Episode Transcript
[00:00:07] Speaker B: Welcome back to another episode of the Code 321 podcast. Prescott and I are here with a very special guest today. Stu hall is joining us. Stu, how are you?
[00:00:14] Speaker A: Good man, thanks for having me.
[00:00:16] Speaker B: Yeah, no, thanks for coming. We appreciate it. We're joining through the virtual sphere. Going to talk about trauma care, specifically pre hospital bleeding. I think there's a lot of new information that's coming out and some old information that's resurfacing. And we're going to pick Stu's brain until he gets s us and see if he has anything to offer, which I'm sure he does. Prescott, how are you doing tonight?
[00:00:37] Speaker C: Yeah, not bad, not bad. Good to be here.
[00:00:38] Speaker B: Yeah. Thanks for joining us. So Stu, if you don't mind, do you want to just share with the listeners just a little bit about how did you get into fire, emergency services, ems, helicopter ems, all those things and, and kind of what are you up to today?
[00:00:52] Speaker A: Sure. So I started a career in college, EMS University in Vermont and kind of like got the bug there and did it all through school and probably did more EMS than I should have as far as like classes and stuff. A hard time like going to class and would rather just do run calls all day.
I graduated and I got out of EMS completely and I was like, man, I don't know what to do in my life. And I was doing some other crazy shit and I like randomly applied for paramedic school at a trauma center like the south side of the city in Chicago. And I got in for some crazy reason and it just started like taking off again. And that's kind of where I got my like paramedic plug and every single one of that class. Everyone was looking to get in the fire service and I was always like, eh, I don't know.
So fitted my school. I worked for a little bit in Chicago as a medic on the west side, not into the city.
And then I got kind of like, I don't really know what to do in my life again. And I joined the Air Force for a little bit as a paramedic, worked there for a little while and then got out, moved back to Vermont, slowly made my way into critical care.
And that's where I was like, wow, the medicine's really cool. And then it just kind of like progressed from there from ground critical care to flight critical care back into the military with some kind of like more austere and environmental medicine.
So right now I like, my focus has pretty much been on like retrieval more or less and kind of, yeah, we're pretty much dabbling on all things medicine and kind of forgot about the fire service. Like all my colleagues 15 years ago in paramedic school.
[00:02:45] Speaker B: Yeah, that's. That's a quite a journey. I, I personally love working with you because I feel like you've had so many opportunities to be in so many different circles of so many different corners of the world that, like, no matter what I want to talk about, from mountain biking to trauma care to climbing to knots to boating to travel, like, you just are like a plethora of knowledge. And so when I was thinking about this episode going into June, as you know, you know, I'm currently sitting in New Hampshire and it's trauma season. You know, I hear a motorcycle Dr. Right by the building, and it just reminds me of what we do all summer long at Health Net. And, you know, one of the big things that I've started to think a lot about as I'm entering, you know, my 15th year of EMS here is this concept of what are we doing for interventions that actually matter for our patients? You know, and, and maybe the intervention is recognizing something bad is happening. You know, I think HealthNet has been a big eye opener to me that, you know, there are some problems that we can't fix and just moving with purpose and getting them to the right place as quick as we can, and managing the pieces of that care that we can is really a big component. I mean, obviously, with what your wife does, like, that's always at the forefront of my mind. You know, it's like, you know, sitting at the bedside for 30 minutes to get an arterial line may not be in the patient's best interest. And I think, you know, bleeding. I remember Matt Hughes, one of our colleagues, you know, mentioned maybe what they need is a sharp knife. You know, maybe they need an. Or maybe this isn't something that HealthNet is going to resolve at the beds played, you know, with. With medicines and stuff. And Prescott, you being the fire chief, you're in kind of a unique place. We're kind of on two ends of the spectrum here. We have a helicopter, Critical care services to the scene, and we have, you know, a first response agency with some, you know, responsibilities in pretty rural parts of the state to care for patients that may be pretty significantly injured. So how do you approach that, you know, as. As a fire chief, as a firefighter in a department like that? You hear, you know, head on entrapment, unresponsive, you know, high mechanism. What are some things you're thinking about? As far as caring for those patients in that type of environment.
