Episode Transcript
[00:00:14] Speaker A: Welcome back to another episode of the code 321 podcast. David Weiss is with me here today. David, how are you?
[00:00:19] Speaker B: I'm good, Nick. How are you doing today?
[00:00:20] Speaker A: Thanks for inviting me over and making delicious coffee. I appreciate that.
[00:00:23] Speaker B: Yeah, of course. Thanks for having me. This is exciting.
[00:00:25] Speaker A: Not slurp in the background as we do this. So if you don't mind, you want to tell the listeners just a little bit about your experience coming up through EMS and how you kind of found your way to this type of work.
[00:00:37] Speaker B: Yeah. So I started EMS on my 16th birthday. Excellent.
Back home in New York, and I joined, like, the junior corps of the ambulance, and I started running there all throughout the rest of high school. Came up to Vermont, went to St. Mike's, where I was on St. Mike's rescue for four years. I got my EMT, my advanced EMT, and was the training officer for two of those years. Really, just really fell in love with medicine.
And after school, I worked as a tech in the emergency department, as a scribe in the emergency department. I worked in the emergency communications center, which is kind of the bridge between EMS and the ER. And then I decided after a year or two of that that I was going to go back to nursing school. Did a quick one year second bachelor's program down in Florida, came right back up to Vermont. Florida was not for me. As soon as I was finished with that, and I did a emergency medicine nursing residency at the UVM medical Center. And since then, I've been a nurse in the ER there for going on seven years now, six or seven years. And recently just joined up with the UVM healthnet critical transport team as one of their critical care flight nurses. And kind of on the side. I do this disaster medicine stuff with urban search and rescue.
[00:01:51] Speaker A: Yeah, that's super cool journey. And I think it's always entertaining. I can't remember if we took our EMT together or just our a. I.
[00:01:58] Speaker B: Don'T know if you remember, but that was a long.
[00:02:00] Speaker A: It was like over ten years ago. And I was thinking about that a lot recently because I think it's so entertaining because you, me, and Olivia Snyder all were in that class, and we kind of had our bifurcations where we left and went on these life journeys where Olivia was traveling and nursing and going all over the country doing all kinds of things. Like, you know, you had the urban search and rescue stuff, and you went and did the comm center work, and then you went and got your nursing license, and I left and did my time in the fire service and now we're kind of all back together as the healthnet transport team.
[00:02:33] Speaker B: We caught the EMS bug and here we are.
[00:02:35] Speaker A: We're still here. It's just really entertaining me that we go have these journeys and then we kind of all come back to the same place and we're like, all older and we've grown, we've had these experiences. And Livia and I were just talking the other day about how it's cool that when I struggle with the hospital mean she's been doing for ever since we left our EMT class and said goodbye to each other at the like. Now she's had those experiences about how the hospital works and the icus and the residency programs, like what you had. And I went out and did the dirty street medicine and decontaminated airways and put tubes in and did that stuff, and then we go to an ICU and there's 15 drips and I can't pronounce any of them. She's like, don't worry, nick, it's okay. Breathe. And I'm like, thank you.
[00:03:15] Speaker B: That's what makes our team so incredibly special. Having both the nurses and the medics on together and kind of having the same scope is pretty cool. Being able to do it all, but definitely everyone has their own little niche, and I think that's really important.
[00:03:28] Speaker A: So disaster medicine is a really hot topic. When I went down to EMS world, they had a member of the FDNY, EMS rescue task force down there talking about this type of work, and it was just wild, some of the stuff they do.
Do you want to just talk a little bit about kind of the origins of USAR and kind of what is it designed to do? Why does USAr exist?
[00:03:50] Speaker B: Yeah, that's a great question. So USAR kind of officially came in as a part of FEMA through legislation back in 1989, and the first teams really spun up around 1991. And their goal is to respond to these disasters and kind of assist the agency in the areas where these disasters happen. With some more technical skills, we're also able to provide 14 days worth of a deployment of kind of daily work. And so that's really important because not all of the. I mean, I think we all know that through the fire service and EMS service, that no matter where you are in the country, things could be different. County by county or even town by town, whether you've got a paid full time fire department who is grade A on technical rescue and confined space stuff, or disasters can also happen in these kind of more rural communities that might all be volunteer based and might not have kind of the lineup to really deal with these bigger disasters. So the USAR teams, there's 28 of them spread across. There's 28 FEMA USAR teams, which are kind of the bigger teams throughout the country. And then almost every state has their own version of state USAR teams, often called SusAr. So state urban search and rescue teams.
