(Transcript is automatically generated)

Matt: [00:00:00] We've got some time here to look at some things before we freak out. Just go doing something we don't necessarily need to do. 

Erik: Yeah, we started to see the kiddo looking around. Okay. And I was like, okay, I'm feeling better.

Narrator: Hey, you're listening to EMS with your hosts, Erik and Matt Ball. 

Matt: Alright, doc, what are we talking about today? [00:00:30]

Erik: Well, it's something that actually strikes fear into a lot of our providers. Um, we asked people the two things that scared 'em the most. Work and taxes. 

Matt: Taxes, yeah. 

Erik: Uh, is, um, an EKG they couldn't interpret or a kid they couldn't resuscitate, right? Yep. So, so pediatric patients can, can be scary.

Especially, you know, the littler they get, the younger, they get the scarier they can become. 

Matt: Mm-hmm. 

Erik: Um, and the, the whole thing about kids being little adults, a misnomer. 

Matt: Yeah. They're not [00:01:00] just little adults. 

Erik: Some ways it might be true. Right. But they're really different. They're unique. Yeah. A lot of unique challenges.

Matt: Do you know why it's scary for those pediatric patients? 

Erik: I think of a few things. 

Matt: Well then, do you know about system one, system two, thinking? I'm sure you do. 

Erik: Oh, tell me about it. 

Matt: Oh, so system one thinking, if I remember correctly, and to give credit where credit is due, uh, this is actually part of the Handtevy class.

They teach you this when you go through their instructor course. Oh, okay. 

Erik: Yeah. I've never done that before. 

Matt: Like system one thinking [00:01:30] is the thinking that we go into when we get like an adult cardiac arrest. Right? Like we don't get worked up. About it because it's like, yeah, we know this, we know what we gotta do, we gotta get on the chest.

We know what the epi dose is, we know what size IGEL or, uh, innovation, uh, ET tube we're using. Like, we've done this before. It's kind of like automatic. We don't have to think about it. System one, system two is where it's like, oh no, like I haven't done this in a long time. I'm gonna have to look up, I gotta do med math.

I'm nervous. It's a kid. I don't know what my epi dose is. And so it just completely [00:02:00] throws us off, which is why people grab their kids Uhhuh and they run to, as I call it, their whoopee, the back of the ambulance. Yeah. And then they run to the hospital. Right. Right. Yeah. And again, we, as we've talked about before, that is not what we need to be doing.

Yeah. We need to stay on scene and we need to work the problem there because, not because we're para gods and we wanna show how cool we are, it's the be, it's the patient's just best chance for survival. 

Erik: You know, one thing I have found to use your vernacular there is that in the, in [00:02:30] the ER, I do a lot of that system two.

Mm-hmm. Where I don't know what's going on. Mom's bringing a limp baby in and laying it on the gur, on the gurney. Yeah. And, and I gotta figure out what's going on. 

Matt: Yeah. No idea. 

Erik: Eyes wide open. I don't know what's going on in systems two, right? Yeah. But then once I've narrowed in on, oh, this is a seizure, I think this is a seizure.

We're gonna go to system one. We system one. Yeah. So, yeah, but staying calm your eyes open to identify and to hopefully be accurate on your diagnosis. You don't run down the wrong rabbit hole. Yeah. Is [00:03:00] important. Keep your eyes open. Don't anchor too. Right. So, 

Matt: yeah, definitely don't anchor, uh, that's, yeah. You, you can get yourself in trouble.

Erik: Yeah. 

Matt: That way anchoring, you know, based off your dispatch notes or what you see. But, and it all starts with a good assessment. 

Erik: It does. And before we get to assessment, I think it's part of assessment, but before we get there though, is to talk about how kids are different. 

Matt: Okay. Yeah. 

Erik: You know, the, like, uh, for airway example, uh, you know, just,

Matt: well first off, they don't pay taxes.

Erik: They don't pay taxes, and they have nothing to be afraid of. 

They have nothing to be, yeah. Boys, you know, that's a cool thing. That's what I loved [00:03:30] about pediatrics though, when I was in residency. And in medical school too. My first experience with the pediatric population is they're not always, but most of the time.

So pure. Yeah. Honest. And it's like they just are hurting, 

Matt: not trying to manipulate the system. Right? Yes. It's, that's why I like 'em. Yeah. That they're very easy to assess. They'll tell you, does this hurt? They'll give you an honest answer about yes or no or what's a number Gimme a faces score. Yeah. They're very honest.

They're not trying to manipulate 

Erik: and even those kids that can't talk. Yeah. It's uh, you know that kid that's crying, that [00:04:00] little infant 

Matt: Yeah. 

