Transcript is automatically generated.

Matt: [00:00:00] You just blow up your house. You just light your house on fire. 

Erik: But what about the ones you missed? Yeah. Well, I don't know. Who did we miss? Yeah, show me.

Narrator: You are listening to EMS. With your hosts, Erik Axene and Matt Ball. 

Erik: Well, this is a good topic I think we're gonna talk about today. 

Matt: All of our topics are good topics.

Erik: Well, you know what I like about this one is that like this, this one is one of the ones that it [00:00:30] really does, it's a tangible way to really save lives and decrease mortality.

Hospitals really care about this, and so they rely upon us in the first responder community to be able to be on point with. This topic. 

Matt: Mm-hmm. Early identification is key. Just like with the STEMI or with strokes. Uh, we're, we're finding out that Oh wow, we have an impact here. 

Erik: Big impact. 

Matt: Yeah. Yeah.

So make sure you like, share, subscribe to our YouTube. Mm-hmm. Like, make comments and like we've been talking about, uh, you [00:01:00] can get CE credit if you are on our website at

Erik: Axenece.com. Yeah. Yeah. If you want CE credit for it, which you can, you can, CAPCE accredited.

That's credit for these things. 

Matt: That's right. Yep. 30 minutes. Uh, at a pop you can get a credit, but you gotta do it through the website so you can get the certificate and take the quiz and do all the things that they require you to. We get asked all the time, why can't we fast forward stuff? Because they won't let us do that.

Like, 

Erik: yeah. Yeah. You know, there's rules. 

Matt: There's rules. Yes. Yes. Everybody, they want to find that CE provider that they can just just go to the end like, [00:01:30] no, bro. 

Erik: Yeah. Death by PowerPoint stuff. I can see why people wanna fast forward, because you know.

Matt: Oh, a hundred percent.

Erik: We owe people that professionalism to be able to, 

Matt: that's right.

Hopefully you enjoy listening to the podcast and now you can get CE credit

Erik: and learn something. Really improve your practice. Or reinforce good stuff. 

Matt: This would be one of those things. So, sepsis, 

Erik: sepsis,

Matt: hot topic.

Erik: Mm-hmm. What is sepsis? How would you define sepsis? Well, 

go ahead.

Matt: Oh, you said, well; you want me to define it?

Erik: Well, I mean, I, I mean, I think we both talked about this. Yeah. I mean, it's really less about the infection, [00:02:00] it's more about the body's response to the infection. We have a foreign invader that gets into your system, and then the system. Recognizes it through the immune system, massive inflammatory response with these deadly chemicals called cytokines and chemokines, all sorts of, we could geek out on that, but we're not going to,

Matt: well, you're not going to.

Erik: No, you won't let me, but we don't need to know that. Right. That's, that's one thing I like about. The way we work together. Yeah. Right's. Like we don't need to know that. Right. Right. I need to know as a physician what we really need to know. And you, [00:02:30] you're the expert there. And then sometimes it's good to know some of the geek out stuff.

Mm-hmm. It's like, oh, why do we do this? Right. Oh, that's why 

Matt: I think there's a, you can give enough information about how it's working. Yep. Right. So that you understand the basics of it, but you know, you don't have to get to down to the cellular level. Right. To understand. How to identify it, you know, how to, what to do about it, all those kind of things.

You don't have to, I mean, it's interesting. Yeah. Like I find that interesting, but not everybody finds what we find interesting. 

Erik: Well, I'll tell you this, and this is the common thing with all disease [00:03:00] processes is right now, when you're in a state of. Health, there's a, there's this idea of homeostasis where things are in balance.

Mm-hmm. And things are constantly changing and, and things are challenging that sense of balance. Right. Whether it's thermal regulation where it gets cold. So you put on your jacket or pH levels. Correct. Um, uh, you don't. Eat enough. And so you break fats down to maintain that energy balance. And if you eat too much, you store it to maintain the energy balance.

I mean, there's, the body is [00:03:30] constantly trying to maintain homeostasis. So when you're in a, a situation where you have, uh, an infectious organism enter your system that's not supposed to be there, and then it takes root and multiplies, and now it's starting to cause dysregulation to your body system.

Mm-hmm. You get sick. 

Matt: It's kind of like, if you think about you got your house, right? 

Erik: Yeah. 

Matt: And you're trying to keep your house protected, right? You want homeostasis in your house, right? Yeah. Everything's at peace. Everything's clean, organized. At least in my house. I like it to be. Yeah. And then you get an, you get [00:04:00] an infestation of bugs in your house, right?

Oh, well, so the sepsis response would be you have. An infestation of bugs in your house and instead of hiring a, a insect guy to come in and kill that thing Yeah. You just blow up your house. Right. You just light your house on fire. That's, that would be an overreaction. Yeah. And that's what happens with 

Erik: sepsis.

Exactly. That's is that the, the response to this infection is way overreaction. Right. And some people. Some people are worse than others. Yeah. Um, so the interesting thing is, like with bacteria, for [00:04:30] example, like, like, um, like a staph infection mm-hmm. From maybe a skin infection, you use cellulitis or something like that.

If that gets into the bloodstream, uh, those organisms release toxins that cause the blood vessels to totally go wonky on you. 

Matt: What's it called? The glyco. 

Erik: The, well, the, with the, we'll just call the inner lining, the, the endothelial lining. Yeah, yeah, yeah. Is, is actually really important to the, the function of a blood vessel.

'cause on the outside you've got these smooth muscles that can cause it to [00:05:00] vasoconstrict and vasodilate, and that helps us to maintain blood pressure and perfusion of organs. Right? You throw a bunch of toxins from an infection. Now they're all. Dysregulated and the blood pressure goes down and, uh, organs don't get perfused.

And that's what kills people. That's right. There's a progression of sepsis from you. You screen positive with some bad vital signs, which could be a sign of compensation trying to get back to homeostasis, right? Mm-hmm. And then if you find a source. Bad vital signs plus a source equals [00:05:30] sepsis. 

Matt: There you go.

Erik: And then when sepsis gets to the point where organs don't work, you go to severe sepsis, you uh, get to low blood pressure, now you're in septic shock. That's right. And then you, when you get to the point where multiple organs start to fail, altered mental status. Yeah, yeah. You start getting way too. And then you mods.

Right. Multiple organ dysfunction syndrome. Yep. So that's the bad stuff. That's the stemmy of the sepsis world is get to mods. And I didn't know this, uh, but when I lectured on sepsis recently, um. At a webinar with mm-hmm. MS. World. Mm-hmm. Uh, no. No. I'm sorry. This [00:06:00] was at E sso. Um, oh, yeah. Yeah. Conference is getting confused, but yeah.

You've been all over the place. Really. But the, I I, I talked about the mortality rates of sepsis. Mm-hmm. And I asked people, you know, these seven things, what's the most life threatening? I'm gonna see if I can remember 'em. Did you see, did I talk to you about this? 

Matt: Uh, no. I don't think you talked it. Oh, this is interesting.

Yeah. Okay. This will be a 

Erik: fun little bird walk here. Ohoh. I think we're on track. I think we're okay with time. Good. Good for it. Yeah. I like 

Matt: it. 

Erik: Alright. Rattlesnake. Bites, rattlesnake in veneration, not a dry bite to rattle. Yep. 

Matt: Yep. Yep. 

Erik: Plane crash. 

Matt: Okay. 

Erik: [00:06:30] Uh, commercial or private? Yep. Um, what's the highest mortality rate that I'm asking?