And so a lot of the times that these teams are highlighted are at different disasters throughout history. So we can think of the Oklahoma City bombings, and that was one of the first true large activations of these teams. And what they were able to provide is kind of specialty collapsed rescue training, trench training, confined space, and they were able to use different search and technical search methods, canines, to help kind of go through the rubble piles, kind of fast forwarding to 911 and the World trade centers. The New York teams were down there working for quite a while, and teams from all across the country came to assist as well, again, because while that's going on, there's still other emergencies happening in that location. So, yeah, a bomb went off in a federal building, and everyone wants to rush there and help, but there are still patients out there that are having chest pain that are completely unrelated to the incident, or there are still fires happening in your city. So this kind of takes the earnest of having the individual kind of local agencies perform these huge tasks while also continuing to run their daily operations. We're there to supplement and help them.
[00:06:28] Speaker A: Yeah, and I can just share from when I was a junior cadet, which is similar to what you were doing on the. You know, it was when Hurricane Irene happened, I was working in southern Vermont on the small volunteer fire department down there, and this was something we had never seen before. I mean, this was huge flooding. I mean, roads were shut down. I remember at one point, there was a giant full size propane tank floating down the river in the rapids, like striking bridges. And we're a volunteer fire department. I mean, these are guys that work in construction and mo lawns and working banks and our lawyers.
This isn't the Houston fire department. We're not designed to handle that. And I remember it was the only time in my volunteer career ever that we worked a 24 hours shift literally on the ladder, because we were the only ladder company in southern Vermont, short of Manchester, Vermont. There's no other ladder companies. So my ladder company was doing those pickoffs off of roofs and off of. We're setting the truck up, moving people off of a roof, over water onto the truck, dropping them off to the sheriff's department loading it up and going to the next town and the next town, and the next town.
[00:07:35] Speaker B: Wow. Yeah.
[00:07:37] Speaker A: And I remember specifically, we didn't have any swiftwater training. We didn't have any gear. Like, at one point, we set up the ladder truck, and the water shifted and was running underneath the truck where the outriggers were. And we were all wearing turnout gear. And I remember standing at the back of the truck with a ladder belt on with, like, a big carabiner. And the person who was in charge of me at the time was like, just clip yourself into the truck so that you don't get washed away. I'm up to my chest in river water in turnout gear, which, knowing what I know now, I'm like, what is happening? Like you said, we were not prepared for that. The only reason that went okay is because they brought in at the time, Colchester Technical Rescue, which came down with boats and made those rescues and helped us with decisions about how to take care of those patients and those rescues. But like you said, some of the places that these teams go, they're just not set up to do that type of work. They don't have boats to have that trailer show up, have trained divers show up, and just unload the boats, put the motor on. And actually affect a rescue within less than an hour is so cool. I mean, that's a cool system.
[00:08:44] Speaker B: Yeah. And I mean, so we're talking about just the swiftwater part of things, which is, I think, a huge asset, especially in Vermont. And it's weird that people don't. I mean, being a landlocked state, people don't always assume that Vermont has a really awesome swiftwater team. And we mean, again, we get deployed to different states yearly to go out and help and assist. So that's a really cool aspect of what we do. So we'll do swiftwater rescues. We'll do collapse and trench rescues.
Anytime that there's, like a large fire in a structure, whether it's still standing or not, we can go and assist with the fire investigators. We'll go in if it's unstable and build up different shoring pieces to make sure that it is stable for the folks to be able to get in or to rebuild if contractors come in later. So having all these different kind of facets is pretty cool. And then we've got our canine search team as well, which is pretty cool. We've got live find dogs currently, and we just believe we're just starting to train up a human remains dog as well. And those dogs are separately deployable from our entire agency. So if, I don't know, let's say the Massachusetts task force goes out on a big deployment and they need another dog or two, they can request just our canine handlers and the canine to go and kind of be an adjunct to them as well. So USAR is cool because there's so many different parts to it and a lot of people specialize in one area, like on the FEMA teams, if you are on the rescue team, that is what you are, a rescuer. You are a rock breaker. You can do ropes, you can do swiftwater stuff. But on a smaller team like Vermont, we don't have the ability or the kind of the deep enough ranks in the bench to just say, okay, I'm only going to be doing medical. I'm only going to be doing search. So a lot of us do different things. We have multiple members that are cross trained in medical and like disaster medicine and also collapse rescue or confined space or swiftwater. So we kind of all do a little bit of everything, which kind of adds to the fun of the team. So I know, oh, I'm not just playing nurse or medic for the whole time. I'm going to be able to get on the boat, do some rescues. I'm going to be able to get into that structure, assist with building the shoring, stuff like that. And that's kind of a pretty unique part about Vermont system.
