1: Introducing additional problems. Right. The natural path that rotuses.

speaker-0: They never really had, they never had access to expertise. so what happened was this maybe one person learned from an expert and then he teaches somebody in the field or he or she teaches someone in the field that is working alongside of them. And then that person gets a certain amount of time in a rate and then they teach it, slightly different. But that's how, that's how you just described residency. Okay. And it's the same problem. Right? When I was a resident, especially on my, well, certainly as a med student, I did my med student rotations in a place that had not very much attending management. was, and so I learned from a third year resident.

speaker-1: Yeah, if you're lucky.

speaker-0: Or say who learned their stuff when they were an intern for the second or third year. Yeah. See your, your, I'm not saying it's good. In fact, I don't it's exact. A lot of, a lot of, ⁓ a lot of medical training in general is still this handed down through generation perspective. even if you look now, like we still, most of us still have those very traditional. type program that you're, you know, you're going to go, you're going to get maybe like in my shop, you know, they get, meet me once and they meet my partners a couple of times. And, then they're off to their, their little field training component, which is a lot of stories handed down and this and that. And I mean, they have a task book they're supposed to get through. So you hope that everything is covered. But at the end of the day, it's still exactly what you described, Jimmy. And what happens is that the other end, when they actually do end up getting exposed to expertise, they're actually skeptical of it. ⁓ yeah, I could see that.

speaker-1: You know, the fun thing is this, what we've just been describing explains the number 17. 17 is the number of years it takes to go from, know this, we've clearly proven this in the literature to be adopted in clinical. 17 years, knowledge translation. Way too long, way, way too long. Wow. So your point about, I think you were being very optimistic.

speaker-0: 17 years.

speaker-1: about the role of social media in ⁓ essentially film ed, right? Getting open access education out there. am obviously, we're sitting here on a podcast doing things that we hope are least a little bit edutaining. ⁓ So there's some great information out there, but there's also some really bad information out there. And the challenge is I think we have probably done a really bad job. of teaching our students, probably our children, how to tell the difference between good information and bad. One of my heroes, Carl Sagan, wrote an entire book about this. And he talks about this below knee detection kit. And he said, here's some really simple ways to tell when somebody is feeding you a line of crap. If they start off, doctors don't want you to know.

speaker-0: Yes.

speaker-1: Have you ever heard a doctor who will just shut the hell up? No, we constantly talk. We want to know. Shut up. Thing. Well, so Jimmy, you and I were talking to Maya ⁓ about something.

speaker-0: Right. interesting. feel like they're inventing noises. think the Michael A was done, I.C. Cheese was finished up.

speaker-1: least the people didn't come right through.

speaker-2: Like a model speed? Yeah, woooo!

speaker-0: Actually, that's Steve. He's great. We should have him on.

speaker-1: So we were talking about something and I remember us having a conversation that this would be great to do and we talked on camera. I don't remember what the hell we were talking about. What were we talking about? it was- Maya? Yeah.

speaker-0: We were talking about, we talked about cardiac arrest. We talked about the supergluttonous about the difference between.

speaker-1: It wasn't really medicine though. was, don't know if it was decision, opportunity cost. And we were talking about the ease of adopting something and how hard it is to unadopt. So C-callers come to mind, backboards come to mind. Mechanical CPR come to mind. This is the reason some of us pushed so freaking hard against Head Up CPR.

speaker-0: adopt. See you.

speaker-1: Because we've seen what happens when you get a bright shiny thing and you push it out prematurely. And then it turns out that as promising as the bright shiny thing was, it didn't pan out. You cannot get that genie back in the bottle. ⁓ Mechanical CPR everywhere and people are absolutely convinced it saves lives despite zero evidence for that. As a matter of fact, there's decent evidence that it decreases survival, but we still grab onto that. So.

speaker-0: kind of look at mechanical CPR, I feel the same way that you do about it. But I also think that the users had determined how we're going to do CPR. It's with mechanical CPR and I don't know how you unring that.

speaker-1: then Yeah, it's a challenge.

speaker-0: the desire line of medicine, you know. ⁓ as I said, let's look at what we have done so far, right? The process. So we get the mechanical CPR device. We deploy it into the field. We give them a set of guidelines to sort of work under like when and how and like, what's the best decision, right? We do that. And then upon further review, we

speaker-1: Yeah. We should do all these right like what we really do is we cash the check and they go up, okay?

speaker-0: That's fair enough. But, the point is like, if, if we try to remediate the behavior and the behavior doesn't change, what are we supposed to do as leaders? We're left with only a couple of options. And one of the options is just take the damn thing. Yeah. Would that get people's attention? Yes. Would there be some kind of ruckus about it? I'm sure it would be. ⁓ but like,

speaker-1: the truck.

speaker-0: I don't know how else you unring the bell. think that's the only way you do it. And I don't know who's gonna do it. They would have a damn uproar.

speaker-1: know, was talking, so the way we do this, as you very well know, in Fort Worth, we still have MCDs. They're all over the place. ⁓ But we, I have said, you cannot put the device on for the first 15 minutes of the arrest. Leave it outside. Great attention magnet. You know, it walks into the room and everybody stops doing CPR.