[00:04:49] Speaker C: Yeah, good question. And it's definitely, it's on the forefront of my mind, especially becoming the fire chief in Heinzburg. Because anyone who knows the geographic area of Heinzburg knows that you got group 116, you get a bunch of back roads. People do crazy stuff on back roads, especially if you get a little straightaway. So the mechanism is there, but. And in my first few months, the mechanism proved itself pretty readily for us. So the first thing I will say is blending the world that you come from with helicopter EMS is getting the right people coming. So acknowledging that the earlier we can get the request in for a helicopter if it's needed, or ground critical care, medics, even just paramedics in general, as we're not a medic level service, get the right people coming.
And then from a fire chief, what truly keeps me up at night is making sure that our people are trained up for that kind of acuity. Because at the end of the day, what I think we're going to dive more into is how basic trauma care can get. But also it can be a little bit scary for people if you get to that exact scene you just described.
You know, we're trained, okay, just drop the, you know, throw, throw a tourniquet on. Well, what if this person is a multi system trauma and they're trapped in the car and you can't really get access to the leg that you might need to throw the tourniquet on. So really diving back to that basic level training of making sure our people are prepared to figure out what is bleeding, what is the highest acuity bleed and how on earth we're going to stop that.
[00:06:14] Speaker B: Yeah, for sure. And Stu, you've got a lot of experience in different roles, both, you know, ground EMS and through flight and through the military and stuff like that. When you're approaching a patient that suffered some sort of trauma mechanism, what are some big indicators that you see for a presentation where you're like, oh man, this person's like really hurt, like there's some serious stuff going on. Are there anything that jumps out at you? Big, big red flags or alarm bells with the presentation that tell you, hey, I'm, I'm worried about this person and we need to move with some purpose.
[00:06:44] Speaker A: Oh, I guess the basic. Is that, that door assessment right when you get in and like. Yeah, how they're, how they're experiencing the world around them. Right. If they're sitting there shouting and they're, you know, as you say, like super heady, right? Like, they have an airway. They're profusing enough that their brain is working somewhere somehow, albeit is probably, like, bruised somewhere, you know, like, that's okay, or, you know, mechanism's there, and they're just lying there and they're sitting there, and, like, everyone looks kind of panicked. Every. Everyone, including the patient, is pale and, like, we're looking at the monitor and, you know, rebuttal signs are abnormal. I will say, to Prescott's point, like, I think the best, like, scenes I've ever been on have been the ones with, like, just. It sounds so cliche, like, good BLs care with, like, good EMTs or paramedics that, like, have no ego, and all they've done is, like, place good tourniquets, started big IVs, and, like, stopped whatever gleam they have. And they're, like, just opening airways, right? And they've done it for, you know, like, 15, 20 minutes.
Unfortunately, as we try to, like, at least our time to get there, like, that. That's the best. That's the best scene I've ever come across, is, like, no matter how sick they are, they have good access. They're ventilating, even though it's artificial, with the best they can.
And, like, there's a little bit of calm to the. To the scene.
[00:08:13] Speaker B: Yeah. I always find it so entertaining. You know, obviously, when we. When we land in those scene responses or those modified scenes and we walk into the back of the ambulance, and sometimes there's a really complicated patient. That's just what you described. They've opened the airway, they're bagging, they're ventilating, they're suctioning. They've got the patient exposed. And they're always so apologetic. They're like, I'm so sorry I didn't have time to intubate. I'm so sorry I didn't give pain meds. I'm so. I'm like, whoa, whoa, whoa. You did amazing. Like, this is an absolute curveball. And they're breathing and they're alive 35 minutes after the impact. Like, we can take care of that. Like, you guys did all of the hard work for us, you know, And I think recognizing that it can be simple, I was just putting together a PowerPoint for patient assessment, and I was reading one of our critical care textbooks, of all things, and I thought it was hilarious because in the patient assessment chapter, it literally says, your general impression and your plan of action, your disposition might be as simple as they look, like garbage. They need to not be here anymore. And that's what it says in the textbook. It's like, maybe, maybe you don't get down to, you know, what their blood sugar is and, you know, how old they are and what they're allergic to and what they ate last. Like, maybe what you get to is this patient looks tremendously ill and needs to be at the hospital. And that might be your first stages of, like, assessment as far as, like, vital signs go. Right. One of the first things we typically are trained to do is put them on the monitor and start to get some numbers as we're doing our hands on assessment. What are some things that you see on the monitor that tell you, okay, this is, this is going to worry me? You know, maybe there's some bleeding going on. Either something I can see or something I can't see.