[00:11:04] Speaker A: Yeah, I remember one of my old business partners was really into the technical rescue. He's just a guru in this whole world. He worked down in the DC area doing a bunch of busy work down. And one of the things he always mentioned to me is the best type of high angle rescuer you would have is a paramedic. And I was like, I'm not really like that. I'm the medicine guy. You guys go do your thing. You load them up or bring them over, drop them off, I'll do whatever. And he was saying, the reason being is imagine you have someone 300ft down a cliff and the only thing you can do initially is get a person to them. You may not be able to get them up right away. You may not be able to set that system up fast enough to actually remove them. He's like, by having someone who has a background like you, who is a nurse or paramedic or a flight nurse and some rope rescue training, you could actually send that person down with some medical equipment and they can render a lot of the aid that you're talking about right at the patient, even before they get the stokes or the litter or the hall system or those other things down the line. And I guess I never thought about that, that the most versatile rescuer is generally someone that has some medical background, has some operational understanding and technical skills to actually do what they need to do at the same time.
[00:12:13] Speaker B: Yeah. And there's. I'm glad you brought that up, because there's been a recent paradigm shift. I mean, just like fire and EMS, we're constantly evolving. We always learn from previous disasters. So what we learned in the World Trade center and Haiti and a few of the other kind of recent collapses is that starting treatment in the whole increases survivorship by, like, 85%. So kind of the old adage was, all right, rescue. You stay up by the ambulance and you'll be there, and then we'll go down and grab these people and rip them out of the pile as soon as we can. And then you'll start your treatment and you'll go away from the scene and go off to your base of operations or your medical tent or your hospital or whatever you're operating out of. But recently there's been this big shift to starting treatment early on in the hole in that confined space and training up these medical rescuers to be confined space certified and collapse certified so that we can start to bring in supplies and start assessing and treating as soon as possible. And sometimes that means that as soon as you make patient contact, you might be down in that area for up to 12 hours until a relief can come in and you can start assessing and treating while the rescue folks work on a plan to kind of detangle them or free them from their entrapment. So it's interesting and something I didn't really think about until I took this week long disaster medicine class down in North Carolina was, you're not going to have all of your equipment, right? Like at the USAR cache, we've got med bags that are similar to your first in bag that everyone has on their ambulances. We've got a monitor, we've got some kind of accessory trauma bags or, like, downrange first aid kits. But if you have to crawl 500ft through twists and turns in confined space to get to the patient, you can't fit that entire bag. You can't fit a whole oxygen tank. Like, you're very limited on what you can bring in.
And so thinking about performing advanced interventions, starting iv, starting vasopressors, giving calcium and stuff like that to treat crush injuries without a monitor on is something that the EMS part of me loves. I'm like, this is great. Back to the roots of really good physical assessment and figuring out different pathophysiologies. And then the kind of critical care nurse in me is like, oh, my God, I can't give him medicine if I don't have an adequate blood pressure. What's going on here? So it's thinking about medicine in a different way, and it's not being afraid to get in there and start providing high level care in the whole with the patient.
And again, like I said, outcomes are improving with every disaster because we have had this huge paradigm shift. Yeah.