speaker-0: I like these put them tell the story tell your tell your thing Oh, yeah, when that when that when I always tell my cruise that when the Lucas walks in the room It's like the little devil dude. Yeah, it's on your shoulder. It's like come on. I'm here. I'm here right now Put me on put me on and it's me the better lose me. Yeah, so we talked about we talked about how You know, need to put it down and put it in the corner. Yeah, and how really we should be We don't have a rule like you have at 15 minutes. But we talk about it be like three or four cycles through that you start thinking about how am I going to get this on. It is interesting because we, you know, we train, we all, think all of us do a lot of reps on cardiac arrest in our system. And I will sit there and we will talk about proper BVM technique. And we will talk about. don't put the dancing on, tell you you're like in a very natural kind of like pause. Right. And then you go, let's just run through in this area. And they run in and there's four of them. And the first guy just puts the bag down and is just doing this. And then the other guy walks in and goes, I've got the Lucas. And I'm just like, this is what I just told you not to do.

speaker-1: Yeah. Yep. Well, turns out, I mean, Humor, we do the same thing. ⁓ that's...

speaker-0: It's a human behavior thing, 100%.

speaker-1: So this is what, when Maya and I were talking about how I do this, she said, well, that's what you think they're doing. What makes you think they're doing that? And I'm like,

speaker-0: It's the protocol. That's what happens on my call.

speaker-1: No, one word, Kirby. We look at every cardiac arrest at the monitor file. You can tell when you go from manual CPR. she times it and we're like 95 % compliant. mine's like, well, how did you do that? I'm like, fuck if I know. We said, this is what you will do. And there was no wiggle room around it. I was just quite clear. And then I did do, I explained the rationale for it and I talked about the science and... what the evidence was. And I said, here's how I came up with 15 minutes. There's how we do these things. And it seems to work. Either that or we're really good at faking CPR files.

speaker-0: I think what you are doing is you're looking, right? And, you know, when in one of my systems, we have a direct line of payment based on performance of... Back to the agency? Yeah. have, if you...

speaker-1: We meaning through a contract. Through a contract. Not to the individual clinic.

speaker-0: Through a contract, if they, there are, have cardiac arrest ⁓ indicators. think, and I might try to talk about this in AAMSB. And if they don't meet them, certain percentage of time, there's a financial, I don't want to call it penalty because it's more of like, they get a bonus if they do really well, but they don't get that bonus if they don't do really well. it's a penalty. ⁓ The behavior change in the, in the agency was amazing. Right. So now I have to tell you in that same agency, you know, we don't, we don't track when the Lucas goes on, but we track the number of pauses over 10 seconds. Kind of same thing. If you never put the Lucas on, you don't have to pause it. And we have found.

speaker-1: right? That's a couple papers that show you exactly that.

speaker-0: No, we found that low on the hold if you track it and you give people feedback and then generate an economic incentive, the behavior change.

speaker-1: Change the system. Yeah.

speaker-0: I need a performance based contract for my paramedic services. No doubt. Right? But you know, when you do like a high performance CPR train to trainer session, when these people are using those high fidelity, they're at all mannequins. Even some of the most data resistant providers, when they see their performance, it's changing for them.

speaker-1: You know, when we, ⁓ and I know Mike and Ritual have heard this story, when I first rolled out DSI in Williamson County, ⁓ I knew there was going to be a massive amount of resistance because let's face it, intubating right is a pain in the ass. It is a lot harder, a lot more steps than just saying ⁓ and shoving the thing in. So I knew there was going to be resistance. So I started off the lecture. ⁓ I explained the science and I explained why we're doing it. And, ⁓ not much happened. So I said, okay, PDSA cycle, let's change how I present this. I went through and took all of our cases and I had case after case of hypoxic bradycardia, cardiac arrest. And I just took the narrative. you know, clipped out names, ⁓ put the narrative up and then showed the monitor file as this, the sats are dropping, the blood pressure is dropping, the heart rate's dropping. They go into cardiac arrest. You see the. compressions case after case. And I'm not seeing who the medics were, but I promise you they knew like, ⁓ my God, I remember this. ⁓ And now I had their attention. They are the biggest advocates for DSI now. So if we get their attention and show them in a, mean, don't point fingers at them. I'm not trying to make anybody feel bad. And I started off by going, and I know it feels bad to see this. Trust me on this. I've done this more than you have. I don't mean done it right, mean I've done it wrong.

speaker-0: to do a bad job, exactly people if in the absence of any feedback or news people just assume that everything's And I do want to say you bring up DSI is almost as likely as Sheldon check the test this spring in a total sequitur. Yeah for sure.

speaker-1: Yeah You know, you're right about what's your passion.

speaker-0: Well, listen, let's get wrapped up guys. more thing. ⁓ sorry. ahead. So I've heard this said again and again, and it's something that I want to get out to my audience right here. That is the concept. We don't innovate hypoxic patients.

speaker-1: Yeah.