[00:09:48] Speaker A: I guess look at the monitor and obviously there's like the big ones, right? Like, if they're super tachycardia or hypotensive, you're like, oh, poop, this is going to suck. And we're going to have to resuscitate a little bit before we have any more interventions.
But the, the ones that weird me out the most are when I look at the monitor and the numbers don't make sense to what I'm looking at. You know what I mean? Like, they're. They're. Maybe they're not hypertensive.
They're like normal tensive, but they're super tachycardic. Or like, the mechanism is pretty, pretty severe, but, like, they're not quite tachycardic enough for me to be like, wow, are they actually bleeding? Man, that's. Yeah, easy. And then, then it. And then I kind of spiral a little bit to be like, oh, man, what is. What is actually going on?
Yeah, yeah. So when the numbers don't make sense, it's really where I'm like, yeah, throw me through a loop for sure.
[00:10:43] Speaker B: Yeah, it's definitely freaky. I mean, Prescott, I think what the. I think what the firefighters do pretty well is that they are good at looking at mechanism. I think they do a nice job at kind of making an assessment of, you know, what are we looking at and what are the potential injury patterns that we're seeing in here? And so when you walk up and you see a car that's just like mangled and destroyed, does that change how you approach your patient assessment or what resources you activate? Like, before you even see the patient, you know, you walk up. Does that factor in? How do you. How do you Factor in mechanism.
[00:11:17] Speaker A: Yeah, yeah, yeah.
[00:11:18] Speaker C: No, another solid question. Because the reality of it is I've had a couple of curveballs as we talk about those, where, you know, you, you pull up to an absolutely destroyed car, it's on its roof, it's pushed in on multiple sides, three foot intrusion, whatever, and you're just like, this person is either deceased or on their way.
And the curveballs are when they're not right, when they get it, they're walking around and you're like, something is horribly wrong here. What is happening, right?
Because the initial thing is you pull up on that. I am no longer waiting to pull the trigger on resources. Like I said earlier, hopefully those resources are already on route. Can always cancel them. That's a big learning lesson I've had, is instead of waiting and waiting and waiting, because in Vermont, especially rural Vermont, it takes time, even the helicopter takes time to spin up.
But the other thing I learned, and we had a patient hit at Taft Corners hit by a car. And it was my first pedestrian struck. And I remember like the shoes were in the roadway as if they had just like the person was launched out of their shoes, which in essence they actually were.
And I remember thinking, man, like this person meanwhile was standing up, talking to a bystander. And I was like, how is this humanly possible?
And as the story unfolded, I kind of had this moment where I was like, should I be less concerned? Like, my pulse rate was through the roof, for Pete's sake, much less his.
Should I be concerned here? And, and we treated it, and I'm thankful we did. We treated it like, exactly like you would this person. Because a bystander, as they get loaded in the ambulance door, shut, off they go. And a bystander tells me, yeah, man, that's crazy. How many times they flipped.
I said, can you come again? Oh, yeah, no, they flipped in the air over end.
And then. So of course I was not in the back of the Amos. The crew took them off they go and found out that they were absolutely internally super messed up. So, like, taking that face value for what it's worth, the three foot intrusion in a vehicle, face value. You gotta have resources coming or better call them right off the bat. But sometimes it's those curve balls where you, the person is up and walking around, you're like, I don't know how. Well, maybe that should draw some suspicion.
[00:13:25] Speaker B: Yeah, for sure. And so, Stu, you were talking a lot about the EMTs and the paramedics that are performing that basic level care as they arrive on Scene and they're starting to do those assessments and manage the patient.