[00:14:58] Speaker A: And we've done a couple episodes in the past about tactical medicine and wilderness medicine, and it kind of all falls under this umbrella of a steer medicine. And I remember going to a training down in, I think it was Orlando, and I was able to meet with the head medical director of the Army Rangers who wrote all the astir medicine protocols, who wrote, like, on the deployed medicine blog and that website and stuff. And one of the things he said is he came up with this definition of austere medicine that I think is really true and rings true in all these conditions, is he found that when people think about austere medicine, they always think about, like, wilderness, like a mountain. But there's a lot of cases like what you just talked about crawling through a tunnel or a subway station where it fits the definition of austere medicine. Even though you're not in the wilderness, you're applying the same concepts. And so his definition is, it's a patient that, you know, needs to be somewhere else and you're with them longer than you want. So think of someone who needs the or and you can't get them to the or and you're stuck with them, essentially. That's austere medicine. You don't have what you need to do the optimal treatment, so you're forced to do something else. And that could be a lack of equipment, it could be lack of evacuation, it could be that they're entrapped. And I think it's cool what you're talking about. I mean, I remember doing a tactical medicine program once with a rural service, and we kind of went over those same concepts of providing care using a radial pulse as a metric or respiratory status by feeling the chest, those types of things, and skin color condition, mental status, making inferences about the medical physiology based on some basic physical assessments. So we get ready to do the scenario. They put all their tactical gear on. We turn around and they have the backboard, the vacuum splints the life pack monitor. I'm like, my dude, we're going to have to be a little bit more mobile than that.
[00:16:41] Speaker B: Yeah. A little bit lighter. A little bit more mobile.
[00:16:43] Speaker A: Yeah. I just think, as you're telling that, I was thinking of crawling through a confined space tunnel, like, dragging the life pack behind you. I mean, they're not designed to do that.
[00:16:52] Speaker B: No.
There's also no guarantee that you're going to get any of that equipment back. That's another thing that you have to think about in these kind of disaster situations. Like, if your search and rescue team has a single monitor, is the best place for that 40ft down in a hole with you? Or is it back at the med tent where, God forbid, something happens to one of the other rescuers or someone else on scene that can be used for that as well, and then also for your patient once evacuated?
So a lot of this is resource management of what you have. Like, I've got one monitor for my entire team of 35 people that I'm deployed with, and I'm responsible for their well being as well as any of the victims. So kind of how do you split up equipment? When do you split up equipment? Can you stage equipment? Like, oh, I can get my big bag 100ft down the tunnel and then from there I can go modular and bring different things down.
So there's a lot of that too, which I think is really interesting.
[00:17:46] Speaker A: Yeah. And I think of, like, I've told this story before about, know some of the people in the military view ketamine in terms of their. I think, you know, one of the interesting stories I remember when I was talking to this doctor down in Orlando is he was saying he went to Fort Sam Houston where they do all the special operations medicine and that kind of stuff. And they were talking about ketamine administration. And when you and I in our critical care world administer ketamine, it's very specific. Right. So if we're giving it for pain control, it's like 0.1 to 0.3 milligrams per kilogram over a certain amount of time. Right. 1015 minutes. So it's very specific.
[00:18:20] Speaker B: Full monitoring entitle co2, correct? Yeah.
[00:18:23] Speaker A: Right. Checking mental size. If we give it for induction, it's a different dose. If we give it for dissociation, depending on the route, it's a different dose and it's all weight based. It's very specific to the point where each milligram is accounted for and does something different to the body. So this doctor goes down to Sam Houston. He's talking to all these guys who have a role of providing some type of infantry responsibilities on top of medicine. They're not just going down there working in an ER, they're out in the field doing things other than medicine. And the docs like, explaining how ketamine is dosed and the weight and the calculations and how to estimate body, and they're like, no, we're not doing that. This is too much. We can't. I'm not going to try to provide suppression support with my rifle and calculate someone's body weight.
[00:19:12] Speaker B: And then they're like, no time for that.
[00:19:14] Speaker A: So the soldiers are like, hey, you need to give us just a standard treatment algorithm. And he's like, no, well, medicine is very specific. Like, this is one dose, this is another. And they're like, no. So what they came up with is basically they're going to give you an I O because it's quicker and easier to hit than an iv, right. You can get that in way more successfully and way quicker than anything you would possibly do with an iv. You're going to give 100 milligrams of ketamine and they're going to go unconscious, but maintain the respiratory drive. And then every time they move or wake up or have pain, you give another 50. And that's their treatment algorithm.
[00:19:48] Speaker B: And I think that's great. I mean, if you think about the Thailand cave rescues, similar thing. How much do those kids weigh? Here's a standard dose, and if they start to wake up, redose them on our swim out.
[00:20:01] Speaker A: And it's because the safety profile is relatively large in that setting. For Fort Sam Houston, the patient population is relatively similar. You're looking at people who are like 60 to 70 kilos, up to 150 kilos. And that's really the parameters that you're looking at. You're not dealing with pediatrics really. You're not dealing with really older folks.