Right. Um, gunshot wound to the head. Oh. Fall from 60 feet. Sepsis. Multiple organ dysfunction syndrome. Um, shark bite. Unprovoked. And there's another one I'm missing. I think I got seven, a six of the seven there, but I, it's not important. So, right. Of those, what, which one do you think is the least lethal? 

Matt: The lethal.

Oh, gunshot. Wound 

Erik: to the chest was the other [00:07:00] one. 

Matt: Oh, head and chest. Head and chest. Okay. So two different categories. Yeah. Okay. I would say, uh, the least lethal. Uh, would be the snake bite. 

Erik: That's correct. Yeah. Less than 1%. Yeah. We played with rattlesnakes. Yeah. Yeah. We, it was scary, but we were Oh, 

Matt: yeah, yeah, yeah.

Nobody scary. Wants to get beaten by snake, but yeah, it's like a fear. It's not gonna really kill you most of the time. 

Erik: And what's the most lethal of all this? Well, golly, I, if you remember a 

Matt: gunshot wound to the head, I would think, 

Erik: no, it's not. 

Matt: It's, 

Erik: it's not 90% mortality rate. Okay. 90%. So [00:07:30] 10% of people can survive a gunshot.

Well, if you look retrospectively. Oh really? I thought that was interesting. Gun. Yeah. I would've 

Matt: thought, 

Erik: uh, gunshot wounds to the chest. I mean, I 

Matt: guess it de qualifies what they're talking about. Like, are we talking about a grazed gunshot, you know, kind of what are the categories based 

Erik: on the data? Yeah.

Gunshot wound to the head. Okay, got it. All gunshot wounds to the head. 90% fatal. 

Matt: Okay. 

Erik: Um, and I thought, I. Uh, 100% of people who fall from 60 feet die. 

Matt: Oh, okay. 40, 40 

Erik: feet, it's 50%. Oh, 

Matt: that's right. 

Erik: I think it was 40 feet. It was 50 or something like that. Or no, [00:08:00] 75 and then 20, I think was 50%. 

Matt: Okay. 

Erik: But yeah, you get to 60 feet, the terminal velocity, you're done.

You're done. You're not gonna live when you hit the ground like that. This the massive deceleration. But what I thought was also interesting is mortality rate. Of sepsis of mods can be worse than a gunshot wound to the chest. Gunshot. Wound to the chest is around 75%. Okay. Mods can get up to 80. So that, that the point, and the reason I did this mm-hmm.

Was to illustrate how deadly. Oh, plane crash, [00:08:30] by the way, was the second least likely 

Matt: to kill. Yeah, kill. Because it doesn't happen it less than 

Erik: 5%. 

Matt: Oh, is that of, of people that have been in a plane crash, all 

Erik: plane crashes, all, like what? What is the mortality rate like of, of, okay. You know? Well, I guess 

Matt: that's because you, if 

Erik: you're in a plane crash, right?

How likely are you going to die? 

Matt: Well, yeah, I guess it depends on like. What they're defining as a plane crash. 'cause like we get planes out here that just, it's all 

Erik: plane crashes. 

Matt: That's what I'm saying. Like a little Cessna does a belly landing. Do they call that a plane crash? If you're in a 7 37 [00:09:00] falling from 30,000 feet, you probably don't have, you're not gonna Yeah.

That you're not. But that 

Erik: happened so rare though. Right? Exactly. Like the, the plane crash we recently had in Toronto actually talked to the Toronto Fire chief about this. Oh yeah. He was, yeah. Helped with, uh, care for these folks. But, um, nobody, nobody died. 

Matt: Oh. Nobody died. Nobody 

Erik: died. They crashed a big plane, hundreds of people, nobody died.

Um, and it was because of the snowbank. The snowbank ripped a wing off. Mm-hmm. So they didn't have all that gas. 

Matt: Yeah. 

Erik: Otherwise, 

Matt: okay. 

Erik: It could have been much worse. 

Matt: Or like he got Captain [00:09:30] Soley landed that. Yeah. Right. See, sometimes he's a hero. 

Erik: But anyways, but the reason I brought this up was to illustrate how a gunshot wound to the chest, comparable mortality rate to mods.

Right. That's crazy. And a gunshot wound to the head was not as lethal as falling from 60 feet. I thought that was interesting. 

Matt: And people ask why, you know, we talked about this, this in another podcast about, you know, why are we giving antibiotics? I had the guy ask me this question and he was just being genuinely curious.

And it's like, well, why do you put, you know, why do you give blood to trauma patients if you [00:10:00] have that ability? Or why do you, whatever? Because you're gonna save their life by doing it. Right. And 80% of these patients in septic shock can die. Can die. It can be that. Don't. That's right. Yeah. So it's very important.

Erik: Yeah. And when we get to management, we'll talk about how important the management is by doing that early. Um, um, but the, the disease, I think we've covered the disease. Yeah. We could have geeked out on it even more, but Right. And people 

Matt: have heard about sepsis. They understand, obviously you have to have some sort of an infection.

What I would be curious to know. I would say think UTIs is probably the most common cause of [00:10:30] sepsis. 

Erik: Good question. 95% of the infections are either skin. 

Matt: Okay. 

Erik: Bladder or lung. 

Matt: Okay. So pneumonia, right? There are, you could 

Erik: have bowel, you could have, right. There's lots of different like meningeal infections and things like that.

That's like neuro infections. Like meningitis. Right. But the, the common ones would be bladder, lung, and skin. Yeah. It seems, and skin would include throat, include ears and kids, you know, all those things. So. 

Matt: Yeah. It seems to me most of the ones I've had pre-hospital, it be either pneumonia or most of them have been UTIs.

Yeah. Seems that's where it [00:11:00] kind of originated. 

Erik: Yeah. Um, so, 

Matt: alright, so presumed source of infection is a big indicator, right? 

Erik: Yep. And then, and then the body's response to that is really what creates the problem. That's what killed people in Sep uh, in CO back in, during COVID, people weren't dying necessarily directly from the, uh, the COVID virus.

It was the body's response to it that killed people. So. We'll just leave it that way. Get into that. Yeah. We 

Matt: won't get into that topic, 

Erik: but, but the body's response, the host response is really the [00:11:30] big part of what, what kills people and what makes, you know, people real sick. 

Matt: Mm-hmm. 

Erik: Is the fighting against the, the pathogen.

Right. Blowing up your 

Matt: house for the anthill. Just think of it. That's right. Overreaction. 

Erik: Very deadly potentially. So, uh, which kind of leads us to the next, you know, kind of topic within a topic and I think one of, I would say the most important thing that we could talk about today. Yeah. Management's important too, but I think this is.

Clearly the most important thing. 

Matt: Well, and and you're, you're saying that [00:12:00] based off the data that you found, 

Erik: right? 

Matt: Is that, is it nationally we're missing a lot of, we're missing, yeah, 

Erik: we're missing a majority, uh, of these sepsis patients and not we're, we're mis um, diagnosing them. Uh, they're not getting the, um, the identification, the early identification, which really saves lives.

So that's it as assessment. Assessment, 

Matt: yeah. 

Erik: And that's a big part of what we do in all diseases is identifying a disease process. 

Matt: Yeah. But doctor, they say that we don't diagnose as paramedics. 

Erik: We do, don't we? Isn't that crazy that people think that? But that's, how do [00:12:30] you 

Matt: treat something you don't diagnose?

I've never understood that. 

Erik: Right. We don't make the official diagnosis. That's right. But we have to put them into the right bucket. That's so the treatment that we offer gets to the hospital and then oftentimes in the hospital that that diagnosis sticks to the patient. Mm-hmm. And brings them into the hospital.

