7 Things Clinical Outsiders with Chris Ebright

This 7 Things EMS discusses several EMS patient presentations that are not very common but are still vital to be aware of during clinical practice. This session covers pediatric topics such as congenital heart defects and autism and conditions such as sepsis, autoimmune disease, hematology, and more. Listen for a great review of the “outsiders" with Dan Limmer and Chris Ebright, Lead Instructor for The University of Toledo EMS Program and National EMS presenter.

Episode Transcript

(00:00):
Welcome to Seven Things EMS, a continuing education offering from LEMUR Education.

(00:12):
Seven Things EMS is designed to give you what you need to succeed in EMS, it's conversational,
informational, and without the fluff.

(00:32):
Welcome to another Seven Things EMS podcast.
My name is Dan LEMUR, your host.
We have the good fortune to be here today with Chris Ebreit.
It's a great topic for this session.
The outsiders, some of the things that we don't think about all the time in EMS, but
they do rear their head.
We need to feel better about these things, need to have an understanding, and there's

(00:55):
nobody better than Chris to give us this information.
Chris is lead instructor for the University of Toledo EMS program.
He does all kinds of EMS education.
He's been a paramedic for 29 years, really all over the place, all over the world, and
he is a very frequent and well-known conference speaker around the country.

(01:16):
You may have seen him here, known here for a long time.
Welcome, Chris.
Thanks for having me.
Glad to be here.
And we don't waste any time.
Not a lot of fluff in the beginning is our hallmark.
We'll go through and do it.
The first one is autoimmune diseases.
I think we all could probably pick out one or two of those, but talking about the important

(01:38):
ones and what they mean to the average EMS provider, how they fit into the care we give,
this one's to you.
Okay.
Well, and again, when you look at the spirit of what an autoimmune disease is, it's something
that unfortunately somebody gets and they just don't have the choice.
Their immune system for whatever reason, and there are a lot of them, basically turns against

(02:03):
them.
And we see in EMS a lot of patients that have a result of this, one of the most common ones
is diabetes, you know, your type one diabetics.
And obviously we start seeing a high incidence of this in children.
And then obviously it's throughout the rest of their life where we may be seeing these
patients quite often because of their insulin deficiency.

(02:25):
But there are lots of different causes and risk factors behind why this happens.
One simply couldn't be just environmental factors.
Sometimes it's oddly enough, you know, sunlight, certain chemicals, certain bacterial viral
infections, all those things can trigger something innate into the immune system that causes

(02:47):
havoc.
And as a result, you know, the patient develops some kind of problem because of that.
Genetics obviously also has a big role with this.
And quite often that's one of the catching points in a lot of these things is because
being genetic in nature, it's very hard to kind of control what the genetic code is going
to actually cause and make the immune system do.

(03:10):
The other thing is just simply their age.
And unfortunately, it tends to happen more often.
A lot of these in females and where they tend to start manifesting is usually in their late
teenager early adult years.
One of two that will kind of concentrate on here real quickly is the difference.
Some people get these mixed up between multiple sclerosis and mycena cravis.

(03:36):
So what multiple sclerosis is, if you know the structure of a nerve cell and you have
insulation around this wire, right?
And that insulation is what's called myelin.
In this case, what happens is that typically somewhere in average patients, somewhere between

(03:58):
20 and 40 years old, this patient now starts having their immune system go after and basically
attacking this myelin sheath in various areas, most notably in the nerves that attach to
the skeletal muscle.
So when that breaks down, what happens is that now that signal going in there to try

(04:19):
to contract that muscle properly is either partially or totally interrupted.
And once that happens, it becomes permanent and it starts to progress.
And this patient has then these progressive signs of symptoms of weakness.
They're more prone to falls.
Elderly patients obviously now are looking at falls with head injuries, fractures, things

(04:39):
like that that we would get called for, but the underlying issue would have been their
MS.
Now, take that and kind of compare it to this other one that's a nerve issue, which we call
myocenia cravis.
And that the problem is, is that the immune system actually attaches or attacks the receptors
that coordinate the signal from one nerve to another.

(05:03):
You have a end of one nerve and you have a receptor on the other side that collects
all the transmitter that goes from one to the other.
Well, in this case, unfortunately, what happens is that the immune system develops antibodies
and they sit on these receptors where the transmitter should go.
And when that happens and it takes up enough of those spaces, now what starts to happen

(05:26):
is that those muscles now that are not being transmitted to or not being stimulated, now
also starts to cause that voluntary muscle to become weak and malfunction.
One of the kind of patterns we see with this, unfortunately, is where you get it starting
usually in the periphery.

(05:46):
They're not exactly sure why.
So your extremities tend to get affected first and then that weakness starts to progress
inward and inward towards the core.
Eventually, in some cases affecting their ability to ventilate and obviously their intercostal
muscles and they have a problem breathing.
One of the things that can manifest what we would get called for a lot of times would

(06:08):
be maybe that respiratory component, but they could also have what's called a myosinic crisis.
In that case, what happens is that this patient goes into respiratory failure secondary to
this.
Maybe they get a respiratory infection that kind of exacerbates it.
Sometimes it's an electrolyte imbalance that exacerbates it, but certain medications that

(06:29):
they either are taking, maybe they get prescribed, some stuff that's over the counter can also
accelerate this process and they go into very severe respiratory distress and failure, like
I said.
Patients that are on beta blockers, patients that take other heart-related medications
like calcium channel blockers, even papes that are on muscle relaxants.

(06:51):
So you get it for something else and all of a sudden these interact and all of a sudden
you've got a patient who is in very severe distress and we get called for something like
that.
I should just give you an interrupt for one second.
We've talked about diabetes, kind of considered an endocrine disease.
We talked about neuromuscular diseases.
So the autoimmune disease is really at the root of all these things.