[00:20:22] Speaker B: You're dealing with people that are fit, have good baseline physiologies. Yeah.
[00:20:26] Speaker A: And guess what? If they don't breathe or stop breathing, they're going to get a crike that's quicker and faster than inhibition.
Battlefield medicine does not include laryngoscope.
[00:20:36] Speaker B: Exactly.
[00:20:36] Speaker A: It's heavy, and there's so many blades you have to bring, and they're not using video scopes. They're putting in superglotic airways or crikes. And that's the extent of what they're doing, nasalfingal Airways. And so I kind of think of that when you're talking about disaster medicine, it's like maybe you want this very specific critical care dose and monitoring and titration to effect, but maybe giving some pain management, recognizing that it's not optimal, but it's operationally efficient and provides some relief while you're making a move, is more effective than don't let perfect get in the way of good.
[00:21:07] Speaker B: Exactly. And I think that's really interesting that you said that because there's a lot of this. Well, like, oh, I can, like, oh, I'm critical care nurse. I can get down there and start pressers and do this and that. But what's really important to that person, right. Then when we get there, right, is it getting pain medication? Sure. Great. I can do that. But a lot of it is back to these basics that we learned in EMT class, like scene safety, which I guess if we're there, that means that the scene isn't safe, but kind of getting back to those roots of how can I make this as safe as I can be for myself and the patient and making sure that they don't become hypothermic. Right. So, like, a blanket is a huge.
I would rather have a blanket and like a space blanket and maybe like a little foam pad. I would take that over a vial of ketamine in the hole any day. That's going to provide some comfort to your patient. It's going to prevent. Concrete is a huge heat sink. Right. So you're just going to lose heat as fast as possible. So if you can stop that and start retaining some heat and kind of optimizing them physiologically, that's going to be the best thing.
Thinking of using.
I know we hear in EMS, right, once you make patient contact, they can't eat, they can't drink. No, nothing. Well, this person might have been trapped for 72 hours. It's okay if they have a little bit of water, right? And so do you. Bring a water bottle and a rag with you. Have them clean off their face, have them rinse out their mouth before they drink anything, and then allow them to drink a little bit. Oral rehydration goes a really long way. I think we all know it's much better if they're able tolerate it than ivs.
And it's a lot easier to give someone water bottle and have them drink it than it is to get a light up, start an iv in this awkward position that the patient won't be comfortable in. I won't be comfortable in that. I'll never be able to really tape well enough to survive. Our long drag out of there.
So it's really interesting to take all this, what you really want to do, and like, oh, I know. If I had this patient and I had full access to them, I would do a full rapid trauma assessment. Well, guess what? You can see their hand, and that's it?
[00:23:20] Speaker A: Yes.
[00:23:20] Speaker B: And so, like you said, what can I assess from just a hand? You can tell the relative age. You can feel a pulse. If you can get to their wrist, you can pop an sp two on, see if they're oxygenating. Okay.
You can assess mental status, right? You can yell out, sir, ma'am, can you hear me? And if they can wiggle their hand or give you a thumbs up, I know that someone's responsive enough to follow a command. So I just did a mental status exam on a patient who I can't see. I can only see their forearm. That's crazy. And that's not something that you would think about in the back of an ambulance or in a brightly lit trauma bay where you have access to all these different things, but it's the best you got at the time.
[00:23:58] Speaker A: Yeah, no, I think that's a great point. I remember getting into just, like, a back and forth with one of the trauma surgeons at one of the hospitals we went to, because this guy got thrown off a motorcycle at 75 miles an hour and basically broke every bone on the left side of his body and hit his head really hard and passed out and had a concussion and all these other things.