Admitted. And if it's the wrong diag. They may not find out for the next day, which delays care for really ultimately what's causing the problem. Right. So I think our assessment of our patients is, is really important. And it doesn't sound sexy at all. 

Matt: Nope. [00:13:00]

Erik: But early identification is what saves sepsis patients' lives.

Matt: Excuse me. Yeah. And so we've got like Thess criteria. Yep. Which you are not a. Huge fan of Nope, I'm not just not very effective based on data. Well, 

Erik: it's good. It's good for what it does, right. In trying to catch everybody. It's 

Matt: more of a shotgun, 

Erik: right? Yeah. Approach. Well, this patient meets sepsis criteria.

Yeah. 

Matt: Their heart rate's above 90, their respiratory rate's above 

Erik: 2020. And 

Matt: you gotta look at it and it's like, okay, what's the context 

Erik: there? And one of them is a blood test. They don't even [00:13:30] do it in the ambulance. Right. And, and other studies I read of 18 of 'em, only one of them, uh, even. Studied the pre-hospital environment.

Matt: Yeah. 

Erik: So Q sofa, the modified Q sofa right, is a little bit better. Mm-hmm. Um, it's, it's definitely better than sirs. Mm-hmm. Um, for identifying sick patients. Um, and, uh, that, that involves organ dysfunction. Mm-hmm. 'cause you've got the ultra mental status in there. Right. Right. Clearly a fast heart rate.

That's a way we can see that on the monitor, right? Why is the patient's [00:14:00] heart rate so fast, right? Why is the patient's blood pressure so low, right? Gosh, is there a cardiac thing happening, 

Matt: right? You do your due diligence, right? You put 'em on your EKG, you run a 12 lead. You ask about history, correct? And then in your history, you know, if they say, yeah, I've had an MI in the past and I'm having crushing chest pain, I'm going down the cardiac route exactly where they say.

She's a little bit altered. Grandma's a little bit altered, and then you ask, because you're a smart paramedic, you're like, she had a UTI recently. Oh yeah. She's [00:14:30] got diagnosed two days ago with a UTI. She been running a fever. Yeah. Okay. Now I'm going down the S sepsis 

Erik: route. Yeah. What's 

Matt: the, yeah. 

Erik: Is that part of your vitals?

Did you get the temp? 

Matt: Yes. You should get a temp. Yeah, but don't always, I get people that tell me that, well, they didn't have it. They were a fibrile. It's like, okay. Just because they don't have a temp Correct, doesn't mean that they don't have an infection. Exactly. 

Erik: Get the temperature. If they don't have it, it doesn't mean they don't have.

I mean, it's like EKGs. Just because there's no STEMI there, it doesn't mean they're not having a heart attack. Yeah. 

Matt: And most of the time, I mean like you wanna get the number for your documentation, that's important. Right. But you can tell, like [00:15:00] I go out and I'll touch these picture like, holy cow, they're burning up.

Yeah. Like you can feel it. They are on fire. They got a fever. 

Erik: And we have to be careful too because if you talk to your patient and you ask them, Hey, have you felt hot lately? Or have you felt like you have a fever? Oh, I need to chill. The chills. 

Matt: Yeah. 

Erik: When our temperature goes up, we feel cold, right? 'cause, because, uh, we're trying to absorb temperatures, the temperature deficit, so we feel cold 'cause we're trying to absorb energy.

Right. That's, that's why we feel cold and we want the blankets. Yep. Our body's trying to raise the thermostat. 

Matt: Yeah. [00:15:30]

Erik: And uh, so if a patient is asked, have you had fevers? No. The opposite doc. I felt cold. That actually is a bad sign. Yeah. Right. So you're right. Clinically, that, that would be to me, more concerning than a temperature that was maybe 99.

Right. 99 9. Or whatever. It doesn't quite meet fever, you know, criteria. It's not over 100.44. Yeah. But the history of the chills is a big deal. So, uh, it's not just heart rates, it's not just blood pressure. It's not just [00:16:00] all these signs and vital signs we pick up on our, our, um, life pack or the zoni or whatever, right?

Matt: Mm-hmm. 

Erik: Um, there's also the, the mental status. 

Matt: That's right. 

Erik: Uh, that's the. First thing to go. Why is the metal status the first thing to change? Do you know? Why? Do you know why? Well, 

Matt: I mean, I would think the, the, the, the brain is so dependent upon oxygen and glucose, right? And it's so sensitive to changes in oxygen and glucose levels.

That with all that overriding response from the host that we talked about, that it's, you've decreased the oxygen [00:16:30] and glucose levels in the brain, and so you're getting, 

Erik: it's the most sensitive cells in the body. It's like a canary in a coal mine. When you have the, the. Patient that gets altered, that's usually the first thing to go because the brain cells, like you said, are so sensitive to deprivation of oxygen.

They need it all the time. Yeah. And if they don't get it. Grandma's throw off acting weird. Right, 

Matt: right. I think the other vital sign that we need to talk, well, first off two things. You talked about heart rate and blood pressure. Okay. But there's something we can do with our heart rate and our blood pressure that we'll talk about in a minute.

Yep. And then end tidal. End. [00:17:00] End tidal has proven to be huge and as pre-hospital providers mm-hmm. We are really on the cutting edge of using entitle for sepsis. I specifically have brought patients into the hospital once. One specific patient I can recall that had a very elevated heart rate, but that was it.

Yeah. She had no temp. She did have maybe a little, they said maybe the flu, but she had an obvious infection that we found. Yeah. But her end title never got above 19. And I'm like, oh man, she is septic. And the doctor didn't believe me when I told him. I was like, Hey Doc. And he's [00:17:30] like, why'd you call sepsis on this?

I said, well, this, this, and this gave him the whole story. And I said, and our end title was never got above 19. I had to run ONT title for. You know, 15 minutes. Uh, so as EMS providers, like we've talked about with our OMI stuff, we're on the cutting edge of this end tidal stuff, and we can help educate people on it.

Erik: And in the hospital, if, if you were to shadow me, we're gonna be waiting for that lactic acid to come back, because that's one of those, right, those measurements. That the hospital watches to, to trigger sepsis. And when somebody [00:18:00] has a, a lactic over a certain number. Right. It triggers all this hospital monitoring thing for sepsis numbers.

Yeah. So this, the lactic acid is huge. And so we have the surrogate in the ambulance. Mm-hmm. The end tidal less than 25. It correlates with the lactic acid of over four. 

Matt: Right. Which is indicative of septic shock. 

Erik: Correct. Right. And that septic shock is the beginning of what could become mods if we delay care.

That's 

Matt: right. 

Erik: And, you know, um, I think as far as assessment goes, the last thing I would say, um, is that, uh, you want to be [00:18:30] really careful with certain patient populations. 

Matt: Mm-hmm. 

Erik: If you have a patient that's on chemotherapy or, um, some sort of an immunosuppressant, your, your trigger for sepsis should be higher.

Pregnant women, little babies, less than a year old, nursing old folks. That's right. Yeah. Those are populations that are particularly at risk for becoming septic. And they could get sick if they. Get missed. That's right. So you get there and you think maybe they're altered and you're thinking stroke for some reason.

And so they get bucketed as a stroke patient, 

Matt: which I don't get altered Mental status [00:19:00] is not a sign or symptom of a stroke. Yeah. They're altered because they can't talk. Right. Maybe. Right. Or But they're not altered. Yep. Altered mental status is they're looking at you, they're. Trying to talk. They're confused.