Erik: Had a hair, tourniquet. Yeah. On his finger or toe or penis or whatever. Yeah. And, and you find it and, and you fix it, and they're. 

Matt: All of a sudden, fine, 

Erik: but they're happy.

But they were crying for a good reason. Right? Yeah. So I think that when a kiddo's not acting right, it's becomes our job. Yeah. As providers to try to do the best we can to figure it out. 

Matt: And I think that I, I mean, I would hope that most providers, that's the other level of the nervousness as we've talked about before, is because nobody wants to hurt a kid.

No. You know, nobody wants to screw up on a kid. Right? That's right. We [00:04:30] know the stakes are high and we don't want that. Number one, we don't wanna do that for our patients. Number two, we don't wanna do that for our conscience, right? 

Erik: Yeah. So young, so much life, potential mom and dad's standing behind you. A lot of pressure.

There's a lot of pressure. Yeah, 

Matt: A lot of pressure. This is why for new paramedics, new EMTs, this is why we do mega codes. That's right, is because we have to put you in pressure, pressure situations to see how you're going to respond. 

Erik: How are kiddos anatomically different, from adults.

Matt: Big heads.

Erik: What are some, big heads? That's right. Big tongues. So for airway? Yeah, big [00:05:00] tongues. Anterior airways, large upper glottis. I mean, there are some anatomic airway differences. Uh, that, that are huge to understand before you even get to the assessment. You gotta be aware of these things. 

Matt: Lung size, they're gonna breathing rates much faster.

If you're thinking that, uh, heart rate on a, you know, infant is gonna be 80, you're sorely mistaken, it's probably gonna be double that. 

Erik: Good point, Matt. Yeah. Bringing, like, being familiar with pediatric vitals Yes. And understanding that general trend of how vitals changes as a kid [00:05:30] get older. Yep. Can really, uh, be so helpful in assessment.

Yeah. 

Matt: Tidal volume. If you're bagging these kids like you're bagging adults. Yeah. Like you're gonna blo pop lungs, you're gonna cause pneumos. So, yeah. I mean, it's a much smaller system. The heart is very strong. Mm-hmm. 'cause it's young. But it's pumping a lot faster 'cause it's smaller. So it's trying to,

Erik: and the body surface area, the volume is so different too. And it, it creates problems with thermal regulation, right? Uh, positioning a patient for airway, right? Uh, you know, all of these things. And then [00:06:00] using the right tools to the, to the right size. You know, the Broselow tape is one thing Handtevy's got some other stuff. Dosing, and that's another, we'll get to that later with management.

But there, there are so many different considerations for the pediatric population

Matt: Length, Like height, weight, yeah. Weight, height and weight.

Height and weight. It's a very big problem. Dr. Axene. Yeah, it's, yeah. There, there. They are a scary, unique, and, and then you look at the med math, right? Yeah. [00:06:30] Traditionally, and like you said, we'll get to that, but that was the other factor that always plagued pediatric calls is that, oh my God, I'm gonna have to do algebra. Right.

Erik: Which is, and that's part of the whole genesis of Yes. Of the Handtevy system. Yes. Peter Handtevy. Yeah. 

Matt: And for the record, like we're not. Sponsored or co No, we, we certainly we're just looking, we, yeah, we do like the Handtevy system. It's a great product. It is a very good, effective product.

Yeah. Uh, I've worked with them. It's also a very good company. All their people are very good. Uh, and it is, but it is a very good product. 

Erik: And it's been [00:07:00] compared yes, statistically to have no significant, statistically significant difference with the Broselow tape, which uses height versus age with the Handtevy system uses.

Uh, but the great thing is you don't need the tape. 

Matt: You don't need the tape. Well, and not only that, but Broselow doesn't give you the mls. That's true. It just tells you the dose. You still gotta do math, right? That's right. So anyway, we'll get to Handtevy more, but yeah. Uh, adult, uh. Kids are not just little adults.

There are some differences there. 

Erik: You know, and I think one of the, I think one of the most [00:07:30] important big rock type differences here is that the little kiddo, they crump fast. 

Matt: I was just gonna say that. Dang it. You took me, they took my thought. Yeah. They decompensate very quickly. 

Erik: They do, yes. But they hold on for a long time.

Yes. Looking pretty good. Yes. And then when they fall off, they fall off quickly so they can. When you're seeing a sick kid, you may not have the amount of time you do in an adult. That's right. Uh, those are, those are important. Yeah. When, yeah. And I think, and as we get to it, we'll talk more about it with assessment, but, um, there are, there are certain things that we [00:08:00] can see in kids that we really can't see as clearly in adults.

Mm-hmm. And I think that that helps us if you know what to look for. Right. It's really a, a special thing that, uh, really can help you with pediatric assessment and management too. 