So we picked him up on the helicopter, and I put a pelvic binder on him, and I brought him into the emergency department, and the doctor is like, well, why is this pelvic binder on there? And I was like, well, he got thrown off a motorcycle unrestrained at 75 miles an hour, has long bone fractures, including his femur, which is a relatively large bone. And he's like, well, did you assess his pelvis? And I was like, well, I didn't because he's in catastrophic pain. And I put the pelvic binder on before we loaded him, and he's like, well, that's not an indication. You can't place a pelvic binder just based off mechanism and signs of shock. And I was like, well, here's the other thing to remember is I'm not in a hospital room. If he develops shock, I can't just get up and go put a pelvic binder on. Once he's in the life blanket in the sleeping bag we use, and he's loaded in the aircraft, I literally cannot reach his hips. So if he develops shock and deteriorates that life, potentially life saving intervention, I can't apply that. Once we put him in the helicopter, whatever needs to be done has to be done before we load him because you don't have access when you're flying. And so, like you said, sometimes we're not making the most optimal medical decision for medical reasons. In a vacuum. Sometimes it's medical and operations where you have to think about, okay, I have all these things I want to do now, but what might I need once they start dragging him? Because once you put him in the stokes and you bundle him up and you lash him in, you're not going to be able to reach in there and put a pelvic binder on.
[00:25:38] Speaker B: Exactly.
[00:25:38] Speaker A: He's isolated from you. And then the rescue teams, God love them, they're ready to go. I mean, they're ready to haul. They're not waiting for you to reassess.
[00:25:47] Speaker B: And no one's ever called them gentle. Yes. No.
[00:25:49] Speaker A: They want to get that person out. So I think that's really interesting. Like the blend of medicine and operational pieces.
[00:25:55] Speaker B: Yeah. And then I think that a really cool part of disaster medicine, too, is that it's not over. When you get them out of the hole, right. You can pop that pelvic binder on, you can make them warm, you can pop an iv in, you get them off that pile. That's great if there's an appropriate EMS agency standing by. But if you think, like, we go to hurricane deployments down south, that entire city might not have power, which means that my closest hospital physically might be 10 miles away, let's say. But are they able to accept a patient who is critical and needs an or, has the potential to need an or? So, then it's thinking about, well, how am I going to get this? Where is my closest actual facility that's accepting patients and how am I going to get them there? Because the roads are so flooded. So does that mean that we take an ambulance ride to a prestaged boat and then cross a flooded highway with the boat and then get back into another ambulance? These logistical things really start to add up. And there's a lot to think about when you're down there with a patient.
And again, your optimal training is like, oh, I want to do all these specific things, and I got to do this or this and this. But you know what? It might just be easiest to put a c collar on or pop a tourniquet on that thing. That's bleeding and move. And you can always reassess and alter your treatment course later where it's light, where you have more hands, where there's more equipment. So not being afraid to change your treatment plans based on where you are, I think is really important, too. Yeah.
[00:27:23] Speaker A: And it's very similar to helicopter medicine. I know when I gave you a little note, I kind of talked about how my mind worked, where I started sorting these patients into, in terms of their treatment, about what has to happen now versus what has to happen but can happen later, and then what's optional. Like, if you go to a patient that's entrapped in a pile of concrete, if they're hemorrhaging from an artery, you have to treat that now. You cannot delay that. There's no choice. Like whether it's cutting through the rock and getting in there and putting a tourniquet on or putting your hand in. Whatever you need to do, you have to stop it now. You have no discretionary choice. Pain control should happen, but it can happen later. It's not an immediate need. You wouldn't want to give pain control before you controlled an arterial bleed, and then something like antibiotics is going to ultimately help their outcome, but that's not going to make or break survival, and you wouldn't want to delay them in the hole for an hour while you're waiting to get antibiotics administered. So I think thinking through that process of what do you have to do now versus what has to happen but can happen later, like when you're out of the hole versus, we'll get to it if we get to it.
[00:28:28] Speaker B: Yeah. And I wonder if part of me is a little bit corrupted from working in the ER and working in this critical care medicine environment where, oh, I know all this patients, they have a traumatic amputation. Great, they're going to need antibiotics. And that's in my brain. But I'm like, yeah, you're right. They don't need this in the hole right now. They need a tourniquet, and they need pain control and airway support and get them out of here. But in the back of my mind, I'm always like, oh, maybe I wasn't able to do everything that I had planned for, or I have all these things planned in my head, and then you have to realize it's simply not going to happen or you don't have enough time for that. So you're right. Prioritization is really important. And again, that prioritization is going to change based on your current environment, the environment that you're extricating the patient to. And also how long you're going to be down there for. Right. If a patient's going to be trapped for, even after you make patient contacts, sometimes folks are down there for 24 hours, if not longer, while the rescue team figures out a way to get them out or kind of reaches a new hole to get them out. So it really is all about what they need right now. And, yeah, it's not perfect. And would I love them to get antibiotics? Yes, but also, that's not my immediate problem. And you're right, that's not going to kill them in the time frame that I'm going to be with them and not to turf that to the hospital, but that's something that they can certainly get once they're out in the hospital.