Yep. It's an altered mental test. It's kind 

Erik: of a generalized thing. Yeah. Like whereas the stroke is usually unilateral. Right. Something asymmetric. Right, 

Matt: right. Yeah. You're gonna see some drooping or their aphasic, you know, something like that. I don't consider somebody that's a, 'cause you can tell with a stroke patient, they're still tracking with their eyes.

You can tell they are understanding everything that I'm saying that's going [00:19:30] on. They just can't respond to it. 

Erik: And the sickest ones, I think are the ones if you, we we're not talking about stroke today. Right. But the LVO, the large vessel occlusions. Yeah. They're staring off to the wall. Oh, yeah. Yeah, exactly.

And you're over here talking to 'em. And they're just looking over here. They're looking all over trying to find you. This voice they hearing. That's right. Yeah. That, those are the bad ones that, but 

Matt: see, I don't look at Yeah, that's very stroke-like. It's, to me, stroke and altered mental status look very different.

Erik: And I think, I think what's happened though is that people, um, can have strokes with, with, [00:20:00] with, um, all sorts of different symptoms. Sure. And then we miss one and you get your hand slapped and then you're like, well. I'm not doing that again. Right. So what do we do? 

Matt: Everybody's having a stroke. 

Erik: But see, this is what's happening with sepsis though.

Mm-hmm. Is that people will go see a patient. Here's true story. I was on a ride out with my paramedics. Mm-hmm. And I smelled the urine when I got in the room and I saw the leg bag on the patient's leg. Oh, under his pajamas. Yeah. Wife says flag, he just got discharged. Treated for TI, red flag guy's got a.

Fever. Yeah. Guys [00:20:30] tachycardic with AFib. RVR actually, yeah. His blood pressure was kind of hanging on a bound. It was just really not so good. 

Matt: Yeah. Yeah. 

Erik: And I told the patient, uh, my paramedics like, guys, this is. Perfect setup for a textbook. Yeah. For sepsis. Right. And as, as, as and as we continued to assess our patient, we, we saw some blood around his mouth.

Mm. Some dry blood. Wow. Hemoglobin ended up being five. Now he's bleeding. And so he had a GI bleed. Mm-hmm. That's what I thought. The big thing. So I remember on the way back in the ambulance on this ride, I was like, guys, see, I [00:21:00] even anchored on sepsis, you know? Yeah. Uh, and it, and it was really probably a GI bleed.

Matt: Were the other signs there, like elevated heart rate, which would be, yep. Yeah, hypotension, certainly 

Erik: pale conjunct. I did. I went through the whole thing on loss of palm creases. Interesting. But I wanna share this story because I was wrong. You what? The patient I got there and the pa, his name's Justin, he told me, Hey, uh, the patient hemoglobin is five.

That's probably what it is. We're gonna admit him to the ICU for transmitted fusion and all that stuff. And that's [00:21:30] a big part of sepsis too, is having the hemoglobin there so you can carry the oxygen. Mm-hmm. If you have a low hemoglobin, it's really tough to, to make yourself better. It doesn't 

Matt: matter how much oxygen you're breathing in.

Right. You don't have enough trains to carry it. 

Erik: And so getting your, your hemoglobin at least up to 10 That's right. Is a really big. Big, big thing for patients, uh, beyond the seven, but to 10 anyway. But it's like, you weren't wrong though. See that? Well, I was though, but that's the difference. It wasn't hemoglobin though.

Matt: Well, yeah, but you had no way to know that I had a third 

Erik: diagnosis. 

Matt: Oh, you did what? Third diagnosis? Oh, it [00:22:00] wasn't the hemoglobin. I was wrong. 

Erik: And so the reason I tell this story though, just to encourage that Uhhuh, I'm a doctor, right? Mm-hmm. And I, I thought for sure it was sepsis. Sure. And then I got, I saw the, the dry blood around the mouth, and so now I'm anchored on.

G GI Bleed. Oh, 

Matt: you, oh, I thought you didn't find this out until you got to the hospital because it was 

Erik: confirmed at the hospital. So I thought I was really right. I get a call on the way home, uh, in the ambulance, get a call from Justin again. It's like, dude, the CT scan just came back necrotic appendicitis.[00:22:30]

And I remembered on the way there, every bump we on the road, oh, the guy was swearing when he hit the bump and I'm like, and I did a belly exam. He wasn't tender 

Matt: like Bernie's point or whatever. He'd 

Erik: had this necrotic appendix for who? Appendix for who knows how long. But it just got to the point where it had really overrun the body's regulatory systems and it wasn't the UTI.

He was, it wasn't his anemia. So he wasn't 

Matt: septic. He wasn't, I mean, he was anemic. 

Erik: Right. May Well, I'll be true. Yeah. And all these things could be [00:23:00] true. Right. It's just the thing that was most life threatening. Sure. The thing that was gonna kill him the quickest was gonna be this, getting that colon out.

Right. He had a necrotic appendicitis. Yeah. And they got, it was really nasty on the CT scan. Mm. And if they would've delayed care on that. Uh, that could have been deadly, 

Matt: which is, that's important to, you know, again, you anchor, we talk about it all the time, don't anchor, right? Yep. And you're going down the road and you're missing this obvious oh, oh.

Every time you hit a bump, you're missing that because you're like, ah, this guy's septic and you're doing your report and you're not paying [00:23:30] attention. Right? Yep. That's the pay attention to those little things, like why is he. Jumping every time we hit a bump. Like what's bothering you? What's hurting?

Right. If they can respond to you. But that also goes back to the fact that the pre-hospital, we don't have access to run hemoglobins 

Erik: and get all these things. So, but I should have laid him back and I should have done a thorough belly exam, is what I should have done. He was screaming out to me, literally with profanities telling me I have an appendicitis.

Matt: Oh, he was telling you that? 

Erik: Well, I mean, he, he was. Oh, but what was doing? Yeah, 

Matt: I thought you were [00:24:00] saying it's like, shut up, you idiot. 

Erik: I'm trying to tell the guys about your anemia. 

Matt: Shut up, Mr. Patient. I, I'm a 

Erik: doctor. Well, we all have the risk of anchoring and I'm just being honest. I, I, I and I, and the guys, it was really cool too, is learning for them because they see their, their medical director saying, oh guys, I kind of messed up, you know?

Matt: Oh, you're human. 

Erik: I mean, it, it's okay. Mess up. But I, I had anchored on the, the blood. Yeah. And I made a point about not anchoring on the sepsis. 

Matt: What was the shock index? 

Erik: Uh, the shock index would've been, would've been. It's terrible. [00:24:30] His heart rate was in the one seventies. Okay. So yeah, it would, and blood pressure was low, around a hundred.

So that's pretty low. Yeah. That, that, you know, before we close out, I guess part one of sepsis. Mm-hmm. Um, let's talk about shock index. Mm-hmm. Because that's better than just looking at the heart rate. I mean, looking at the heart and the blood pressure together, I think it's a pretty powerful tool. 

Matt: Mm-hmm.

Erik: And it's actually part of a screening tool that I think is the best one. Mm-hmm. The smart S-S-M-A-R-T. 

Matt: Right. 

Erik: Um, smart, um, screening tool. So 

Matt: let's, I say, let's take a break and we'll come [00:25:00] back, we'll talk about smart and then we'll talk about management of septic patients. 

Erik: Perfect. And then the future. And then the of sepsis management future.

Get 

Matt: excited folks. 

Erik: I'm excited. Be a futurist. 

Matt: Uh oh, he's excited. Here we go. That's not true. So 

Erik: we ended the last one. And we're talking about sepsis. We talked about the physi finish up with shock index. Yeah. Assessment, which I, again, is the most important part 

Matt: right. 