Matt: Yep. Well, you wanna get to the pediatric assessment triangle. 

Erik: Let's, let's, let's do it. So three parts here and we can break down each of the three parts.

Yeah. Um, so, uh,

Matt: I mean there's different ways that they say, you know, work of breathing, but basically it's, uh, you know, appeared work of [00:08:30] breathing and circulation of skin or circulation. 

Right. Is kind of the respiratory work of breathing uhhuh, different people saying different ways. 

Erik: Yeah. For these are, these are, I like, I like to call them doorway. Signs that's Oh, yeah. From the doorway. Yeah. When I'm teaching baby doctors up, uh, I used to work as an attending physician. I'm teaching doctors how to assess patients and, and trying to help them to understand the value of what you can see from the doorway. Absolutely. Uh, these aren't necessarily from the doorway, but, but they. They're 

Matt: well, appearance is, yeah. Yeah. What does a [00:09:00] kid look like? 

Erik: Right. So these are, these are really, really helpful and it's a good, gives you, if you're new to, to, uh, being a paramedic or an EMT. Yeah. This gives you a good framework to work from. For a pediatric patient that might at first be like that, what did you call it?

Level two? No, he call it a static system. System two. System one or system two, thinking not quite sure what to do. Yeah. Well this gives you a little bit of a system. Mm-hmm. One type of an approach where let's, let's see, let's start with work of breathing. You can, you can see work of breathing [00:09:30] from the door.

Right? Um, 

Matt: you can see skin color, which is part of appearance, but goes to work of breathing. 

Erik: Yeah. Do they have bluish lips? 

Yep. You know, and then of the appearance. An appearance might be as simple as. Looking at me from mom's, mom's arms and, you know, sitting up or, you know, 

Matt: completely limp in mom's arms 

Erik: laying, or mom's phone.

I mean, these are, these are things to write down. Mm-hmm. Uh, whereas the appearance might be asleep or whatever, and you get, and you wake up the kid, they're lethargic and, you know, [00:10:00] hardly responsive. I mean, the appearance of a kiddo. Can give you big clues if you walk in and kiddos crying like crazy.

That's, that's actually a good thing. You can see the work of, you can see the, the airways P. Yep. And, uh, you can also see the, uh, kiddos, uh, got a lot of energy. Yeah. Fighting something, something's bothering the kiddo, whatever. We can figure it out. But as far as the, um, you know, a kiddo that's crying is usually healthy.

Matt: Yeah, that's a good sound when you're in the [00:10:30] ambulance, right? Most people get irritated by screaming, crying Children, paramedics and EMTs do not because that means that, okay, my kid's doing okay right now. That's right. You know, they're not, you know, it's when you have that limp, quiet kid that you're very concerned 

Erik: and appearance.

Yes. You know, you can see the skin color, the circulation of the kid, the pale. That's huge. Yes. Huge. Uh, blue. Yep. Pale red. I mean, there, there are certain things that can be signs to us based on appearance that can really help us. Yeah. So Sorry, with the circulation. 

Matt: No. Yeah, you're good. Yeah. You see 'em come, you come through the door and you see that [00:11:00] kid, you know, like, again, what do they look like?

What does their skin color look like? Are they interacting with you? Obviously, that depends on the age of the kid. Infant's not gonna interact with you, but are you dealing with a 3-year-old? Mm-hmm. If you have a 3-year-old that freely comes to you like they're, that's weird. That's unusual. He'd rather come to you a little than mom.

Are we dealing with a child abuse issue or are we dealing with a medical problem's problem? Holy smokes. Yeah. But so yeah, like things that, like this 3-year-old, why is this 3-year-old walking up to five dudes that had never met before? When mom's right there, yeah. These kids naturally will gravitate towards their [00:11:30] parents, their guardians.

They will be clinging to their leg. They don't want to talk to you, they don't want to interact with you. Right. So why we use mom and dad as a helpful tool to communicate with the kid? 

Erik: Well, let's, let's break down each of the three parts of the triangle. Uh, let's start with work of breathing and talk about some of the things that we can look for.

You know, the, the, the way that a kiddo breathes can give you a lot of clues onto what's going on. It's that RSV season and you hear that barking cough. Yeah. Maybe a foreign body you hear ask like a strider, striders, you [00:12:00] know, an inspiratory strider or, uh, or whatever. I mean, there's a lot of different things you can see with breathing, especially with, uh.

Upper airway. Yep. Tugging, uh, that's right. Um, belly breathing. Yeah. That's the other thing. Yeah. So that's something I like to teach is, um, when you're looking at the, the work of breathing, a kiddo shouldn't, should not be working hard to breathe. Right. Right. Um, but you see a kid at rest. Who has got some, you got some belly movement.