[00:29:46] Speaker A: Yeah, for sure. And that was like something I learned from one of my buddies who was in the military. Is like, this concept of antibiotics is like anytime they get injured in the field, they're going to get antibiotics at some point just because it's dirty. Like, everything's dirty, your clothing is dirty, the environment's dirty. But giving them an oral antibiotic before you move them off the battlefield is great if it's feasible, but also waiting an hour and administering an antibiotic iv, you're going to get great effect. It's not like we're waiting days to administer this stuff.
And I thought it was just interesting, this concept of kind of teamwork behind operationally planning and providing good medical care, even on the fire service. I remember a lot of calls where you might have a patient who's in a dangerous environment or a bad situation or a trauma. Right. And there's a lot of things you want to do to provide the perfect medicine, but sometimes the fire lieutenant is kind of like breathing down your neck, being like, hey, you're ready to move, you're ready to move, you're ready to move. And maybe you're not going to get like a serial EKG. Maybe that's like the best thing for the patient. But maybe in that setting, getting them up off the cold pavement is going to be more beneficial to them than delaying to take more diagnostics. Person with alert and oriented times four mental status, like delaying to get a blood sugar, does that make the most sense in the whole, or do we know, can we infer that they're mentating so their blood sugar is probably not catastrophic, at least at a minimum.
[00:31:09] Speaker B: Yeah. And I mean, let's take that diabetic example, for instance. We do this one training evolution, where it's simulated of a car into a house and the house kind of collapsed on top of the car, but the patient's awake, but they're altered, and you're like, oh, man, are they altered because they just drove into a house? Are they drunk? Are they high? Or is there something else going on? And they're mumbling something about sugar and maybe diabetes, and you're like, okay, I can't really get to them fully. I can't get a finger stick. But is this something that I can take the chance and assume, all right, if they're really low and I give them something sugary, that's going to help fix my problem?
Conversely, if their blood sugar, if they happen to be in DKA and that's why they're altered, is a rice Krispies retreat, is that really going to matter that much once your blood sugar is already 1000 or 1200? Right. So operationally, it makes more sense to just give the sugar or give the dextrose however you can, whether it's a granola bar or, I mean, I always have snacks on me, so here's a Hershey's kiss or a starburst, something like that. And is that perfect medicine? No, but is it realistic medicine for what's going on? Yes. And it's all about, does the benefit of this right now outweigh the risk? Yeah.
[00:32:24] Speaker A: No, absolutely. I mean, it's the same how paramedics approach a heart attack. It's like, you got chest pain. Okay. Do you have any bleeding anywhere? Any GI stuff?
[00:32:32] Speaker B: No.
[00:32:32] Speaker A: Any allergy stuff? That aspirin? No, just give it if they're not having a heart attack. Okay. You got some aspirin? Like, I took aspirin yesterday for a headache. It's fine. It's not a big deal. So I think that's a great point about what are some interventions that have a high yield, low risk and are operationally feasible, and then doing the minimum to provide some comfort and some stabilization and then prioritize that movement towards definitive care, like not delaying, don't lose the forest through the trees type of thing? I think that's a great point. So if people are interested in getting involved with Usar, if they're listening to this episode and they're like, oh, man, that's a cat's pajamas, I want to get in on that. How would you suggest they start to go about that?
[00:33:11] Speaker B: Yeah. So I think the first step, just like with applying for any new job, is kind of a quick self evaluation. And you can say, what can I bring to this team? And what can I learn from this team? So if you're out there and you love ropes, or you're a boy scout and you know 50 different types of knots, and you can practice a little bit and kind of get up to snuff with that, or you're in the fire service and you've got some rope stuff, some structural collapse stuff. If you are really seriously considering something like applying to one of these task forces, I would say like a quick online search for wherever you're living is kind of a good way to start.
If you go to the FEMA website, USAR falls under FEMA jurisdiction. There's links to all the different states and all the different state teams for all the bigger teams. And then if you go online to the state urban search and Rescue alliance website that has all of the smaller teams, and you'll be able to find links to everything through there, a quick search for Vermont Urban search and rescue, or Vermont Task Force one, will get you to where you need to go. It's on the state website. We're technically under the Division of Fire Safety, which is under Vermont emergency management.