Erik: Of. Of what we do in the pre-hospital environment that is identifying disease accurately.

Matt: Mm-hmm. And we're, we're saving time in the hospital because we're doing our due [00:25:30] diligence and we're getting all this evidence together to say, this is what I think is going on with the patient, giving it to you at the hospital so that you don't have to waste time doing all those 

Erik: things. Right, right.

Exactly. And, and I think, and a lot of this is gonna come out in our last part when we talk about data, but, um, data, the data, data data is when, when we identify somebody early mm-hmm. Um, they, that early treatment and treating somebody earlier is, is is better. Is better. Yeah. And that, and data may not show some things when you look at it from one [00:26:00] perspective, but I think I'll, I'll make a pretty good case for it based on the data I've read, uh, that I think we've got a great case for early.

Assessment and And management. 

Matt: So you talked about SIRS is not great, qSOFA is a little bit better Uhhuh, but at the end we were gonna talk about the smart criteria. 

Erik: Correct. And there are other ones too. Right. Um, and then in the last part with some of the other future stuff and some very exciting things happening right now in this very field and sepsis screening.

Mm-hmm. But I think in my opinion, the best one that we have is [00:26:30] kind of complicated, so that makes it maybe not so good. 

Matt: Yes. 

Erik: The smart. Uh, S-S-M-A-R-T, which 

Matt: most people probably go through it because they probably don't know it. 

Erik: So for me that I, I do like a lot of it, but I think that qSOFA is so simple.

Mm-hmm. And it involves organ dysfunction, which serves, doesn't, to me, the qSOFA is maybe the way to go pre-hospital. Yeah. Yeah. And, and like I said earlier, there's no studies really. Uh, that [00:27:00] really focus on the pre hostile environment. There may have been one out of 18 that I looked at right. That, that, but it wasn't very considered that no comprehensive observational retrospective studies.

And it's tough too to really get a good blinded, you know mm-hmm. Randomized trial that, um, you know, gets, gets that real, um, that that perspective that, you know, studies something, uh, in, uh. And the longitudinal kind of perspective, you know, looking ahead, right? A lot of what we do is we [00:27:30] look out the rear view mirror, right?

And, and we're, we're trying to find correlations, um, less causation, right? Causation to me is that's really where it's at, and sometimes it's hard to do it. It's hard to get the IRB approval for that, but based on the data that we studied, there's really no great assessment tool. It's really doing what we want.

And if you look at the sensitivity and specificity, it's kind of like the, the quality of predictive value of a test of screening tools. Mm-hmm. Of things like qSOFA and [00:28:00] sirs. Mm-hmm. I mean the, the sensitivity and specificity's pretty poor when you compare it to some of the other screening tools that we use.

You know, like a good sensitivity might be 99%, right? 

Matt: Mm-hmm. 

Erik: Which, which is good for ruling out people, uh, for a screening tool. But when you start to look at the sensitivity and the specificity of cs mm-hmm. And Silfa getting down into the fifties. Yeah. That, that got a coin flip. 

Matt: Yeah. 

Erik: Um, so we gotta be careful with these, but we don't have a great.[00:28:30]

Tool yet. So it's tough. This assess. That's why this is so important, is to look at your patient. Don't forget to get that temperature, don't temp 

Matt: history, heart rate, respiratory rate. End title. Yep. Right. Is there a presumed source of infection? Do they look sick? Are they altered uhhuh? That's a big indicator.

What's their SPO O2 at 

Erik: and what are the risks? 

Matt: Yeah. What are their risks? Yeah, exactly like you said. Are they in a nursing home? Are they elderly? Ask history of pti. Immuno suppressed. 

Erik: Yeah. 

Matt: Have they been in the hospital recently? Maybe they [00:29:00] have pneumonia, right? Yep. If you put 'em on oxygen and their spo two's not coming up right.

That's not good, right? No, not good. Uh, their blood pressure, you're giving fluids, their blood pressure's not coming up. All these are signs that are pointing you down the sepsis route. 

Erik: Yep. And there are a lot of things that can make a patient altered. It's just one of the common ones. A sepsis context. And here's another thing, um, that kind of back a section here, but do you know that the most expensive thing that the hospital treats is sepsis?

Matt: I would think just because of the sheer number. 

Erik: The [00:29:30] sheer number, yeah, that's true. Uh, but also the leading cause of death in the hospital too. Yeah. This is a big deal. Disease. Yeah. A lot of people die of infections and it's very expensive. 

Matt: Yeah. 

Erik: The other thing that we really haven't talked a lot about, um, but when you identify somebody early mm-hmm.

And you start treating them early mm-hmm. They become less complicated and less complicated. Patients cost less money. 

Matt: Hence why we start giving antibiotics pre hospitally. Right. Because it's helping. Globally the patient problem. Yes. Or the sepsis problem. Right. [00:30:00] Right. Not just helping the patients, but helping the hot, it's a global, uh, somewhat of a remedy.

Right. And 

Erik: if you identify them early mm-hmm. I think this is a good transition now into management. Right. Right. So you early identification, early treatment, you've got all the 

Matt: signs and symptoms of sepsis. Yes. What are we gonna do 

Erik: with them? So how do we, uh, you've identified a patient, you're at a nursing home.

Yep. Actually I remember the patient. Yeah, we were together. Yeah, we, we pushed some pressers, I think on that, that, that lady up that nursing home. Mm-hmm. And, um, so, so when you've identified a [00:30:30] patient as being a potential sepsis patient, you've, you've gone through your protocols, maybe you're using SIRS or qSOFA, high heart rate, low blood pressure, febrile, slam dunk.

This is probably sepsis Keep. Don't put your blinders on because it could be something else. Right? Don't forget to get that EK, G when you're in route. It's just basic stuff. 

Matt: But no matter what, if they're high heart rate and a low blood pressure, guess what folks? Yeah. They need pressure. Yeah. They need a little bit of fluid.

They need some pressure. They need something, regardless of what's going on. We gotta get that pressure up. 

Erik: Gotta get the pressure up because when, uh, pressure's [00:31:00] low, organs die. That's right. Now there are some situations where you wanna be careful with the presser that you choose. Sure. Because, you know, if you don't wanna whip the horse, if it's a cardiac issue, then you can send the person into, you know, right.

Overload. F, you know, pulmonary edema, but, right. But you're right though is like you see somebody that's tachycardic and hypotensive. Right. We need to support them. 

Matt: Yes. 

Erik: What is making, I mean, is their heart failing or is it their heart being overloaded? A, is there pain closed? That's right. It's right. I mean, who knows?

That's a 

Matt: problem, right? 

Erik: So a sepsis though. I think [00:31:30] once, once we identified our patient in the nursing home mm-hmm. Which is a high risk place. Yep. To find a sepsis patient. Mm-hmm. Um, we identified it and we started treating quickly. Mm-hmm. And she was pretty hypotensive. She was and altered I think so. I think she was altered.

Uh, sweet old lady. Mm-hmm. Um. And so we, we, uh, started early, we identified pretty quickly, and then we started treatment right away. Mm-hmm. So what are the cornerstones of treatment for our sepsis patients? 

Matt: Well, first off's, fluids fluid. Right. Get your IVs going. Now I've just, the little 

Erik: one. It's like a 22 [00:32:00] gauge.

Matt: Well, so that's the thing. So I've had this discussion with people and medical directors because they're like 18 gauge. I'm like. Okay, bro. I'm picking up 80-year-old grandma from a nursing home on her best day. I'm probably not getting an 18 gauge in her right. If I can do that, I will do that. Right? For sure.