(07:15):
The immune system attacks the pancreas, takes out the ability to make insulin.
The autoimmune system attacks our nervous system.
So really this is a big underlying thing and a lot of things that happen in our body.
It is.
And quite honestly, there's over 80 different types of autoimmune diseases that are out there.

(07:35):
And they kind of separate them into two separate categories.
One what they call organ-specific.
So you would have the pancreas, the nervous system in this case.
Sometimes it's a thyroid gland, sometimes it's the adrenal glands.
Those can also be attacked and cause, you know, have problems because of that.
So there's any number of reasons why it happens and it starts to manifest internally.

(07:59):
But now externally we see those signs and symptoms and it comes in as all variety of
types of calls.
And we have to manage that because obviously the underlying disease is something we just
can't manage.
Right.
Well, we've got six more things to do.
I'm going to move on from that, but it certainly is food for thought as we go through.
The next one, congenital heart abnormalities.

(08:23):
I think congenital heart abnormalities, you know, when paramedics are taking their registry
and the things they're studying from special populations and all that stuff, that's there.
I think there's a couple of big ones that we should get into and let's clear that up
a little bit.
Yeah.
And I'm actually, I'm just at the point now in my paramedic course with my students that
we're just about to hit that this month.

(08:46):
And every time I teach this, I get the during the headlights look and it's like, why do
I need to know this?
It's like, because registry loves to ask questions about this.
And Dan, you and I have been doing enough with, you know, prepping people for registry
over how many years and we see these common things start to pop up and this is one of
them.
And as providers, we don't see these patients a lot, fortunately, because most of them are

(09:08):
getting care either in a hospital or when they do have an issue, the parents are usually
responsible enough and they're taking them to the hospital and we don't get involved.
But there's three that I kind of going to focus on here just real quickly.
One of them being what's called tetrodesia fallow.
And basically what it is is there's four things that are wrong with this newborn slash infant's

(09:31):
heart.
The first thing is that they have a hole in their heart.
Well, they do when they're born anyways, but those eventually seal up this one, not so
much and it's in the ventricle.
This was called a ventricle septal defect.
The problem with that is that it allows blood that's oxygenated to mix with blood that's
not oxygenated.
And so the underlying problem that we see with kids that have this is they are sort of

(09:58):
on the borderline of being hypoxic even on a good day because of that.
But that's just one part.
The second part is that they have an issue with their pulmonary valve that basically
separates the right ventricle from the pulmonary trunk.
And with that what happens is actually it's been narrowed, as we'll call it stenosis.
And that narrowing is now causing back pressure on the right side of the heart.

(10:24):
And it also then obviously lessens the amount of volume that can go forward into the lungs.
So that also contributes to the hypoxia because the volume that's moving through the pulmonary
system on average is less than what it should be for their development.
So that's the second thing.
Third thing is they have a problem also with the other valve that goes to the aorta.

(10:47):
And in that case what happens is actually someone enlarged.
And what it tends to do is that it grows into and actually kind of encompasses both and
lets blood come from the right and the left ventricle mostly from the left but a little
bit from the right as well.
So now I get a mixing not only from that hole that's there but now I also get this mixing

(11:07):
of blood that now is being pushed out to the body that is still not completely oxygenated.
There's still a deoxygenated component to it.
So with that the problem is at any one point their blood's not carrying enough oxygen and
they now start to develop a kind of a bluish ashenish tint.
It's anything other than pink which we like for their skin.

(11:32):
Fourth thing is that now because of this back pressure the right side and the left side
go under a considerable amount of strain.
So that muscular wall on the right side that normally should be relatively thin compared
to the left.
Well now it starts to get very, very large and starts to hypertrophy.
Unfortunately in this case when the right side hypertrophies it doesn't really become

(11:55):
efficient it becomes more inefficient.
So now I have a pumping problem also moving to the belongs against a lot of resistance
from that narrowed artery on top of the fact that I'm not moving a lot of blood.
So on a good day these kids are kind of like I say borderline but now you get into a crisis
where they get sick or they're coughing or crying or feeding or something like that then

(12:15):
this kind of discoloration which they call a tet spell kind of accelerates itself and
these kids turn quite cyanotic in some cases and get into a little bit of distress and
we may be called to a system at that point.
So that's one of the things.
Another one is-
That was a great explanation Chris.
People would say now I get even pronouncing it people have trouble with.

(12:37):
Yeah I always get everybody says it's phallid.
It's like no.
It's a shallot.
It's got all kinds of ways things been explained.
So but thanks.
It is one of those things out of all of them this is probably the most common when we may
come across the other one which is kind of the brother to this is what's called the coarctation

(12:57):
of the aorta.
Put simply there's a pinch in the aorta right where the ductus arteriosus the connection
between the pulmonary artery and the aorta when you were in utero sometimes produces
a pinch point sometimes as a result then what you start having is bounding pulses and extreme

(13:18):
perfusion if you will go into the upper extremities in the head and in some cases you can actually
see these kids and this looks like their arteries are going to pop right out of their
neck you feel their pulse and it feels like they're going to jump out of their skin but
in comparison what you also have is poor perfusion basically everywhere from that self
depending on how constricted this actually is so long term this can obviously cause

(13:43):
organ damage to lower extremities to the abdominal area even in some cases to some of the thoracic
organs as well depending on how bad it is so we may see complications of that which
we again may have to manage in some cases or long term down the road they may have developed
complications when this gets fixed but they have residual issues and you know we see things

(14:04):
like that the last one which is probably the rarest of the three but it's something that
kind of found when I was doing a lecture for something else and what it is and this one
is kind of a hard one to say it's the arrhythmal arrhythmic cardiomyopathy and basically what