What are some initial actions that you think everyone from a responding physician all the way down to a emergency medical responder should probably be doing in those first few minutes? What are some good practices, you know, when you roll up on a trauma patient to identify, you know, potentially knife life threatening bleeding, you know, that, that we can control or impact or at.
[00:13:57] Speaker A: Least recognize it happened the other day.
We need to go back to trauma assessments. Just really simple hands on exposure and hands on trauma assessments. And I think what happens in, in hands is like EMS and the first true first responders, like they have a hard job, like they're starting from nothing and like trying to figure out where we're going from there. And then like we get there and you're like, we found this, that and the other. And we're like, we look like, great, sounds good, let's go. And everything kind of makes sense. Cool. But like, it's when you get there and I think when something doesn't quite add up or even if it does, like, people need to get hands on and actually expose everything to see what the hell's going on. Like we had a guy the other day, they like got the report, he got rolled over by his own car, for God's sakes. And you seem mostly okay. And they were like, kind of like half said, like, oh, yeah. Then we got there and like they had a gauze that was like in his crotch and was like super saturated. Oh, weird.
We didn't even think anything about it.
We should have like, we didn't look for any kind of source of the bleeding. We were like, oh, that's weird. Maybe, I don't know.
That's not his problem right now. And we look back at the chart and he has a massive laceration in his groin. It was so big. It was gaping like stem to stern laceration that like we probably should addressed. Right. It wasn't bleeding. It was okay. But like it was definitely a big eye opening moment. Even recently, right. This was like a week ago. I was like, oh man, I messed up that one.
And that's the biggest thing. It's just like the highs on. It's huge.
[00:15:37] Speaker B: It's tough, man. You know, and if you do a good trauma assessment, it doesn't take a tremendous amount of time, but it's that process of making sure you do it. It can be so easy to just look over and be like, yeah, yeah, you know, and then you get to the hospital and you're moving him to the bed and you unroll the life blanket and you're like, were you carrying a gallon of Kool Aid in between your legs? Why is it, why is there so much red? Oh, that's blood. Okay. Like, you know, and so just like, it's hard, you know, especially in helicopter ems. You know, it's been an adjustment for me because you can't just unbuckle the seatbelts and unwrap them and do a quick assessment. Like you're, you're. It's like I've described to people, you're like sitting in the back seat of your Toyota Yaris in your kid's car seat, trying to make a five course meal. Like, there's no room for anything. You know, you're just cramped and you can't reach anything. And definitely, I mean, that's, that's like my biggest fear is not finding an injury, you know, and, and not looking. I know Doug doesn't like the entrance and exit. He likes the high velocity penetrating trauma. Because unless we're the. At the scene when it happens or we're tracking the path, we don't know. But I was like, all right, fair. So.
But yeah, I mean, the assessment's key for sure.
And as we, as we progress. You know, Prescott, you have a lot of providers with you, some of which are, I'm sure, very passionate about ems, and some of which are there to support the fire department, its operations, and do what's asked of them.
How do you approach that from a training perspective to make sure that, you know, if a volunteer firefighter or a person that's maybe not a paramedic shows up on scene, how do you make sure that that patient's still getting a good trauma assessment? Is there any. Any courses you.
Specific training that you like to provide to make sure that they have what they need?
[00:17:17] Speaker C: Yeah, and ironically, one of them for my department is coming up real soon at the end of this month. We're doing a TECC course, tactical emergency Casualty care course. And what that is is that's a blend. Like, yeah, it is pretty centric to ems, but we do refreshers. So the TCC course offered to our EMS providers, a lot of them, dual role firefighters as well, but we do refresher courses in house that involve our firefighters, even just if they have no EMS certification.
Because I'll use a quick example. On the interstate one day, we had a tractor trailer box truck, I guess, crashed. Guy was heavily in trap. We're getting him out.
Firefighters all over the place. Love the Extrication tools, that's like the main priority. Let's get him out. Use these jaws, right?
[00:18:01] Speaker B: Yeah.
[00:18:02] Speaker C: And this guy, I remember we uncovered his, like I was in the extrication too, right into it, not thinking anything of ems, right?