But sometimes, especially if they're in septic shock, you're talking about, they gotta tough 

Erik: to find. 

Matt: It's gonna be really hard to find any kind of a vein, right? Yeah. But get the biggest one you can. Hopefully not less than a [00:32:30] 20. Yeah. If you can help it. Right. 'cause a 20 two's really not gonna do anything anyway.

Yeah. Um, if they're that altered and they're that, uh, down the road, you know, you might look at doing an io, EJ is always an option. Yeah. Ultrasound. Ultrasound have, 

Erik: have you used ultrasound? Yes. Yet? Yes. 

Matt: Its, it's like cheating, but not everybody has that, you know? Sure. Financially, whatever the case may be.

Uh, 

Erik: get the biggest you can find. That's 

Matt: a gift. Get the best one in every, whatever way you can find it. Get the biggest IV you can find and start giving 'em fluids. 

Erik: That's right. Yeah, [00:33:00] fluids. So certainly. Benefit for fluids. Yes. 

Matt: But they're going away. We, I don't know if you wanna talk about that now. Later.

Yeah. No, we should. 

Erik: Yeah. I think, um, the, it used to be the 30 ml per, oh, sepsis. 30 per kilo. How many kilo? A hundred kilo. Okay. Three. Three liters of fluid. Let's go. 

Matt: It's like when I went to paramedic school, trauma patients, two large four IVs, pour the fluid to 'em, and now we're like, whoa, whoa. Poke the brakes, cowboy.

That's killing people. That's right. That's right. Now we're kind of the same thing with sepsis. 

Erik: Yeah. So the net, the, the recommendation now, well. It used to be a recommendation. Now it's gone downgraded to a suggestion. Yeah. As of [00:33:30] 2023, I think the study, yeah. We were looking at, um, so there may be some other data that I've missed in the last couple years, but clearly our reliance upon massive.

Fluid boluses. Right? It's not, may be causing harm in some patients. So now we're like you said, pumping the brakes a little bit. Um, so we're not 

Matt: saying don't give fluids, 

Erik: right? Definitely need fluids. 

Matt: Yes. If you're a pre-hospital provider, we're not saying don't give fluids, obviously follow your protocols, but, and I would even like giving 'em a liter is probably gonna be fine.[00:34:00]

Uhhuh, right? There's no data to show that a leader's gonna, you know, kill 'em or anything like that. Obviously be cautious if they've got CHF or you know, something like that. Or kidney issues, right? Yep. But. You look at your transport times, I got 10, 15 minute transport times, I'm probably not gonna fluid it over my patient.

Correct. If you're rural and you're looking at an hour plus. Mm-hmm. Okay. Then you might wanna be a little bit more cautious 

Erik: with have you've push those pressors ready. Right. 

Matt: Have your pressors ready. 

Erik: Right. And that's the indication I've used in the ER For somebody who's non-responsive to fluid therapy, that's when I start thinking pressors.

[00:34:30] Right. Sometimes I'll even just have. The the patient ready to go. Because oftentimes what can happen is they can tank in the ER even after you've started the fluids. Right. There's a, there's a co It's a dynamic disease. Mm-hmm. It can change quickly. 

Matt: Yeah. Volume isn't always the answer. 

Erik: No. So volume is good.

Mm-hmm. Early volume, get it started. Mm-hmm. That's the fill the tank. Yep. And fill the tank. And that decreases the hypo. Perfusion, which, um, just so people understand, I think all of us understand is that when an organ system goes down, [00:35:00] for example, the kidneys mm-hmm. So as patients altered and the blood pressure got so low, the kidneys will actually shut down.

Mm-hmm. They'll hibernate, they're not dead. Right. But they hibernate, they stop functioning as kidneys. They're just taking just enough blood so they survive. Mm-hmm. Um, and the cellular machinery isn't. Destroyed by Right. Lack of blood flow. And then, but the problem is though the blood keeps pumping.

Matt: That's right. 

Erik: Kidneys aren't doing their job anymore. Right. So now we're not filtering out toxins. We're not volume, you know, managing fluid volume. [00:35:30] We're not reabsorbing things properly. And so then we get, we run into some problems with, with kidney failure. Right. Even though it's temporary kidney failure, we call it an a KI, an acute kidney injury.

Mm-hmm. That actually can cause a cascade of other problems that if we don't get it fixed soon Right. And you start to perfuse right away, it's not like the kidneys automatically turn on. Right. It's almost like they go into this postictal phase where they don't start functioning right away. 

Matt: Yeah. They're groggy, what's happening.

Erik: Right. But after a while though, they, they'll kick in and then start working, but [00:36:00] if we can start treating early mm-hmm. And avoid that hypotension, we might be able to keep those kidneys alive or. From hibernating and then we never get to that point with organ dysfunction. 

Matt: Yep. 

Erik: And you, so you could actually get to a point with organ dysfunction where you just go down a slippery slope Oh yeah.

To mods and, and then your mortality rate goes really high like we talked about. But if we can volume resuscitate these folks early and get 'em done, start right away, we might actually prevent that from happening. 

Matt: That's right. And get 'em on oxygen. Right. [00:36:30] Right. Obviously watch their SBO O2. Right. But get 'em oxygen.

Oxygen, get 'em on tidal. Mm-hmm. Right. If you have tidal, please, please, please put them on end tidal, see what their end tidal is. 

Erik: Uh, and so, yeah. Good. And then some municipalities, uh, IV antibiotics. 

Matt: Yep. IV antibiotics. And if they're that altered, like look at, just like with any other airway assessment, if they're super altered mm-hmm.

Their SPO two's crummy, their blood pressure's crummy. Yep. You're, you've got 'em on high flow, uh, non-rebreather. Yep. They're SPO two isn't coming up. Tube, these [00:37:00] patients, right. They may need it. Get 'em inate resuscitate before you intubate. Get that pressure up. Mm-hmm. Right. Try to get 'em stabilized, but intubate these patients and that could get your pressures, all that kind of stuff.

Erik: Yeah. It's, it's kind of, um, it's a scary situation when you get that, that sick of a patient that's so altered they can't protect their airway. That's right. Um, and you've gotta, you've gotta breathe for them. That's right. Um, and we need, we need. We need oxygen to fight these things. We gotta keep the organs perfused and these are really complic, you know, a 

Matt: stroke patient.

There's not [00:37:30] much I can do for those patients pre hospitally besides recognize, activate and transport to appropriate. Same with STEMIs, you know, recognize, activate. Yep. Fluids, nitro may, aspirin. Yep. Oxygen, uh, transport. A septic patient, you get a really sick septic patient. Now you're looking at trying to start IVs on a hard stick patient.

You're giving fluids, you're drawing up pressors, you're getting your antibiotics out, you're managing airways. There's a lot going on with these patients. A lot. That's right. These are the kind of [00:38:00] patients I like. I enjoy because they're challenging. They make you think. Um, but. 

Erik: And there's some controversy right now with one of the things we talked about, the antibiotics.

Mm-hmm. There, there's a lot of studies that have said it doesn't help. There's a lot of to say it does help. Yep. So it's a bit controversial, but I, I would argue, and I put my medical license on the line with my agency. Mm-hmm. Um, is that if we can do a good job of selecting the sick ones That's right. And use the septic shock, patients are getting the IV antibiotics maybe an hour early or more.

Mm-hmm. That I think is gonna [00:38:30] decrease mortality and the evidence proves it. I I 7% increased mortality. That's right. For every hour we delay treatment. That's right. And treatment was defined as fluids in antibiotics. Mm-hmm. Not, not just antibiotic one or the other. So I think that there's some benefit to it, and I think that if you select the right.