speaker-0: for you guys to expound on that a little bit because it's something that's almost profound to some providers. just never heard this. sounds ridiculous. Let me, let me lead it in a little bit from the provider side for a second and then I'll kick it off to you guys. So what you just told me seems completely not intuitive. I'm integrating because they're hypothesis. They're hypothesis. My method of doing fixing that, cause we're fixers, we got to fix it. is to put the plastic in there and that will fix it. so. It doesn't fix that.

speaker-1: Yeah, exactly. Well, congratulations.

speaker-0: It may fix something, but you've caused some problems down the road with other stuff.

speaker-1: Yes. it turns out number one an ET tube doesn't ventilate anybody. It doesn't oxygenate anybody. All it does is keeps the tongue out of the way. Now it allows you to do some cool things like oxygenate and ventilate, but the tube itself is not taking care of the hypoxia, regardless of what it is. So what you've done is add dead space. You've actually made your job a little more difficult. The process of getting that tube in is incredibly important. Intubation takes way longer than we think it does. I promise you, I don't care how good you are. You can put a supraglottic in faster. So that is an opportunity cost and it's an opportunity cost that the patient has to pay. So if we are saying that hypoxemia, the dose of hypoxemia, meaning how low it went and how long it was down is bad. increases mortality, which it does. If we're saying the dose of hypotension is bad, then anything we do that makes that problem worse is bad and harms the patient. Intubating does both of those things. It has the potential to lower your saturation and it will lower your blood pressure no matter what you do. Now, a perfectly healthy person You may not notice it. may not be clinically relevant, but their blood pressure will drop a little bit. that ain't our problem. So one thing that is really important about the don't intubate hypoxic patients until you do something. So you have to make it safe in order to intubate them and then by all means, intubate them. So you prepare them for this first. And this is not a radical concept. It's just a radical concept in EMS. Talk to anesthesia and they're like,

speaker-0: in our population.

speaker-1: I don't know why you're putting fancy words on this. This is just how you should manage an airway. You're sort of right.

speaker-0: Well, when we were going through residency, we almost made fun of anesthesists. Right. they don't have to do an RSI like, know, IVs. And it turns out that they were right.

speaker-1: Exactly. They don't do crash. Right. Those damn pilots, you know, they're just so methodical about things.

speaker-0: But you know, what I talk about with my agencies, what I talk about with mine, is that we used to see intubation as a solution. used to see intubation as a goal. What was a successful airway management? Walking into the emergency department with a piece of plastic in between the cords and waving everybody the app, who I am and I got this. you know that, but now when you really look at, that is not the definition of success, the definition of success. is improving oxygenation, improving ventilation, and improving blood pressure. That's how you're successful.

speaker-1: without causing harm in the process.

speaker-0: I guess the way when I say you're going to take this patient from here to here, you're not causing harm. Again, the journey is much more important than the destination. There are lot of different destinations that you go to that are equally kind cool. You can go to casino, you can go to the beach, they're all equally fun. That's fine, whether it's supraglottic or BVM or...

speaker-1: Yeah.

speaker-0: What are you calling the mega, the mega airway? Max medium. Mega BVM. like mega BVM. I thought he could use that. know, yeah, the journey is more important than where you got to. ⁓ It's resuscitate before you intubate, but it's so much more than that. It's like complete your resuscitation before you intubate.

speaker-1: Dr. Miller is twitching somewhere. Yeah So I'm a big fan. I am probably one of the most, ⁓ one of the biggest advocates for EMS intubation. ⁓ I'm constantly, people accuse me of not being an advocate for intubation because I've restricted it pretty significantly in my systems. But I'm like, no, I'm an advocate for doing it right. Because it's not about us. It's not about our egos. It's about taking better care of our patients. We're doing tomorrow. That's the problem.

speaker-0: medic is the intubation.

speaker-1: Right? Don't get yourself so wrapped up in one skill. ⁓ Because it's not about you. It's about our patients.

speaker-0: Well, paramedic is not a bag of skill. Paramedic is on mind, you know.

speaker-1: Yep. Yeah. And both of those are incredibly important, both the mind and the heart.

speaker-0: My earliest mentor in EMS told me, don't fall in love with your interventions. Salient pieces of advice I'd ever had in my career and I've never forgotten it. And I never, at that point, I've always considered innovation something like my practice is innovation avoidance.

speaker-1: That's what the mox suggests. You know, it turns out anesthesiologists, they're like, I do a lot of things. I have a lot of knowledge. I'm not an intubationist. I'm an anesthesiologist. ⁓ they, in their practice, have dramatically decreased the number of intubations. For sure. And they still feel just fine about themselves.

speaker-0: Yeah. All right. Well, that's a good place to stop. on behalf of Jimmy, Jeff, Ritu, Mike, you've been watching or listening to the EMS show and the EMS Avenger pod.

speaker-1: AMS Lighthouse Flavor. ⁓

speaker-0: Yeah, there was we talked about research for a minute. Yes, sir. Yeah, anyway, I'll see you guys all later take care

speaker-1: I'll take care of y'all.