Urban search and rescue is this weird thing. There's no real great spot for it in normal matrixes or matrices, but that's where you can find it.
We're on Facebook.
We've got an Instagram. Our dog handlers have their own instagram as well. If you're into the doggos and you love some search and rescue hide and seek stuff. So there's all different ways to get out there and then just being really open to trying new things. I mean, I came on primarily as a medical specialist because that was my background and I had picked up my equipment on, like, a Tuesday. And then we have team trainings once a month on Wednesday, and it happened to be the next day. And my program manager was like, hey, come on over and come on tomorrow, and if you're free, and we'll get you kind of up to snuff.
So fast forward 24 hours, and all of a sudden I'm cutting a railroad tie with a petrogen torch. Have you ever done that before? No. Was it awesome? Absolutely.
But knowing that I was doing so in a safe environment where everyone around me is the best of the best in their field. So, I mean, I was being taught some kind of technical rescue stuff by folks that have been doing this for 20 years, for 30 years, that are chiefs on their department, but are one of the guys and one of the crew members on USAR. So it's really cool to see.
And some folks love water rescues. I was talking to someone about joining the other day, and they were like, listen, I'll get into a confined space. I'll dig through rubble. I'll set up a rope system. I'm not getting into any water. No, that's not for me. And I was like, great. We always need shore support. Or folks, conversely, really love water rescues. That can be their jam. And if we get called for structural collapse, maybe they don't come. Or they say, okay, I can come. I'm probably not going to be a team leader, but can I assist in other ways? Can I be doing some of the grunt work or some of the operational stuff? So if you're interested in any of that, I would reach out, apply.
There's usually always openings for different things, so find out what would suit you best.
If you're really into tech and stuff like that and you want to get into the technical search side of things, we fly drones.
They sometimes use, like, ultrasound and sonar. We've got these fancy and really expensive, like, 360 cameras, some snake cameras as well. So you can get into the search side if you're like, oh, I love breaking rocks and setting up these systems. Okay, well, then you're more of a rescue kind of person. Or if you're like, I don't really like to get my hands super dirty, but I like logistics and management of fleet operations and making sure that the equipment's kept up to date. Great. You can join the logistics team or the planning team if you're really into Hazmat, and you have hazmat certs, congratulations. You've just become our new hazmat guy.
[00:37:09] Speaker A: Excellent, right?
[00:37:10] Speaker B: Yes. So I think that's a really cool thing, is that there's something for everyone that's interested in it, and it really is just diving in headfirst, being open to learning new things, and it's all kind of about putting in what you get out. If you want to go take another certification class, they'll support you. You'll go take it. You come back, congrats. You're now licensed, or you're certified in confined space rescue or collapse rescue or something like that. So just get out there, start asking questions, and apply if you're really thinking about it.
[00:37:41] Speaker A: And that's kind of the cool thing about this whole system, is you don't need to be a world renowned rock climbing rope rescuer to start. You just need to be interested and have something to offer the team and be willing to explore the new options. And they'll put you through whatever you want. I mean, most of the people I know that are on USAR, they came in with some basic, fundamental skill sets, and now they've been sent to all these large classes all over the country and the world to become who they are today. And that's done through USAr.
[00:38:08] Speaker B: Yeah. And again, like I said, there's always room to grow and branch out. I mean, never in a million years did I think I'd ever be in a partially collapsed building that had been on fire 12 hours before building supports and shoring it up. When I joined USAR, I was like, I'm the med guy. I'll treat you if you get hurt. I'll treat a victim if they get hurt. And all of a sudden, I was like, oh, this is actually the coolest thing in the world, for sure. Now I got some basic carpentry skills, and I can go in with them and help shore up a building.
Or I was taking that disaster medicine class, and I found myself in a little, really confined space trying to assess a patient, and I was, huh? This is not what I thought it was, but this is pretty.
[00:38:48] Speaker A: Yeah. Yeah, no, that's really cool. Well, David, I appreciate it. Thanks for coming on the show.
[00:38:52] Speaker B: Yeah, thanks for having me. This was awesome.
[00:38:53] Speaker A: Yeah, absolutely. Well, stay safe out there. You too.
[00:38:56] Speaker B: Thank you.