(14:30):
this is here is the heart develops overall like it's supposed to problem is that again
this is more of a genetic abnormality that causes this it's pretty common it's about
one every five thousand cases and what happens here is that the myocardium the muscle of
the heart actually gets replaced with this genetic abnormality with scar tissue and fat

(14:55):
so it's actually that's what part of that wall is is just scar tissue and fat it's not
muscle because of that what can happen is that under extreme stress and especially if
there's excessive stress put on the heart this can excessively dialy and when it does
it kind of interrupts the normal flow of the electrical system in the heart and very easily

(15:18):
could put the child or the adult in this case into cardiac arrest secondary to V-fib
and so when we see kids going cardiac arrest it's a very rare thing with this congenital
issue it's one of those things that kind of sneaks up out of nowhere even though they
do know in some cases that they've got this there's no right or wrong reason as to why

(15:38):
it would happen it's kind of a ticking time bomb and once these kids going to V-fib the
collapse and obviously then we could call for the arrest which can be resuscitated but
in the end eventually these kids start needing to start thinking about either a total heart
replacement or they get on ventricular assist devices or something like that temporarily
and that may be something that we manage down the road as well until they get that new heart

(16:01):
so yeah wow well we're going we're going to keep going with the pediatric concept here
with number three and we're rolling along really well you know the dimension you know
with kids you kind of think respiratory first these kids have got heart stuff and the next
topic is pediatric chest pain we don't traditionally think of pediatric chest pain as ischemic

(16:23):
like we'd have it in adults the Kid Coronary Syndrome so what causes this what what's your
outliers for this one yeah and and just to keep it in mind I mean if you ever come across
a child who's complaining of chest pain you take a little bit of grain of salt because
their sense of pain in a lot of cases is very you know visceral you know instead of just

(16:45):
hurts all over that kind of thing but in some of these cases it gets very specific because
you'll start to see certain things with these kids that is very kind of easy to pick off
if you know what you're looking for a lot of the things you see or that will come across
with kids as far as cardiac origins of chest pain basically is in three different categories

(17:07):
it's either structural electrical or some type of inflammatory process so structural
wise I guess the one that I want to kind of highlight here is something that some people
have probably heard of it's called Kawasaki disease and basically what it comes down to
is that it's first and foremost the child has a temperature if there's no temperature

(17:29):
involved here if they're not spiking a fever you throw this out automatically but with
that fever and the complaining of chest pain we look at five other parameters and all the
child has to do is have four of these five parameters and they would be considered to
have developed what's called Kawasaki disease but in the meantime it produces a lot of changes

(17:52):
in the coronary arteries causes aneurysms sometimes dilation as well as in some rare
cases you get effusions in the pericardial sacs so you could have kind of small complications
related to what looks like a tamponade in certain aspects as well but the five points
that you want to look for there's all different mnemonics of course in NEMS and so this one

(18:18):
is different and what they usually use for the mnemonic in this one is that they say
it's hot cream so hot is the fever and then cream is CREAM those are the five aspects
so the C stands for conjunctivitis so what we will see is evidence of that so you look

(18:39):
at their eyes you'll see that redding of the sclera you can look underneath their eyelids
and you'll see maybe even some Perlian discharge or something like that simply because of the
infection process that's going on here it's a reaction basically to this infection is
what's causing this Kawasaki manifestation right second thing is you get is a rash which

(19:01):
gets a lot of times mistaken for anaphylaxis it gets mistaken for measles it gets mistaken
for a lot of things but the rash itself tends to be very similar is that it is pretty much
throughout the whole entire body you see it front back and everywhere the third thing
is redness and more specifically in this case it's redness on the palms of their hands

(19:24):
and the soles of their feet this is where it tends to manifest fourth thing is they
get another thing which throws people off the technical term for the medical term for
us called adenopathy but basically what it is it's like it looks like the mumps they
get these lumps in their adenoids down here and it kind of looks like they got little
chipmunk cheeks as a result so it gets mistaken and put off as that even though they may have

(19:48):
even had MMRs and all those things there you go and the last thing is that they get these
really dry mucus membranes so their tongue kind of turns almost like a consistency of
like a strawberry very very bright red very dry very kind of crackly their lips same thing
and so if you have at least four of those five things along with the chest pain and the temperature

(20:08):
then that can be pretty much construed as Kawasaki disease and actually my colleague
I used to work with down south at Acadian his daughter had it when she was younger so
he's got a very first hand knowledge of all that stuff.
There's going to be EMS people out there now checking off these things looking anytime
they have a kid patient like that we're going to be looking for that now.
Well and that's just it because you know that's the thing too you get the stigmas like you

(20:31):
hear pediatric or child or you know infant or whatever over the radio and you know I
tell everybody so well what do you hear after that and everybody says well not a whole lot
it's like yeah you hear Charlie Brown's teacher because you're so freaked out that you got
to take care of a kid and then you hear chest pain on top of it or something like that then
it makes it ten times worse right.
So and there's a couple other things and one's related to something we're going to talk about

(20:54):
here also in just a minute is what's called acute chest syndrome and this is secondary
to sickle cell disease.
So there is a documented history the child has it typically what happens here is that
they have an acute lung injury secondary to the sickle cell manifestation and this can

(21:14):
be anything that looks like a pulmonary embolism to you know it could be an infarction of the
bone marrow itself and actually is a fat embolism that kind of gets loose from some distal
long bone in that case but in either way what happens is that the end game is that the pulmonary
capillaries and a lot of the circulation going in and out of the lungs because of this reaction

(21:39):
starts to constrict and so now they start having problems not so much ventilating they
have problems with perfusing and like I said it comes across looking like a PE but in a
case where again this will come this will be a very acute onset of chest pain very much
like a PE but the child has a history of sickle cell and this very well could be what it is
as well.
Fortunately or unfortunately how everyone look at it still manage the same way you know

(22:01):
we oxygenate ventilate and try to support them as best we can and then usually this has to
be treated in house as far as resolving that sickle cell crisis so.
And it can be really painful.
Yeah.
Really painful.
I mean these kids are screaming you'll hear them before you see them in a lot of cases.
Adults adults too and not a big eye.
Absolutely.
That's great the sickle cell coming up it really is something we need to know about.