And we uncover this dude's legs and the description that Stu just gave about that base level trauma assessment. You know, I truly have firefighters, we're all looking at the same thing, which is this dude's genes that appear as if there's just. It appears if his leg is like floating, right? It's like they're full of something and we're like, oh, it's just got big legs or something. Meanwhile, upon, you know, secondary look and actually when we really stopped thinking big extrication tools, we're like, no, man. His jeans, which were tucked into his socks. Don't ask me why. I don't, I don't ask these questions. Right.
Were full of blood, just absolutely full of blood. So these firefighters, I blame myself 100%. But there's.
We need to get these providers, no matter if you have any EMS experience or not, to at least recognize the base level trauma assessment of, of like, hey, big picture, should we be doing something more than just ripping this vehicle apart? Because, hey, if this dude's leg is actively beating that much that he's filling his jeans, maybe a tourniquet would be applicable. Or maybe we do something magical towards you know, get these raptor shears, which people pay big bucks for, to put them to good use and cut that, expose that and actually see what's bleeding.
[00:19:30] Speaker B: Yeah, I think it was George Henry, of all people, that actually taught me. When I first started, he was like mentioning the unchecked tachycardia. He's like the persistent unchecked tachycardia. He's like, if you have a patient who is a trauma patient with mechanism and they have persistent unchecked tachycardia with no explainable causes, they are bleeding until proven otherwise. Like they are bleeding somewhere, you just can't see it. They're bleeding in the pelvis, their belly or their chest, like, or their femur. There's big areas. And you know these people, the 22 year olds who fell off their motorcycle and they're just sitting at 135 beats a minute, 120 beats a minute for an hour and a half at a time. Like, it's not anxiety about wrecking their, you know, ninja. It's. It's probably something else, you know, and that has always treated me really well because Worst case scenario, I show up and I say, hey, I'm really worried about the heart rate. We have an elevated shock index, like there's a high mechanism here. They do a scan, they do a fast, they do whatever they do. And worst case scenario, they go, hey, good thought, but I think we're okay. Best case scenario, they go, you know.
Yep, he's bleeding and he's going right to the or. Nice catch. As opposed to. Yeah, he's, he's anxious because he's, he had a fender bender in his dad's Ferrari and then all of a sudden they find out that he's got a, you know, massive pelvic fracture with a bleed inside and he's, he now becomes hypotensive because he's transitioning from that compensated to decompensated shock. So.
So Stu, as we like start to move more into the advanced, advanced procedures here, it seems like every time I go to a conference or a talk or watch something online or go on foam frat or any of these courses, it's just a plethora of information about all these amazing elixirs and fancy medicines that are going to revive people, resurrect them from the precipice of death. You know, between whole blood packed red blood cells, plasma, txa, calcium, life flows, blood warmers. What have you seen in your time that you feel like makes a difference and what do you see that you maybe not sold on yet?
[00:21:33] Speaker A: Man, that's feels.
Yeah, that's a lot there. That's a tough one.
I mean obviously like gotta stop the source of the bleed, right? Yeah, that all aside. And so like the question is how, what are we trying to do when we give these elixirs? Are we trying to fill the tank? Are we trying to stop a clot from breaking down or adding more clots? Right.
Or are we trying to add some kind of like oxygen carrying capacity?
And in my mind like in trauma, it's kind of like once we've stopped the source, let's fill the tank with a natural fluid that you know, can do its job as far as like plotting and stuff like that.
And I think like my, and I'm surprised that health that doesn't have this yet. And I know there's talk about is like the trials that showed like plasma being kind of like a first line agent as far as like what we should be doing with like a balanced resuscitation opposed to pack cells seems like kind of like the best bet. And then like logically that makes sense in my Mind is like, a lot of these people don't have. They're not anemic, per se. Right, right. They don't.
They don't have, like, iron deficiencies. They have plenty of ways to carry oxygen around their body. They just don't have the ability to carry it around as well. But they're doing just fine with it. It's really. We need to add those clotting factors as much as possible because we've just all bled it all out, and adding those as quickly as possible is probably the best bet for them.
Elizabeth, talk about whole blood. Are you talking about whole blood? I think whole blood is pretty cool.