That, that's the, that's where things usually start right now. I'll say [00:12:30] that with little kids, sometimes the, the nasal flaring mm-hmm. Can be your clue. Mm-hmm. Uh, but, uh, with, with, with kiddos, typically starts down low. Mm-hmm. Belly breathing. Mm-hmm. And you can see the belly moving with the breasts. That's not normal.

Matt: Yeah. 

Erik: You know, we shouldn't, I mean, it may see a little bit of movement of the belly Yeah. With the diaphragm going up and down. But typically, uh, that's, that's not normal. And then as things get worse, you start to see the costal retractions, or sternal retractions. Mm-hmm. And, uh, the sternal notch. The sternal tugging.

Mm-hmm. [00:13:00] As you move up mm-hmm. That, that is this bad sign, you start to see the, uh, the neck, the sternal mm-hmm. Tugging. That's the kind of breathing where you're. You are, you've been breathing poorly for a while. Mm-hmm. And now we're an extremists here, and now we better be ready. Yeah. To take, uh, you know, emergent action.

Yeah. So those are the kind of basics. Now, another thing I'll mention with the work of breathing too, is the sounds that you hear, right? Mm-hmm. It might mean listening to the lungs. You hear the wheezing, you might hear the strider just from the doorway. Yeah. [00:13:30] There's, um, doing the full assessment of work, of breathing is, uh, it's, it's not a, it's not a simple task.

It, there's a lot to it. 

Matt: And you have to manage or you have to prioritize management with assessment, right? If you walk in and your kid looks cyanotic, they've got bluish lips, they're breathing super fast, like don't be getting out your stethoscope and like put the kid on some oxygen. We've talked about this before, like get 'em on some oxygen, some blow by, you know, whatever the case warrants.

Get 'em on some os Yeah. You [00:14:00] know, quickly if that's needed right away. 

Erik: I've also, um, sometimes I'm careful with that because I know that with a kiddo that's got ours, you're gonna irritate them. I can irritate 'em and then make the strider worse. 

Matt: Epiglottitis those kids hanging, you know, CRU, same thing. You don't wanna tick 'em off 'cause that's gonna make it a lot worse.

Erik: So let's, there's some, there's some experience involved here in knowing exactly how to approach these kids and sometimes I don't do it differently based. 

Matt: Right. That would depend on how the kid's interacting with you For sure. 

Erik: So then, uh, so work of breathing, then we go to appearance. Yep. You know, I, [00:14:30] I mentioned this earlier, but when I walk into a room and kiddos on mom's phone.

I mean, I document that on my chart. Uh, it's, that's a good thing. That's a good thing. Yeah. Uh, you see kiddo playing, they're relaxed, right? 

Matt: They're playing. 

Erik: Yeah. You know, is, uh, or is, uh, is asleep in mom's arms or was nursing or, you know, the fact that kiddo was nursing in, in the exam room is it's a kid that's feeding, uh, you know, a kiddo that you can see has got a full, big old wet diaper.

Yeah, that's, these are, these are good things. So, uh, appearance, [00:15:00] uh, you can see a lot from that doorway. But, uh, the most important thing I would say would be the, uh, the, the appearance of a kiddo when they, when you walk into the room, you want a kid to be a little scared, a little bit scared of you, a little nervous of you make hold onto mom's arms and when you're doing your physical exam, they're, they're, they're fighting you a little bit.

Yep. I think these are important things. That work towards, 

Matt: yeah, the look, the gauge speech. Are they crying? Are they happy? Do they seem content? Yeah, they're 

Erik: documented. Documented, documented. And then finally, the circulation. Circulation. So this is, [00:15:30] you mentioned earlier, we see that with skin color. Yep.

Yeah. They osis potentially or model, model skin sepsis or, um, maybe there's, uh, some sort of a, a united patient once from the door. I could see this kid was looked like a China doll. Just white skin. Oh yeah. Hemoglobin was about two. Whew. Uh, very, very, very anemic kiddo. Yeah. Mom and dad just thought he wasn't getting enough sun.

But this, this kiddo is really sick. Oh. And uh, it really, I have pictures. I mean, it's [00:16:00] just white skin was as white as this paper. Yeah. Is really, really impressive. But, uh, that's an appearance thing. Right. And that's a circulation thing. Mm-hmm. And that's, you know, it, all of these things kind of come together for one picture Yeah.

Of the patient in your assessment of the patient. Then you can dig in deeper because that kiddo is breathing. Looks like they're breathing rough. You do your lung exam very carefully, right? You see that, uh, skin looking a little bit of the appearance of, or circulation of the skin. You see that, right? Yeah.