(22:26):
So do we have one more pediatric chest pain.
Yeah the I'm just kind of putting a few of these together and I caught one it was actually
kind of interesting.
A lot of times this is something that's very simple it's structural in nature but it's
what's called pre-choreal catch syndrome.
And this is something that's more this and that vaso occlusive acute chest syndrome we

(22:51):
just talked about are more kind of non cardiac in nature as far as the origins go.
But this again is something where unlike the rest of them where they're going to kind of
compare this this real type pain here this kid's going to point right to it.
And typically they're going to localize it literally about the third fourth rib down
and it tends to happen just in this area for some reason.

(23:13):
It usually gets worse when they take a breath in gets better when they let it out and it
doesn't last very long so it kind of comes and goes and it can have multiple instances
where this happens over the daytime and there could be you know numerous instances where
this happens well eventually they start to freak out and or the parents do and they call
us.
The typical scenario with this is that the pain begins at rest and there's not really

(23:38):
any other symptoms other than just I take a breath it hurts right here.
And what's happening here is what they think happens is that the intercostal nerve that
runs the muscles in this area because of the attachment of the cartilage may be a little
bit off it actually is pinching when they take that breath in that shifts the muscle
actually pinches the nerve and that irritates it and causes that acute pain but when they

(24:01):
let it out of course that pressure is relieved or back to normal.
Eventually again that irritation just kind of subsides and it goes away but then it can
come back with activity or stress or anything else that may you know pop up during the day.
So that's something that's pretty benign there's nothing they can do about it maybe a muscle
relax under slight pain meds but that tends to pretty much just take care of itself after

(24:23):
a while and it's pretty much a diagnosis of exclusion but it can look and present because
they're going to point right to this area here and you have anybody that does that we
always think you know hurt first and so we have to at least give them the benefit of
the doubt you know do your due diligence and you know check the rhythm and all that stuff
but you're not really going to find anything and you're not really going to have a whole
lot of history behind them if any other than this acute event that occurs and it again the

(24:46):
age range usually is somewhere between like one and eight years old where you start to
see this so.
I think that people here are going to have a lot of knowledge about things that they

(25:14):
either had never heard of or may have heard of but didn't couldn't really put a description
to it I think that's awesome.
One that we have heard of is sepsis yet we still I think struggle to understand some
things about it you put it in your outsiders here tell me about it.

(25:36):
Well it I'll be quite honest with you I've been doing and I'm not nearly the expert
I mean I don't claim to be by any means but you know I'm constantly trying to keep on
top of this and I always seem to never really get a concrete answer to how do we even start
suspecting this right I mean you look at five different references you're going to five different

(25:57):
answers and no one really has said anything specific and I think that that's something
that's still to this day we're still working on but one of the things that we can look
at to be suspicious not every person that septic is going to spike a ton at least right
away one of the things we see especially with children but even younger adults and geriatrics

(26:20):
to a certain degree is that there's two big pathways a lot of people will take one is
what's called the surge criteria srs and one is what's called the sofa criteria just
like your sofa couch so it depends on who you talk to it depends on what medical director
is in charge but the the surge criteria is it's pretty pretty easy to kind of go by just

(26:43):
think of the mnemonic hat just like a hat that you wear so the key is with anything
with sepsis is that you suspect they have some type of infection regardless of what it is
and then what you're looking for is that do they have at least two of these three things
also present one being for their age are they hypotensive right secondly do they have any

(27:06):
change in their mental status if they're not a gcs of 15 then that is considered to be
obviously altered and the third thing is is that are they to kipnic and or are they sustaining
a very low co2 I'm going to come back to that here in just a minute because that has some
relevance to talking about septic shock and organ failure and things like that so that's

(27:27):
kind of related to what we see with the sears so HAT so hypotension, ultramental status
and to Kipnia the sofa or a modified version of this what they call Q sofa the quick sofa
type of administration is going to be something where same thing you suspect they've got some
type of bug I got an itis of some sort but now it's kind of proliferated now you have

(27:49):
at least two of these things one is that they do in this case have a temp and this is again
based on their age so if it's older than three months then typically we're looking at a temp
of 101 or more if they're younger than three months then it's typically a temperature of
around 100 spurs they kind of cut that off they are to kipnic in some cases and or are

(28:15):
they tachycardic or bradycardic for their age right so again you have to know based
on their age what is tachycardic consider bradycardic their normal values so you have
to pull out some kind of a chart and figure that out if they have at least two of those
parameters along with the suspected infection that puts them into that category of okay
your septic now going further which is more rare and quite honestly the only place I've

(28:42):
ever seen this is when I've been transporting people out of one hospital to another is you
have a patient in septic shock now I know some of the listeners out there are probably
living in these outlying areas where you've got 45 days just to get to the patient because
I've been to some of those places so I know what that's like and so you may come across
a patient like this simply because they don't have access to health care it's going to take
a long time for them to get help but your average you know area septic shock first thing

(29:08):
is is that well you've defined that substance but we just talked about but now what you
add into it is that they are also now hypotensive for their age and in most cases usually they
are refractory to fluid replacement they're not fluid responsive so you're trying to
give fluid to try to get their pressure up and it's just it's not budging at all the