I have a friend in the, like, New England area who did the program's like, blood program, and they had an opportunity to use whole blood, and they were like, just. It's very. They have a ton of money. This program has a ridiculous amount of money. And even then, we're like, jury's still out on whole blood. It's not worth the money. Let's just do balance gestation with plasma and PAC cells, and they have the ability to get whole blood. Like, there are. There are EMS agencies in the area that have whole blood. And they were like, now jury set out, the science isn't there yet. Like, balance gestation, what we got because of the cost.
I think there's a lot to be said about that, too.
[00:23:56] Speaker B: Yeah, for sure. And I think, like, for the listeners that maybe aren't super familiar, there's a couple schools of thought on what we can give as intravenous medications for people who are bleeding. Right. So we can be giving something as simple as normal saline. Right. So the AEMTs, they get released from AEMT school, they get blessed by the national registry, and now they have access to the plethora of unlimited warmed or unwarmed isotonic crystalloids, whether that's lactated ringers, if you lift, if you live west of the Mississippi, or if it's normal saline, if you live more on the East Coast.
Saw a fascinating article that said that the biggest difference between those two fluids is the geographical location, tends to use more in one area than the other. So I just thought that was funny. Like, there's not any statistical. Huge difference. It's just where you live, you know? And so then you become a paramedic or you start to become in critical care, and there's this big war against isotonic crystalloids. They don't carry oxygen, they don't have clotting factors. They dissipate into the, you know, Extravascular space within, you know, an hour. They don't do a lot, you know, so that's like level one, level two. Is this what you're mentioning, which is these blood component therapies. So parts of the blood. So you could do plasma, you could do platelets, you could do.
You could do obviously packed red blood cells. And then we have like the top tier and the programs that do it in the country would argue that the best thing would be whole blood.
And so for you and your experience, what types of products have you used? Obviously you've used isotonic crystalloids as a bridge. You know, when people are hypotensive and you need to fluid resuscitate. Have you used mostly, you know, blood components like, like packed red blood cells and, you know, and plasma and stuff like that.
[00:25:37] Speaker A: So the military, we did a lot of like walking blood break programs. Military is pretty sold on, like, we're going to get blood, we're going to do a walking blood blank. It's obviously going to be whole blood, like spitting the guy's blood down. Like next to the mrap, the civilian side. Yeah, it's always been pack cells or plasma. I worked at a program that had two units of never frozen plasma and then two units of pack cells. And the guideline was for trauma.
You get two units of plasma and then you move on to the pac cells. And they're pretty big on that. And it was a really busy trauma center too. Like, that was. That was beat into us and it made sense. Like, logically it makes sense. I don't, like, I'm not as, you know, familiar with the studies anymore, but I think it was pamper. Is the one that kind of really, like put that out in there.
[00:26:31] Speaker B: Yeah, definitely. And I think there's also this concept of with the packed red blood cells there obviously packed with citrate. And so there's this big debate. Everywhere you go, people are really worried about calcium and making sure that if you give lots of units of packed red blood cells, that we're also supplying calcium because the citrate is going to reduce the, you know, intravenous calcium inside of your bloodstream. It was pretty interesting. I think it was Michael Frakes, of all people from Boston Med flight was giving a talk over at the last conference I was at, and he was basically saying, like, you got to stop freaking out about calcium. Because the reality of it is in the. In the amount of blood that we're giving, in the window that we're giving it, that is being cleared through the body relatively quickly and dissipates. And all we're doing is solving a problem that is going to resolve itself very shortly. You know, unless you're giving 20, 30 units in an OR, you know, there's really no reason for us to slow down and continue to move towards calcium, which I thought was really fascinating. And that being said, I don't remember any trauma patient I've brought in, even after.
I think the most I've ever given on a single patient was like six or seven units because our flights are pretty short. And so we took some from the sending and we burned through ours and our, in our block.
And even that when we showed up at the hospital, it wasn't like they were screaming for the pharmacist to run and grab cat. Like that was not the priority. And like that got done eventually. But it, I didn't see any harm come to the patient. So anecdotally I could see where, you know, Dr. Frakes is coming from there for sure. But, um, yeah, I think, I think it's really interesting. And so as far as like, let's just touch on TXA as we wrap up here because I know that's like your favorite topic ever.