You, you're getting into looking at the sub conjunctival, uh, [00:16:30] mucosa to see if there's power there. The, the oral mucosa, the hands Yep. The finger, the fingernails, Capri refill. Yep. All of those things. And then you, uh. With the appearance. You doing your exam and you're watching how kiddo responds to you.

Matt: Yeah. 

Erik: These are, these are huge. This is a good place to start. Yep. Anytime you're doing pediatric assessment. Yep. So, so Matt, you went through that. Okay. And, uh, the Handtevy course. 

Matt: Mm-hmm. Yeah. The instructor course. Yeah. Very good. I

Erik: think that can be a huge part with [00:17:00] pediatric management. You've, you've seen your, your patient, you've, you've studied the, the pediatric patient.

You understand some of the anatomic and physiologic differences and Yeah. You've done your assessment. You used your trying pediatric, you know, assessment triangle to get us started, and you finished your assessment. You have a pretty good idea of what's going on. Mm-hmm. Talk. Talk with us a little bit about the, the, the Handtevy.

So there are many systems out there. Mm-hmm. Yep. We're not a proponent of any one in particular. We may favor one over the other, but Right. But we're not, 

Matt: I have the most experience with Handtevy. [00:17:30] I'll say that. Yeah. Like, I've used Broselow, but I definitely have the most in my career, I've used Handtevy the most.

I find it very user friendly and easy to use. Um, but yeah, I mean, and the whole, I think it's important to, again, talk about, this all started with Dr. Handtevy. Realizing that we've gotta get first responders to slow down, to stop rushing to the ambulance, to stop rushing to the hospitals. We've gotta get them to stop and treat the patients on scene.

And this is something that's crucially important. This is a [00:18:00] philosophy, this is a mindset that we struggle with in the fire service, especially people that have been doing this for 20, 25, 30 years, right? They don't understand this. Why are we staying on scene with these kids? We need to be getting 'em to the hospital.

No, we don't. No, we absolutely do not. Do you wanna save this kid or do you want to feel better? Do you want to be more comfortable and just be over this call? Right. And our job is to. Yeah. To treat the kid. Right. Right. And the data overwhelmingly shows that the, the best cha [00:18:30] chance of survival that patient has is for us to stay on scene, calm down, and start working the problem.

And the good 

Erik: with, with like a pediatric resuscitation, I mean, of some trauma situation. Yes, yes, yes. I'm 

Matt: sorry. Yes. Yeah. With a pediatric medical cardiac arrest. Right. Yes. Obviously with trauma or something, you're gonna be moving to the hospital a little bit faster. Um, the good news is that most pediatric issues are respiratory.

Erik: They are most of 'em vast. We talked about this in some of our courses. Yes. Vast majority. It's not, it's not even close. No, it's, yeah. 

Matt: So, uh, you know, addressing, you know, [00:19:00] assessing quickly the respiratory, um, just like we talked about in the last segment, the, the respiratory drive, their appearance can tell you about mm-hmm.

You know, how well they're breathing, circulation, all those things. But most of your problems are gonna come from a respiratory, 

Erik: especially with neonatal resuscitation. Yes. The surfactant, which we've talked about many times. Yes. Yep. Is something that in, especially in a premature. Neonate Yep. Is gonna be a problem.

Yes. And um, and, and even in, in infants, I mean there's, but the, the, the, the, uh, [00:19:30] the respiratory 

Matt: mm-hmm. 

Erik: System itself is working, but the lungs Yeah. Haven't quite developed fully. Yeah. And they don't have that, that surfactant or whatever to, to keep those lungs open. That's right. That's a big reason. So that's, uh, oftentimes why too, with drownings.

Totally different issue, but very similar. Yep. Um, is that the rescue breathing is so important Yep. To do that first? Yep. Yeah. 'cause oftentimes it can like a. Kick starting your, your dirt bike. That's right. Get those rescue breaths in. It can start everything up again. Yep. So it's important. 

Matt: Yeah, [00:20:00] very important.

Um, 

Erik: so back to Handtevy. Sorry. 

Matt: Oh no, you're good. So yeah, Handtevy. So, I mean, it kind of started off with the Handtevy method, which I think most people have probably heard of this. You know, you've got your hand and you go off. Patient's age, 1, 3, 5, 7, 9. Yep. Right. And then 10, 15, 20, or, yeah, 10, 15, 20, 25, 30 on kilograms.

Erik: Correct. 

Matt: For your, for your different patients. Then you go in between there, you can look this up. 

Erik: So there two. They're between 10 and 15 at 12 and a half, 

Matt: exactly 12 and a half kilos 

Erik: and it's [00:20:30] kilos, and it's been, it's really amazing how accurate it really is if you've got a good idea of the age. 