(29:31):
only other thing would be is that if you tried fluids and didn't work and now you're trying
to get breathing pressure if the pressure can not or barely can maintain a mean arterial
pressure of about 65 those by definition put them into what's called septic shock now those
you that know mean, mean arterial pressure is it's basically your blood pressure at
any one point. It's kind of a snapshot of a true profusion to the brain. And there's

(29:55):
a range that we like to keep it in between the probably about 70 to 110 so 65 is still
considered very borderline baseline OK,
but it would like to be higher.
So with that, how do you calculate it?
Well, you don't have to.
If you look on your machine, on your cardiac monitor,
you've got your non-invasive blood pressure cuff,
which is very good at calculating the miniaturial pressure,

(30:18):
because that's kind of how it's been developed,
is to do that.
There's a little number in that corner.
You see your systolic and diastolic,
and a little number off to the corner?
That's the miniaturial pressure.
And that's going to give you your true accurate reading
as far as perfusion at that point.
So go by it.
And if it's above 65, well, you're OK.
But if it's at or below 65, despite fluid or pressures,

(30:39):
now they're in septic shock.
Now, lastly, how do we know if they're an organ failure?
Now what we do is go back to that carbon dioxide I told you
about earlier.
So they're in septic shock.
They fit that definition.
And now you might see a correlation,
because one of the parameters is that they

(31:01):
have to be metabolically acidotic.
There's a lot of ways we can tell.
But the way you can tell in this case
is you look at the monitor, and you look at their CO2.
And most literature will say that if they're
sustaining at or below 25 on their CO2,

(31:22):
because they're breathing very rapidly,
because they're trying to fend off all these toxins,
and they're trying to get rid of all this heat that they've
built up.
But they're also, in that case, very acidotic.
So the brain's trying to blow off carbon dioxide
to balance it out, trying to create
a balance between the acid and trying to make them basic.
Won't work, because it's metabolic in nature,
but the brain didn't know that.

(31:42):
And so the brain keeps telling, keep breathing, keep breathing,
keep breathing, keep breathing.
And they sustain this 25, around that 25 line or less,
as far as their CO2 on their own.
What that equates to is a lactate level of around 4.
All that's required to put them into organ failure

(32:04):
is a lactate level of 2.
So this is double, in this case, what normally
would put them into that issue.
And now you're going to see other problems, which we'll
have to deal with, as far as now not just
do they have the blood pressure issues and the perfusion
problems and obviously the temperature issues,
and they're losing volume in their third spacing
and doing all that stuff.

(32:25):
But now you have other organs, which
are now being under perfused, and now it
becomes a multi-system issue.
And this is when these patients really start to have problems.
And so the end goal of this is obviously
get to these patients as soon as we can,
sooner, hopefully, than later.
And early recognition and obviously managing this
is going to be probably the benefit,
as far as providing a positive outcome.

(32:48):
A lot of what I just told you is also
a lot of the basis behind what you
see where certain services will develop their substance alert
protocols based on that information.
And fortunately, there's a card or something
that you can go by to do this.
Some services have even gone as far.
I know there's at least one in the Carolinas,
because a good friend of mine works there,
that they've been doing substance alerts forever.

(33:09):
But they're actually drawing labs and doing blood cultures
in the field.
So it accelerates the possibility
of getting antibiotics in the field, which is now
what's progressing in our profession,
and getting the care to these people that maybe, again,
are in these outlying areas a little bit sooner,
getting it on board much quicker, and hopefully having
a more positive outcome.
So substance is always going to be there.

(33:32):
It's one of those things that we don't see a lot of on a routine
basis.
But when we get these patients that are really qualified
as far as being septic or in septic shock,
these are really sick patients, and they're
really hard to manage in a lot of cases.
Yeah, I know that's great.
And I think those points that you made very early on,
the mental status and tachypnea really

(33:53):
should be what's heightening our suspicion,
and they're used in a lot of the assessments
that you mentioned before, that in that,
without the raging fever we see, mental status and tachypnea
are big.
Yeah, and it was actually interesting when
I was going through all this.

(34:14):
In the last few years after post-COVID now,
they've been doing a lot of looking back.
And we saw a lot of instances where people were just
flooding these hospitals and becoming septic.
And they came across and made this correlation between COVID
and sepsis.
And it kind of got its own little moniker because of it.

(34:36):
And now it was treated in a little bit of a different way,
simply because of the fact of that underlying viral issue,
which was causing the problems, which required
a different therapy than obviously your typical sepsis
patient that usually is most of the time bacterial in nature,
but can be viral and other things as well.
But COVID being what it was, and we didn't know exactly what
it was doing in some cases, it was causing all kinds of havoc

(34:58):
and led to a lot of things, including myocarditis
in a lot of kids.
We saw those numbers just spike through the roof
for a couple of years, which that's very rare in kids,
but now it wasn't.
And it was attributed to the same thing.
So it's kind of interesting, a period of about two or three
years back then.
Oh, that's one certainly one way to put it.
Going on with our number five, I believe,

(35:22):
the hematology and sickle cell, where time is ticking on here.
I think we've covered in some of sickle cell.
Hematology, anything else you want to throw in there?
Yeah, I mean, you get the patients that are
thermoenemic.
And there's lots of different ways
that people can get anemic.
Simply one, they can just be low on iron.
And as a result, and they don't have a very good capacity

(35:44):
to capture and or circulate oxygen.
So that can be a big problem for them.
In a lot of cases, simply just by females getting pregnant,
that will make them relatively anemic for their first few
trimesters, simply because they get
excessive volume to fill the big pipes that they've now built
to feed the uterus and feed the baby and everything else.