The idea behind it, Right. Is that it's supposed to solidify the clots that are, that are, that are already there. Right. It's not a clot forming agent. It's just supposed to solidify any clots that are there. And there's kind of some trauma centers that prefer it being used and some places discourage it being used. And there's kind of a big debate. Can you just touch on maybe a little bit why some places are not in favor of it and why some places maybe would be in favor of it just with, with your knowledge of, of research.
[00:28:35] Speaker C: No.
[00:28:36] Speaker A: So first place I used it that they used it. It was. We didn't have blood at the time. But it's based on shock index, I mean talk index of a point nine we would give it as long as you're within three hours of injury.
And that was like early Crash two, like Crash two, like just kind of come out and, and people were really jazzed. And I think there was a little bit of like the social media world going on and pushing it. Yeah. And people not like looking at like kind of maybe. And I'm no statistician and I'm not one to like say when studies are flawed, but I think people started to look at Crash two and like, ooh, we, we cut a couple corners. Maybe we didn't look at like why TXA worked in crash 2 per se. Because it was a hard like largely military study from my understanding.
[00:29:23] Speaker B: Yeah.
[00:29:24] Speaker A: So then fast forward, I went to another program and I was like, hey, we give a ton of product, we have a ton of trauma. Why are we not doing txa? And I talked to medical director and he was like, TSA is trash. Then he walked away. That was it. It was it. I was like, what do you mean it's trash? Like no, it's trash. And he walked away and they sent him an email and I was like, what do you mean? And he sent me a bunch of papers about the problems with TXA and why this major center doesn't use it anymore. And yeah, we just didn't use it. His argument too was their trauma center would run a tag like in the trauma bay. And I'm not like as high as, I don't know as much about it as I probably should the tag. But pretty much it's a, it's a graphical reputation of the clot and how it's broken down. And based on the shape that is produced on this computer screen you can decide on where the clot is broken down. So if it's a different shape or it should look like a, like a wine glass, right? A really like bowl shaped wine glass.
[00:30:23] Speaker B: Yeah, this is like this, this is like the champagne glass or the spade. Yeah.
[00:30:28] Speaker A: And depending on the shape, it's like, oh, you definitely give TXA or you definitely give something else. And they could run it within like three minutes of trauma showing up. So they always said they could review anyway, but they were really anti txa. And I think just talking to friends around the agency, like around the country that give it, a lot of people aren't giving it anymore. It's definitely not my.
On my forefront when I'm doing trauma, it's kind of towards the last. Like I'm going to look for a reason to give antibiotics before I give that grammy txa.
[00:30:59] Speaker B: Yeah, about when the time that I'm pulling out Tetris at the trauma call waiting for my radio report is probably when I'm going to start thinking about it. If we have time to do it, let's do it. It's not going to withhold it from someone. But also, you know, like our medical director clearly states all the time, you know, life saving interventions first, then blood product, you know, then pain control, sedation, airway management, all the priority things have to be done before we go into that medicine. And also with the way it's currently written for us and our system. I know there are some places that, that push it, but for us, we're still dripping it in and, you know, it. It takes some time. You know, you got to mix it up, you got to put it in a bag, you got to find it. And I don't know about you, but my scene trauma calls, I'm like, the IV sites are a hot commodity. They are limited quantity. And I am always running out. I need one for blood that's out, and I need one for meds to keep them asleep. And that's. And then that's usually what I have. So it's very difficult for me to come up with, you know, a lot of access points. It's not like an ICU patient where they have a triple lumen and three peripheral IVs and an IO and, you know, a bunch of other things. You know, a lot of these patients, they may have one, they may have none, or they may have one or two IVs. And for me, blood and push dose meds are kind of like what I need those for. And that's. That tracks with most of the people that I work with, for sure.
Prescott, how about, how about you? What's your favorite shape of tag? You have a preference on the, on the graph shape?
[00:32:24] Speaker C: My mind just exploded, gentlemen. I'm not sure.