Sick ones. 

Matt: Mm-hmm. '

Erik: cause the studies that came out recently, just in the last few months, they, they only represented about 4% septic shock patients in the selection in the septic patients they studied. Right. So [00:39:00] 96%. We're, we're less sick. 

Matt: Right. 

Erik: So if you have a healthier septic population, you may not see the benefit.

Matt: That's right. 

Erik: But I believe if you can select the sick ones, the septic shock patients. 

Matt: Yes. 

Erik: The ones that are hypotensive. Yep. With a source, a sub suspected source. Right. I think you'll see the benefit there. The other reason we give antibiotics would be open fractures and things like that. And that's, that's a different issue, but very rare.

Matt: Yeah. Yeah. Oh, not super rare, but less rare than sepsis for sure. Yeah. 

Erik: And le less controversial too, 'cause they're gonna need antibiotics. They're gonna get it anyway. There's a [00:39:30] little bit of controversy on what antibiotics we choose. We use cefepime or that's what we use. Yeah. CEP and Ceftriaxone. Iss another one.

But, but by, by getting the antibiotics early, you start to kill those bugs off. That's right. Right. And then, uh, kill the bugs off the body can ramp down a little bit. Return to 

Matt: homeostasis. 

Erik: Talked abouts at the 

Matt: That's right. Yeah. Yeah. 

Erik: And you mentioned pressors. That's another. 

Matt: Yeah. Yeah. So you have different favorite pressors.

We just have one option. Mm-hmm. We just use a push dose, heavy push dose. Pressor. 

Erik: Yep. Phenylephrine, I think was the one. Yep. That we 

Matt: just mix and we, we give it. [00:40:00] Uh, and then you like Levo fed. I know. Levo fed has been, especially for sepsis. Yeah. Uh, because it's just that potent vasoconstrictor. Yep. That's gonna really help out those septic patients.

Erik: That's right. It it, it's good vasoconstriction and also. Um, increases your cardiac output, 

Matt: right. 

Erik: Can help, um, with the, the, uh, uh, the push that's right, as well as the, uh, the hoses. That's right. Uh, so the, the pump and the hoses, whereas fentanyl effort is the hose, uh, hose vasal constriction, which can help, uh, but, [00:40:30] uh, it can hurt too.

Uh, so it's, um, it's, it's a good, it's a good way to get the blood pressure up. But, um, yeah, norepinephrine has been proven multiple trials to be the, the best. Pressor. Mm-hmm. Vasopressor for sepsis. Yeah, dopamine. I've read some studies comparing dopamine, but uh, 

Matt: we're going back to the dopamine clock. 

Erik: Yeah.

Yeah. Right. So that's, that's, I think that's, that's, that's the kind of those, I think we hit all the buckets. Yeah. If you're not 

Matt: using pressors, if you are pre-hospital [00:41:00] providers, you know, maybe antibiotics are a little bit controversial. We get that. You know, maybe your medical director's not comfortable doing that.

I, we get it, but pressors for sure. You know, and if you carry epinephrine, you can make a presser. Yeah. Right. There's no reason why you can't use what you already have. It doesn't gonna cost you anything. Yep. There's a little bit of training on how to do it. It's pretty 

Erik: easy. I. I don't know how you do it at your place, but we, we squirt out a nine.

There's lots of different ways to skin a cat, 

Matt: but Yeah. You can get rid of one. Yeah, exactly. Follow your protocols, follow your pro. Well, there's different ways to mix it. [00:41:30] Obvious, but you're mm-hmm. You're basically taking it from milligrams to micrograms. Yeah. Right. You're just reducing down the concentration of your epi one 10.

That's all you're doing. Yep. And instead of giving one milligram, I'm giving like 10 micrograms per dose. Mm-hmm. Right. And then I'm, I'm dosing that. I'm giving 'em 10 mics. I'm seeing how they do. Right. Obviously I'm trending, my patient, I'm, if they're that sick, uhhuh, I'm running blood pressures every five minutes.

Right. Once they're pressure now it's still, you know, below 90 or whatever the threshold is, right? Mm-hmm. Okay. Let me give 'em another 10 mics. Mm-hmm. See how that does Running fluids at the same time. Right. [00:42:00] Um. 

Erik: And I, I, we have, I've done that and I think actually phenylephrine is one of the ideal ones for like an AFib RVR that gets hypotensive.

Mm-hmm. 'cause you don't wanna ramp up the heart rate when you're already high. You wanna try to just Yeah. Get the hoses right. Exactly. So, um, so there, that's a cool thing about different pressors and we did a cool lecture on Vassopressors. Mm-hmm. Going over each of the main ones and how they affect the body in different ways.

Yep. Um, but the, but having an oppressor when they don't respond to fluid could be really, really valuable. Yeah. Um, so that's, that's [00:42:30] management. So as we've assessed our patient, we're treating them now, uh, we get to the er, we can drop them off and they can continue the care there. That's right. Um, don't forget the value of the end title.

Matt: Mm-hmm. Huge Shock index. 

Erik: Shock Index. Yep. 

Matt: Yep. 

Erik: Um, oh, the other, we didn't mention this actually. The rock score. 

Matt: Oh yeah. 

Erik: Rocks. Yeah. You 

Matt: were telling me about it earlier. 

Erik: It uses the auction saturation and the FI O2, um, and then divide that by the respiratory rate. And if it's less than 10, then. 

Matt: Tell 'em how to figure out [00:43:00] the FIO two pre-hospital.

Erik: Oh yeah. So FIO two. So if you're Bre ble breath bleeding. If you're 

Matt: bleeding, if you're bleeding, if you're bleeding 12 times a minute, probably 

Erik: so. So five liters nasal cannula. I, I think the study I read it even had up to six, but let's just say five. Um, you're, you're getting, you're getting up there I think to about an FI O2 of about 40, 45.

Mm-hmm. If you use a non-rebreather, you can get your FI O2 all the way up to 95, not quite to a hundred. Right. But, but pretty high. [00:43:30] So nasal cannula, you know, think about it, can maybe get up to 50% ish. Right. And then, uh, and by the way, room air. Or 21%. 

Matt: Mm-hmm. 

Erik: So nasal cannula adds, so five liters equivalent to about 40.

Mm-hmm. And then, um, a, a non-rebreather, you know, bag valve mask type situation. Non-rebreather a hundred percent. Um, oxygen goes right, you get close to a hundred percent. About f about an FI O2 of about 95. Yeah. 

Matt: We're losing a little bit. 

Erik: That's correct. Yeah. [00:44:00] So I think, I think that these are, these are the types of, uh, tools that can help us assess patients better.

Mm-hmm. Mm-hmm. And then we got the treatments. Mm-hmm. Hopefully IV antibiotics. Um, hopefully data will come out and prove me. Right. Right. But I'm, I'm, I'm betting the farm on the fact that, uh, the early treatment in the right patient population, the sickest ones, will improve mortality based on what we've read.

By decreasing, we can increase mortality rate by delaying an hour. That's right. So what's the future? What is the future? This [00:44:30] is, this is exciting to me. 

Matt: This is the data stuff. 

Erik: Yeah. 

Matt: Yeah. They're looking at these outcomes. 

Erik: Yeah. Ai. 

Matt: Yeah. 

Erik: So get this Matt. Imagine the time when you would be able ever seen somebody 

Matt: get so excited about AI before.

No, it's really cool. Your face just lit up. Be so excited. 