(36:07):
But it takes time for that blood marrow to, or bone marrow,
should say, to build up red cells.
And that relative lack of red cells
compared to the volume that's excessive in those early stages
of pregnancy that mismatch creates that anemic problem
in your patients as well.
So they have this need for, we always
try to keep them on oxygen.
And we try to make sure that they're being ventilated very

(36:27):
well, even though when they start to get those later
trimesters, that ventilation becomes a problem
because of the big bulging ball sitting in their belly.
Vitamin deficiencies obviously can also
cause various types of anemia, especially B12.
A lot of times, this also deficiency
can be related to the fact we talked about your type 1
diabetics.
They can be prone to developing that,

(36:48):
as well as the patients with those autoimmune thyroid diseases.
Can also be prone to having anemia secondary
to vitamin deficiencies.
So you have lots of different possibilities,
along with sickle cell, that can cause
those types of anemic issues.
The other thing that we look at with blood in general,

(37:10):
or hematology in general, is that you have these hemophilia acts.
And it's no fault of their own.
But again, it was a genetic miss up
that they lack a what's called a clotting factor.
And there's 12 of them.
Typically, there's a couple of different types.
One which is called hemophilia A. And in this case,
just think of the clotting factor just like a ladder.

(37:31):
So you need each clotting factor is like a rung
in that ladder.
And if you're missing a rung, you stop at that point
of the ladder.
So in this case, being a clot, if we
stop at a certain point and don't finish,
the clot only partially forms.
So you have hemophilia A, which is going to be your patient who
is lacking what's called factor A. This is the one that's
called classic type of hemophilia,

(37:53):
which you see a lot of instances of.
The other one is what they call the Christmas disease.
And this is what hemophilia B. And this is a lack of factor 9.
So you have those problems that occur.
These patients are getting more prone to bleeding internally
as well, externally.
We have a hard time controlling these patients
if they get into trauma types of incidences.

(38:15):
Do as well in some cases because they just don't clot as well.
They may need that assistance of wound packing in some cases
and in the extreme case.
TXA has some benefit in this case.
But because the clotting factors aren't there,
TXA is kind of meant to help enhance those clotting factors
to do their job.
Well, if it's not there in the first place,

(38:36):
TXA only has a small benefit, not as much
as we would see in a normal patient.
And it'll vary from person to person.
So we have those problems with those people as well.
The last one, which is kind of an odd one,
is what's called von Willebron disease.
And they're missing this clotting factor, which
is called von Willebron factor.

(38:58):
What happens is that this factor attaches to the platelets.
This is what allows the platelets to kind of stick together.
This is what makes them sticky.
And so when this is lacking, those platelets
don't stick together.
You don't form that plug.
And of course, then you continue to bleed as a result.
And there's three different types of it.
One exists where the person just has lower

(39:20):
than normal values of it.
And along with that, these are also
the ones that tend to have low factor 8.
So they have a little bit of hemophilia along with this,
which makes it twice as bad.
The other type is where they have normal amounts,
but it just doesn't, for some reason, still,
it's like glue that's been sitting too long and it hardens up.
Well, it's kind of what happens here.

(39:41):
It just doesn't stick like it should,
even though there's normal amounts.
And then the third type is where they just don't have it at all.
And these people, again, need to have that replaced
in certain instances.
And we may be seeing consequences of that as well.
So there's lots of things as far as hematology goes.
And we see consequences of cancers,
all kinds of things with patients that we deal with,

(40:03):
the signs and symptoms of.
But unfortunately, there's not really much.
Even with sickle cell, there's only so much we can do,
pain management and fluids and things like that,
to make them comfortable.
But in the end, they're going to have
to manage on a daily basis this deficiency
for their whole entire life, just
like your autoimmune diseases.
And it gets to be somewhat troublesome after a while.

(40:23):
Yeah.
That was a great review of those things you've read
in your books on Willa Brands.
You've done these things.
So it's good, I think, to bring these back.
Just what a great way to.
And it's the way I think EMS people like to learn things.
Just open up the fire hose.
I'm going to get a drink.
Let's give seven things and a lot about them.

(40:43):
And with that, we'll roll in number six.
Special technology.
Patients with special technology.
Yeah.
There's more and more out there now.
There are.
And quite honestly, the reason is
because, well, just like anything else in medicine,
we progress.
And what's available now versus what was even available
10 years ago is a whole lot different.
And quite honestly, the parents want

(41:05):
to have their kids at home.
The kids don't want to be in the hospital.
The technology is more portable.
It's more user-friendly.
It's a lot less expensive.
A lot more insurance companies are actually
willing to pay for it.
So those are all advantages.
The support services outside of the hospital
are much more plentiful.
The money that's there for people to go to clinic

(41:26):
or to go to even stand alone emergency departments
or clinics that way, that's there,
which again, wasn't there five, 10 years ago.
So they have a lot of access to these.
So they're going to be in your catchment area
if they're not already.
You're going to see these kids.
And you're going to see these adults.
A couple of things just to kind of consider
with some of these patients.
One, for example, that happens to have a shunt.

(41:49):
Kids, you know, they get into everything and they fall.
And they hit their head and so on and so forth.
And things happen.
Well, the shunt's actually meant to drain
excessive cerebral spinal fluid from the brain.
And it has a couple of different components to it.
But most of it is a large catheter that runs from their head.
Usually in later years, they snake it behind the ear
and they run it down the neck and it collects in the abdomen.