[00:32:29] Speaker B: So what can you. What can you add Prescott for? For. As we start to think about this pre hospital trauma system and we start to bring this episode to a close here, what are some concepts that you prioritize as the fire chief? Making sure that the constituents in your response area are going to have equitable and fair access to a high quality trauma response. Like what, what do you see that system looking like? What are some key pearls that you want to make sure you bring to the scene for those folks?
[00:32:56] Speaker C: Yeah, very first and foremost, and I'll say it again and again and again, over and over again, right. Is making sure that my people are properly trained at the base basic life support level. Right. First for trauma care, but then going further than that. They are trained in the basic basics of trauma life support, but they also then know who to call to make sure that extra help is coming, both in the form of paramedic and as you guys are just talking about whole blood plasma, things like that, knowing you can be a BLS provider, but knowing enough to be dangerous. That is where this person probably could use some of that. They've been involved in a very serious traumatic injury. Right. So getting the helicopter coming, getting the ground crew coming, getting the paramedics, you know, who can minister that, that blood, that plasma, stuff like that coming. So I would say the. The. The pearl that I would take is for our people making sure they're bls, trauma trained and yet knowing who to call down the road.
[00:33:58] Speaker B: Yeah, for sure. That makes a ton of sense, Stu, as far as your experience and kind of like what you bring to the table.
What. What are some.
Some ideas you have for folks that are looking for the next step in trauma training? You know, where. Where can folks go to get really high quality trauma training? Do you have any book recommendations, podcasts, training courses? You know, what would be the next step? If you have somebody that's just like, man, this episode really struck a nerve in me, and I really want to improve myself. And I like the things we're talking about, you know, do you have any recommend people could go, oh, man, dude, I don't.
[00:34:39] Speaker A: I think the best thing is for you is to just get out and work and, like, run these calls over and over and over again.
I think, like, ACS or not ACS, ATLs is fine. And.
And all those trauma courses with TPTC AC is, like, pretty interesting in, like, ITLs. I think they're all, like, kind of talking about the same thing, just different ways and using different words.
It's hard to. Hard to beat just experience.
[00:35:07] Speaker B: Yeah.
[00:35:07] Speaker A: Because it is so basic. Trauma is so basic. Yeah, right. And the best care really is like that. Basic care.
[00:35:15] Speaker B: Yeah, definitely. And I think you and I have talked about this before and. And Prescott and I have mentioned this in other episodes, but I think a really good quality of people that progress in medicine in general is this attention to detail. Like, when things don't go right, not just brushing it off and going back to your Netflix show. Like, think about it and ask questions, talk to your co workers, you know, read about why maybe, you know, the patient didn't react the way you wanted to. If you had a big dsat during intubation or you gave a medicine and they reacted poorly, like, poke that nerve a little bit, you know, and try to think about, you know, how can you improve on that case? And the best providers that I like are people that come back from a call and go, hey, this. You know, this worked really well. And. And this went really good for us. This part didn't go so good. You know, does. Does anybody have any ideas? You know, what are you thinking? And I think some places, you know, like, our job does a really nice job of facilitating that with case review. It's a nice way to kind of go through someone else's call or your own call and just get a lot of brains on the same problem and just kind of see different angles of it. And not every place does that. I know fire departments do, like, hot washes for fires, but I would pose this challenge. You know, when was the last time your fire department that runs EMS took a really bad medical call and did a case review for a training night? You know, that that's kind of foreign to the culture, but maybe it could add something for sure.
So, Stu, I want to thank you for joining us tonight. I know as a. It was a late night for all of us, but I really appreciate it. All of us are lucky enough to have partners who assist with our children who are hopefully sleeping soundly at the moment, and we thank them gratefully for doing so.
I wish you all the best. I will see you at work shortly, hopefully next week. And thanks for coming on the show, man.
[00:36:55] Speaker A: Yeah, thanks for having me.
[00:36:57] Speaker B: Prescott. Always good to see you. We'll catch up with you next month.
[00:37:01] Speaker C: You too, brother.
[00:37:02] Speaker B: All right. Stay safe out there, Sam.