Matt: Yeah, for sure.

It's very accurate and like you said, they've done studies and just ball parking, like if you, you know, just ball parking it, uhhuh, you're very close. There's no statistical difference as sitting down and figuring out exactly what dose I need. This is close enough. Get it, and it's much, much faster, much easier to remember.

The other thing is, do you know about epi and amio doses? Uhhuh, is that your 1-year-old? 10 kilos? Yeah. All you have to do is move the [00:21:00] decimal point. Okay. You're gonna give one ML of epi. This is a cardiac arrest situation. Yeah. One ml. Of epi one to 10, one ml of amio, and that goes all across the board. For a 15 kilo, it's 1.5 mls.

For a 20 kilo, it's two mls. So you already know your dosages for those. And they actually talk about, and this was a huge takeaway for me, is getting out of that system two to system one thinking is pre-planning. Mm-hmm. You get that call. The call that we all dread 4-year-old cardiac arrest, 

Erik: you know it's [00:21:30] four.

Matt: Yeah. Well, I mean, I mean hopefully they say, you know, it's three or four. 

Erik: Yeah, but I mean, when you know it's four, you can start to come up with things when you know 

Matt: for Yes. Or you know, that's what the dispatch notes say Mom called 4-year-old male unresponsive performing chest compressions. Right, right.

You get out your app and you can pull up, and again, the Handtevy app's a great app. It has more than just dosages on it, but you can look up, um, uh, equipment sizes, so. They talk about knowing the age, the kilograms, how much epi because [00:22:00] they, there's studies that show that the faster you get epi on board, the better outcome the kid has.

So that's crucially important, is knowing what the depth is and then your I gel or whatever. You know, superlo airway tube size you use, getting on the chest, getting the ventilations, getting an IO or an IV ready, and then getting that epi on board is crucially important. Yep. That's the first things we, and you know, all that information before you get there.

Hey, you're gonna throw in system one. System one, but we're gonna get there. Erik, I need you to put in an igel I number one igel. Yep. Matt, I need you to get on compressions. [00:22:30] You know Jimmy, I need you to get an IV or an IO and the epi dose, he's, you know, 15 kilograms, 1.5 mls. I don't care what the dose is, I need to know how many mls it is.

Right. Super important that way. Now we walk in and we're not freaking out. Yeah. We walk in and we're like, we know what we have to do. Yep. And we set it up right? And we train over this, right. But we set it up right And everybody goes to work. And what does that do for the parents too? Mm-hmm. If we're freaking out throwing things out of the bag and we're freaking out, that's not making mom feel any better.

That's right. [00:23:00] When we walk in calm, we get our bag out, we know exactly where, where we need to go to get the IGEL or whatever the thing is, we know exactly where we gotta get the IO drill, the epi. And everything's going smooth. It's like, Hey, these people know what they're doing and you do, and that's helping out your patient tremendously, 

Erik: and you can incorporate that into your training and 

Matt: Oh, big time.

Erik: The thing I really like about this system is that it frees brain RAM. I like to say. Yeah. You know, it's like a, computer's got a certain amount of RAM, like a desktop of what it can handle. Mm-hmm. At the same time, the brain's the same way, [00:23:30] and we all have different amounts of things that we can handle.

Matt: Yeah. But, uh, I'm in the megabytes. You're in the megabytes, megabytes mega.

Erik: Oh gosh. But, but we have a limit to what we can handle Yes. In our mind at the same time. And by having these sorts of checklists and, and, uh, you know, systems Yes. That we can use it use for medic, it takes something off of the ram of our brain.

Yes. So we can use more of our brain to do that critical thinking to identify disease processes. Yes. And the things the checklist can't help you do. Yes. Uh, that's one of the reasons I love that. And I [00:24:00] love systems like that. 

Matt: Yes. That are helpful for anybody? I mean, when you think about the level of things that we have to know as first responders, right?

You know, if you're a nephrologist, all you gotta worry about is kidneys. Right. You're a master with kidneys. Obviously they go to med school, right? But like emergency room physicians, like I've gotta know how to deliver a baby that may be breach. Right. And then manage baby and mom and resuscitate them. I might go from that to a major accident trauma, like we have all this stuff we have to know.

Right? Totally. [00:24:30] Super complicated. So the more systems that are in place that help us, like you say, free up RAM in our brain. It's makes it, I don't know if simpler is the right word, takes a lot of the stress out of it for us. Yeah. And we're able to perform better. 

Erik: Do you remember a chief I introduced you to?