(42:12):
If you're looking at a smaller child or toddler, school age
kids, something like that, for example,
as compared to an adult, what they'll do with those kids
is that they actually have an extra long catheter
and they kind of wrap it up like a curly queue.
And so the theory is that as the child starts to grow
and gets taller, it should hopefully unwind.
And there'd be less reason to have to kind of go in there

(42:33):
and fix things.
There is a certain amount of change
that's going to be expected regardless.
I mean, there's a failure rate of about 50% by the time
most of these patients hit about age 5 or 6,
and that's expected.
But what I want to kind of admonish about this
is that let's say you get that child or even that adult that

(42:53):
gets an abdominal injury.
Blunt injury, penetration injury doesn't make any difference.
This itself that's in the abdomen may not
be very serious when we're managing it OK.
But if there's swelling or if it was a penetration injury
and it's severed that end of the catheter or basically
pinches it off and tamponuts that catheter,
that volume can't drain from it from the head.

(43:15):
And so eventually it's going to back up through the system.
And now their intercranial pressure
is going to build up when we start to see
signs of symptoms of that.
That's not much we can do to manage it other than recognize
and run because we've got to get that shunt reopened
or at least the distal of the catheter opened as well.
And sometimes that's easier said than done.

(43:35):
So it's kind of especially with a smaller kid
just a little more of a consideration.
But even for adults, abdominal injuries, chest injuries,
head injuries, neck injuries, all those things
can damage that shunt and obviously impede that ability
to drain that fluid that we normally can do on our own.
Another set of patients are going to come across
and these are probably more numerous
ones that have trach tubes.

(43:57):
And there's 100 different reasons
why they've gotten trach from being just malformations
to infections to trauma in the past, whatever the case may be.
If they have that trach tube, one of the things that may happen
and happens quite often is that it just pops out.
Sometimes they take it out and can't get it back in.
Sometimes, especially with the smaller ones that don't have

(44:17):
cuffs, they just cough and it pops out.
And you have the stoma that's left over.
Now, the first thing is that at any level, what we can do
is just try to ventilate over it.
And it takes a little bit of manipulation,
but it can be done.
Just have to be careful not to obviously crush
any of the vital organs.
But let's just say we can't do that.

(44:38):
We can't oxygenate this particular stoma.
But we still have access to the stoma itself.
Now, people have protocols to put the tubes back in.
And if it's still available, some people
have some trepidation as far as, well,
how can I really get it in there and make
sure I get it in the first shot?
The easiest thing to do is get into your suction airway

(44:59):
compartment and pull out a whistle-tipped catheter that
can fit into that lumen of that particular trache tube.
If you have to replace it with endotracheal tube,
you can do that too.
And you'll just cut it down and have that ready.
What you do is you snake the suction catheter
through the trache tube all the way to the end,
and then you put the suction catheter into the stoma.

(45:19):
And then hit your suction.
If the suction works and it doesn't stop the suction,
you're in the trachea because you're pulling air.
If you happen to go through, if there's a perforation back
there and you inadvertently put it either not in the trachea
because you're either above it, or if there's
a perforation behind there and you inadvertently
get into the esophagus, you put the suction on there,
it's going to get a back pressure.

(45:40):
And you're going to hear that snapping, that wheezing,
that popping.
So you know you're not in the right spot.
So once you realize that that suction catheter is in the trachea
because you get still good flow even though you're
suctioning, all you got to do now,
well, you got yourself a guide wire,
just slide that trache tube in over the suction catheter,
pull the suction catheter out.
You're done.
Yeah.
Real quick fix.

(46:01):
Real easy.
No, I like it.
And it works every time.
OK.
I also like that you went with things that, I mean, there's
a lot of, I mean, tech tech, a lot of vents, and a lot of LVADs,
and a lot of stuff.
I think we talk about those.
Yeah.
What I like about that is that it wasn't necessarily the high tech.

(46:21):
Now, I've got to move on now for the next five minutes.
We've got one more topic.
And we're getting near time.
I guess that's the risk of taking a big swing.
It's trying to get everything in.
Yeah.
I think you've been awesome coming up to this.
So let's finish strong.
Let's finish with something important.

(46:42):
This is about autism.
Assessing patients with autism and some other considerations
about that, because I think it's close to many people's hearts
because of the family and something we encounter pretty
frequently on the truck.
Yeah.
And I'm one of those families.
I mean, I have a nephew and a niece that are both autistic,
which is kind of odd for all of us,

(47:03):
because at least formally, nobody on either side of the family
has ever been diagnosed.
So they are the first two that have.
Now I look at myself, and I've done, you know,
talks about autism relating to them for a long time.
Now I look at them again, I'm probably autistic too.
But the point is, is that you keep hearing more and more
and more about it.
And it's like, well, gosh, it must be something in the water.

(47:24):
It must be something that, you know,
it's medicine related or whatever.
And it's not.
I mean, it's been around forever.
It's just that, just like we talked about with medicine
and the technology, what happens is that they just
get better diagnosed.
And so now we're at that point where about every one in 36
children has been diagnosed now with autism.

(47:44):
So that's a very, very close ratio.
Wow.
There are a lot of things that go with this.
And they have, among other things,
they have social interaction issues.
They've got communication issues that we know well of.
They have, you know, patterns in what we call stimming.
And, you know, flapping their arms or yelling or smacking

(48:06):
their lips or whatever the case may be.
And to us, it looks odd.
But honestly, to them, that's their calming mechanism.
So if you see it happening, just let
them keep doing it.
It's not harming them.
It's not harming you.
But if you try to restrict them, that
could actually cause more of a problem.
They also tend to do some very unique things.

(48:26):
And one of it is that they don't really
know much about consequences.
They don't consider consequences.
So they tend to wander.
If they're in a situation where they're overstimulated,
they will do whatever they can to kind of get away from it.
And they won't tell anybody.
They'll just take off.
They'll walk out the front door.
They'll walk down the street.
And they're attracted to a couple of different things.