Erik: I'm excited about this. 'cause this is gonna, I think, change a lot of what we do. Uhhuh is wirelessly we can be hooked up to huge databases mm-hmm. Where we put, we plug in our patient's data and then we get, we can, we can then correlate that data [00:45:00] with our patient to millions of other patients who've been, uh, been.

Kind of put into buckets for sepsis. Mm-hmm. So we can identify now a septic patient based on historical data, millions of of pieces of data, 

Matt: right, 

Erik: where we can add more accurately and live real time based on data and based on patient demographics, put them in a more accurate. Bucket of, of sepsis, potentially.

Mm-hmm. So I think, um, and it's, it's not necessarily something where you're like going through [00:45:30] surge criteria. Mm-hmm. But it's more of something where the data is entered into some sort of an algorithm in the cyberspace somewhere. 

Matt: Right. 

Erik: Where 

Matt: in the cloud, real 

Erik: time in the cloud, basically real time getting feedback on the risk of your patient.

Matt: Right. 

Erik: I mean, that's. Very exciting to me. Yeah. Less thinking that concerns me a little bit. 

Matt: Right. 

Erik: Relying on a computer somewhere. 

Matt: Right, right, right. 

Erik: But that, that AI integration for sepsis screening, I think is a huge deal. 

Matt: Well, it's kinda like the, you know, we're using [00:46:00] AI to look at 12 leads now. Yeah. You know, to pick up patterns that we might miss.

And so I think it's a conjunction of using, you know, our experience and our knowledge level mm-hmm. In conjunction with these, uh, tools. Yep. These AI type tools, uh, to help us be a little bit more accurate in our diagnosis 

Erik: operations. Yeah. Then there's also the analytics on the back end. And I think in looking at our accuracy, how, how well are we doing?

Right. It's sometimes I feel like it's a bit of naval gazing in the fire department where we [00:46:30] look at the patients that we've identified and we say, Hey, wow, a hundred percent of the sepsis patients we treated last month got fluids within X amount of minutes or whatever it was. Mm-hmm. 

Matt: Mm-hmm. 

Erik: Or if they got fluids or uh, maybe you're doing antibiotics.

Right. And all your patients that you identified, the sepsis patients got antibiotics. Right. But what about the ones you missed? 

Matt: Yeah. 

Erik: Well. I don't know. Who did we miss? Yeah, show me. 

Matt: Yeah, 

Erik: we'll look at the hospital data. Those outcome data that that outcome data can give you a real accurate idea of how many patients you actually missed [00:47:00] potentially.

Or maybe you didn't miss any. Maybe you really are really good. Yeah. But you don't know if you're really good unless you've really looking at the discharge diagnosis of a patient that's. That you brought to the hospital, 

Matt: right. That you called a stroke and it actually turned out to be a septic 

Erik: patient.

Exactly. 

Matt: Right. And they're looking at the vital signs and all the stuff pre hospitally. Oh hey, you missed a shock index of 1.2 or whatever. Right. You know, you missed that. You missed, yeah. They had altered mental status and low O2 SATs and an end title of 15 for 20 minutes. Yeah. You know, and you called that a.

Whatever. Right. A stroke [00:47:30] patient. 

Erik: Exactly. 

Matt: This was like textbook sepsis 

Erik: and like we talked about earlier, it's all of us, regardless of our level of care, whether you're an experienced ER doctor or a new EMT, it's easy to diagnose something and then anchor on it. 

Matt: Yes. 

Erik: And that's how we miss things. 

Matt: Yeah.

Bouncing down the road. Yeah. Your patient's screaming at you. 

Erik: I've, I've told this to you before, but what is the most commonly missed diagnosis? It's the second one. 

Matt: Oh, yeah. 

Erik: Because we get stuck on the first one. That's right. And we miss the second one. 

Matt: Yep. 

Erik: And the second one could be the most life threatening or the third, like a story I told.

Matt: Yeah. [00:48:00]

Erik: So I think that's a big part of what analytics can do. Yeah. Um, is to kind of eliminate that. That anchor, human anchor, human element, 

Matt: where we have a tendency to get bias. 'cause we're like, oh, this is this patient, this is what it is, and then we're missing the complete and obvious glaring signs of, Nope, it's actually this, bro.

Yeah. Pay attention. That's absolutely. And we're all guilty of that, right? Yep. Right. We're human. 

Erik: And then a cool part about the outcomes is that we can then, um, see where we really are. 

Matt: That's 

Erik: right. Yeah. A real, 

Matt: yeah, exactly. Yeah. You thought you were really [00:48:30] good at this and actually you suck. 

Erik: Right. 

Matt: And, and I 

Erik: think most, most, uh, uh, based on the data that I've seen is that we're not as good as we think we are.

Right. And I think that, uh, we're fooling ourselves if we can look at a hundred percent number in compliance with some benchmark for our, you know, what do they call it? Those, uh, mission Lifeline things. Oh, yeah. And, and our own internal. Kind of a qi QA of our own data. 

Matt: Right? Right. 

Erik: We can pat ourselves on the back say, we're doing a really good job.

Yeah. But we gotta really look beyond that, I think, and that's where I [00:49:00] think the future of our whole field is going. Mm-hmm. We're gonna be more accountability now by looking at the right outcome measures and we're gonna see, wow, we really matter. Yep. What we do. Yep. I think that that's, that's, we're doing things 

Matt: and things are gonna change, right?

Yeah. Sepsis care is gonna change. It's gonna evolve. Yep. Right? So what we're doing today probably isn't gonna be what we're doing in two years. So, no. You know, why are we doing that? It's because of we're they're looking at all the data, right? Yeah. And we're trying to improve patient outcomes at the end of the day.

Erik: Well, it's gonna tick off a lot of hospital executives and doctors when I say [00:49:30] this, but I've always believed this and my time working with payers and government agencies and hospitals all over the country. I really believe that the hospitals should only be ICU and er. The sickest people that need care, they're the ones that should be in the hospital.

Mm-hmm. Most of the people in the hospital really shouldn't be there either getting home care or some outpatient care or something that's far less expensive, but they make money off of it. I know, I know. Uh, and that's kind of the way we've always done things right. Sure. And people [00:50:00] don't like change.

Right. Um, and it's interesting, I read recently that there's a company that's actually trying to develop mobile ICU medicine, so they can set your house up a room in as an ICU. Wow. I mean, that's crazy. I could tell you lots of stories about. Reform within healthcare, right? And all these different reimbursement models.

But the point is that's a whole 

Matt: separate podcast. 

Erik: It is a whole separate podcast. But the point is though, is that what we're doing in this pre-hospital environment with patient identification, sepsis is a great example. Yep. Is we have a lot to [00:50:30] say about the most expensive thing the hospital does and kills more people in the hospital than anything else.

That's right. We have a hand in that and we can do a much better job. So I think, I think sepsis is a really. Really a, a, a, it's a hot topic. Three full topic. Yeah. Yeah. 

Matt: And one that's, like I say, it's evolving and changing, so Yep. Stay up with the research and the data and Yep. You know, stay on top of it.

'cause it's important stuff. 

Erik: Ask questions if you think, is there, there's a way, you know, you're, you're, you're working in some agency somewhere. Is there a way I we can make [00:51:00] our sepsis protocols better? So we can identify more patients? Or how many are we missing? Ask If you don't know, ask start. Start with 

Matt: your medical director.

Erik: Right, 

Matt: right. Talk to your medical director and see where they're at, and then do your due diligence online. Yep. Like you're doing by listening to this podcast, right? Yep. That's really good. If you're not doing these things, you probably should. So see you on the next one. 

Erik: Safe out there.

Narrator: Thank you for listening to EMS, the Erik and Matt [00:51:30] Show.