He's from Washington. I think he was from Skagit County. Um,

Matt: that's where I got married, skagit County, Washington. Really? Oh, Harbor, Washington. Yeah. Really? No, that's, I'm sorry. I know you're from Snohomish. No. Skagit County. Yeah. My wife's from Snohomish County because that's just south, I think. Yeah. Skagit is south of, [00:25:00] yeah.

Erik: And I could be wrong, so if Chief Maxwell, I'm wrong. I'm so sorry. Sorry Chief, but we got to speak together. And we really in, in Phoenix, we spoke together. Was this the guy 

that looked like me or somebody thought it was me or something? Who was? No. 

So he had a, a friend named Matt. 

Matt: Oh, that's what it was.

Erik: Okay. And we thought we were talking about the same person. We realized we weren't, he was nowhere near as handsome, so No, but poor, poor guy. We were, we were talking about this and, and, uh, he went and talked to jet pilots and Oh yeah. I remember this. Yeah. And [00:25:30] to keep, yeah. To keep, to decrease errors. Yeah.

They would form checklists. Yeah. And and they go through the, and pilots do this. Yeah. And, and it's like, why don't we do this? Yes. And so he actually developed this system using checklist, which was brilliant. Yeah. And that's really what's happening here. Yes. Is that we're doing things to simplify and decrease errors.

Yep. And to improve the quality of care we deliver to our pediatric patients. Oh yes. This is a huge source of error. 

Matt: Yeah, it's, it is, and it creates a lot of stress and it's, that's this [00:26:00] Handtevys taken a lot of stress out of that situation. It's still stressful, obviously, but it's taken a lot of that guesswork and the stress out.

Erik: No, it really has. 

Matt: Um, and then, you know, one of the things that they talk about too is ideal body weight versus actual body weight. And does it matter how tall the kid is? Does it matter how fat the kid is? I get this question all the time, like, I do a body weight. Well, what if the kid's, you know, 10 years old and 300 pounds?

Yep. Well, what matters? What medication are we pushing? Right? Yep. And is it fat soluble or water soluble or what's the fillic? Lipid, [00:26:30] hydrophilic, hydrophilic, hydro hydrophilic. 

Erik: Hydrophobic. Yeah. Phobic. Lipophilic and hydrophilic, 

Matt: yeah. Yeah. So going toward into water or away, uh, absorbing into water fat, right?

Erik: That's correct, yeah. Yeah. So compounds like water, um. This would be hydrophilic. Mm-hmm. And so it's charged and so it will, um, it will enjoy a charged environment. 

Matt: Right. Which, so ideal body weight is what you want to go off. Most of our medications pre hospitally are hydrophilic. 

Erik: That's [00:27:00] correct. Because the blood, um, you know, these, these medications go into the blood and they distribute 'em throughout the body and.

Uh, they won't distribute into the fatty tissues, right? 'cause that's, that's a lipophilic right? Now, if you have a medication that's lipophilic, you gotta be careful, right? Uh, because, uh, it can just, just to be aware of it because it'll, it'll dissolve into the, the lipophyllic tissues, the fat tissues. And then, so now the ideal body weight, then.

It may not [00:27:30] be the ideal way mm-hmm. To dose these medications, so, 

Matt: right. So that's important to keep in mind. And then, uh, but the length of the kid, how tall the kid is now that comes into play with tube size. You and I are the same age. Right. But you're quite a bit taller than I am. Which isn't so, isn't saying much.

You're like five eight and you're tremendously taller than, I'm just kidding. 

Erik: Well, relative to, you know, but go ahead. No, I was, no, you're right. I mean, there may be some differences based on our height, but 

Matt: Yeah. Equipment [00:28:00] wise, like especially ET tubes. Yeah. Right. You, I mean, I'd probably. If I had an eight or a seven and a half, that's probably what I'm going with you.

Yeah. 

Erik: Probably at least an eight I would say. 

Matt: Yeah. In you. 

Erik: Yeah. 

Matt: Yeah. 

Erik: And I think, I think that there's, you don't have, I mean, you could probably fit a bigger one or maybe smaller. That'd be just fine. Right. 

Matt: Everybody says, I have a big mouth, 

Erik: so most men, I was. Most men, like you said, seven and a half or eight.

Yeah. Most women. Seven or seven and a half. Yeah. I mean it's just, 

Matt: it's funny how they, these We do, yeah. I was recently doing some mega codes and as we're going through 'em, the doc always [00:28:30] ask like, what's size tube are you gonna use? You know, it'd be a 50-year-old male. Uh, we'll do a six and a half. And he's like, why are you doing that?

Yeah. Why are you doing that? He's like, no adult men should get anything less than a seven. No, no, none, period. Just the. Well, yes. And that's what he says. He goes, what size do you, he, he brings that up. But yeah, but oral intubation, if you're out there using smaller than a seven on pretty much any adult, unless it's like little 80-year-old tiny grandma, you know, it's, uh, you want to get the biggest size tube you can.