(48:47):
And you're not really quite sure why,
but there's a very commonality between autistic patients
and their love of water.
It's maybe the calming aspect of the water, the cool water,
just the sound or whatever.
I don't know what it is.
But that's something that you have to consider
if you have a child that's missing or an adult that's
missing.

(49:08):
Is there anybody of water nearby?
Start looking there, because they may have headed toward it.
Now, unfortunately, you may be dealing with a drowning.
The other thing is that they tend to also like traffic,
trains, automobiles.
They hide in cars all the time, because they think it's safe.
So if there's a junkyard nearby and the person took off,

(49:30):
go look there.
You might find them there.
They're hiding in a car.
It's odd things like that that they do,
but it's very, very common among that population.
The one thing that we may be called for quite often,
just because it's out of the realm of what the parents can
control or the caregivers can control,
is what's called an escalation event.
And this is where it's kind of like they turn in the Tasmanian
Devil.

(49:51):
They get overstimulated.
It's an involuntary response, and they just kind of blow their top.
Now, most of these events occur on a daily basis,
and we never get called for it.
We've had them happen with my oldest nephew.
And most of the time, we just let him run his course,
and he calms down, and it's all good.
But any change in routine, any change in activities

(50:16):
that isn't explained, or if it seems to them to be very acute,
they can, again, they can just kind of lose a little bit of control,
and that's what happens.
They also get overloaded by stimulus.
So you have to be careful with that, too.
When you're going in talking with these patients,
just your general, your colon, your aftershave, your deodorant
sometimes can be, to us, doesn't seem like anything,

(50:37):
but to them, can be overwhelming.
The sounds that come from the ambulance, so the sirens,
you know, you tend to want to turn the turn signals down
before we hit the scene.
If it's at night, if it's at night,
or if we're going to be taking the child outside to go
to the ambulance or the adult, the lights sometimes
can be overstimulating.
So just turn them off.

(50:59):
Touch, texture, they don't like to be touched.
You have to explain everything 100 times as to why you're
doing what you're doing.
Let them touch your things.
Let them see the texture and stuff like that.
The other thing is, a lot of them are technology dependent,
which is very advantageous because the technology is out
there now, where you'll have quite a few of these patients

(51:22):
that are nonverbal.
But through technology, they can actually speak.
And for everybody that's listening out there,
if you look up, she's on YouTube,
and her name's Carly Fleishman.
Just one example, she is completely nonverbal.
But you can actually hear her talk
because she is able to type on an iPad that then coordinates

(51:44):
that, turns it into a voice, and she communicates that way.
And that may be the way your patient communicates to you.
So you're going to have to have time.
You're going to take time, have some patients,
let them use that technology to help communicate with you
and vice versa so that you can have a positive outcome
for whatever you're called.
Because they get sick, they fall,
they have very poor depth perception in some cases.

(52:06):
My nephew thought he could fly out of the second story window
and he didn't.
Fortunately, the tree caught him before the ground did.
And so they do kind of crazy things sometimes
that we could call for.
So we take care of the problem that we're there
to take care of.
But those are some of the aspects you kind of got to remember
when you're dealing with these patients.
And then when we go to transport them.

(52:27):
In very rare cases, does it come down to actually having to
do any kind of restraint?
Sometimes it may be necessary, but you have protocol for that.
Otherwise, there's a lot of places,
and you can look these up as well,
where they, services have built their own sensory kits
for the ambulance.
And they have anything in there from weighted blankets

(52:47):
to Rubik's cubes, spinner things that are there,
which I love by the way.
So that's just one of those things.
The fidget toys, all kinds of stuff
that kind of keeps them focused,
but also decreases their sensory inputs
so that they can themselves become a little more calm
and feel like they've got a little bit more control.

(53:08):
And again, they're kind of a unique population,
but they are also, again, going to be those patients
you are going to see.
It's not a matter of if it's probably when
you're going to come across one of those people.
All right, so at the end, what I generally do
is all our guests, we just give a chance for a last word.

(53:29):
I suppose it could be on any one of these things,
just a brief encapsulation, maybe
generally with all these things.
What do you do if you have something that's an outsider,
that's an outlier?
What would your advice to someone be?
The best thing I can say is just treat your patient
as you find them.
If they're in extreme pain, we deal with it.

(53:53):
If they're having difficulty with breathing,
we take care of that.
The underlying issues we've talked about here,
a lot of times, have their own manifestations
that unfortunately we can't fix.
Because if we could, well, you probably
wouldn't be listening to this, and I wouldn't be telling you
if I could fix it because we have a patent on something
and make a lot of money out of it, right?

(54:15):
Maybe send them a beach somewhere, hopefully.
So we're dealing with these patients,
and obviously in some of their worst scenarios.
And sometimes it looks worse than what it is,
but you still have to take it at face value.
And don't negate the fact that, OK, it's an autistic patient,
or it's a child.
It's like, well, children don't get chest pain.
Children don't have MI, so it can't be that.

(54:36):
Whatever the case may be, don't get your tunnel vision.
Get the best of you because that's
where you'll get in trouble sometimes.
Great, great clinical advice.
So Chris Ebride, lead instructor for the University
of Toledo EMS program, also has done half marathons
in how many states?
Actually, this weekend I'm going for number 42, so I'm almost

(54:59):
there.
All right, well, best to you in that for success and health.
Thank you for sharing such a depth of information for us here.
I'm sure people will find this very enlightening.
Sure hope so.
Thanks very much again for having me.
Thank you for listening to A Seven Things EMS

(55:22):
podcast by Limmer Education.
If you've listened to this podcast on a streaming service
and you're interested in getting continuing education credit,
please go to lc-ready.com for more information.