Erik: But with kiddos, the great thing too is these desk [00:29:00] references, these mobile devices can help you. 

Matt: It's all in the app. That's right. I just pop up the app and I know exactly what size I'm supposed to do. 

Erik: It's actually not very complicated too. I mean, you think about it, um, you get a kiddo, the smallest size is a three.

Matt: Mm-hmm. 

Erik: And. You know, as, as you get older, uh, you know, the adults are up at a a seven seven. Yeah. 

Matt: So you don't have lots of room for No, it's got some half sizes and stuff, but yeah. So there's 

Erik: some, there's some margin for error, but, uh, and, and there's also the cuff versus non cuffed. I mean, there's a lot of things here, but.

[00:29:30] We're not gonna get into those nuances. But these apps though can be really helpful. Yes. And you don't have to worry about calculating tube size. It's there for you. It's all there for, you have to worry about drug calculations, that's all there. 

Matt: That's right. You just gotta work the patient. Work the patient.

Yeah. It's uh, so again, the fat soluble versus water soluble, it's all based off ideal body weight, which has been proven a very effective way to do it. No statistical clinical difference between the two. Mm-hmm. Height wise, you might wanna look more at, if you're using equipment. [00:30:00] Go for the, you know, measure put, get out the tape and measure 'em that way.

Right. Um, but the, the important thing is, is that you have to train on these, these calls. Mm-hmm. These patients, right. Practice. Yeah. You gotta practice with these patients. You can't just be always talking about STEMIs and breathing difficulty with adults. Right. You have to run your crews through a pediatric arrest scenario.

You have to do it because they're few and far between, thank goodness. Um, but we have to be ready when we get them. Yeah. Right. We have to be every bit on point when we get them. I [00:30:30] remember we had a pediatric arrest. Uh, I was fairly new. Um, I was, oh gosh, I'd been outta paramedic school maybe two years, and I was, I was not on the ambulance that day.

And, uh, we got a, a, a pediatric arrest. And long story short, like after the call, um. There were some things that went good and there were some things that went not so good. Right. On the call, as most calls, that's what happens. There's always room for improvement, always room for improvement. But there were some things that like really didn't go well.

Yeah, [00:31:00] and I remember this captain who was, uh, really well known as being a very, and he was a very competent fire captain, right? Mm-hmm. Pulling us all in to the room after this call. And he was not happy. And he was not happy because he's like, that is the 1% of calls. That we absolutely need to be ready for.

Yeah, and I was, I was impressed with the fact that he was kind of known as this really good fire captain. Right. But he never really, not that he negated EMS, but. He took that EMS call [00:31:30] very seriously and the things that went wrong, he's like, that will never happen again. He goes, that's unexcusable for us to make these mistakes in that call.

That is the call where we need to absolutely be on our game. And I respected him for it and he was right. Mm-hmm. And so, yeah, we have to get out. We have to. It's better to be uncomfortable in training than be uncomfortable on scene. 

Erik: Yeah, we talked about that, uh, in previous episodes here. Yes, it is. That's what training is for.

Yes. Make the mistakes while you train. 

Matt: Yes. Make the mistakes screw up. 

Erik: Right, but [00:32:00] you're okay though. You gotta live with yourself If you do make a mistake. When things matter, things happen. And I think that's why like what you're captain to did, which was so brilliant, is to debrief afterwards. 

Matt: You have to do that.

We 

Erik: recently had a tough patient in the er and it, it was a difficult situation, kind of pushed us a little bit and we debriefed afterwards. Yeah. What went well, what didn't go well? What could we do better? Yeah. What could be praised, right? Yeah. There, there are always things to learn. It and it went pretty well.

But, you know, there's some [00:32:30] things that happened that we don't want to have happen again. Yeah. No bad patient outcomes, but no, it was, there's always something to learn and debriefing afterwards. Uh, we didn't add it and talk about it until now, but I think that's a been, that's a really important part of, of, uh, working together.

Matt: You think about a football team, you've worked, you know, been the physician for the Dallas Cowboys. All those guys do is just train and train and train. That is their whole life. Like Tom Brady. That's all he would do is preparation. Mm-hmm. He [00:33:00] would just master the playbook, master the defense, watch hours and hours and hours of film.

That's really where you win the game is all that prep work. Right? That's right. And then you're out on the field and you're practicing. Think of all the practice and time they spent to play a game for an hour, and then how many mistakes did they make in that game? Mm-hmm. Hundreds. Tons. They make constant mistakes that, or they didn't, we wouldn't have referees throwing flags every five minutes it seems like.

Right? Yeah. And so the, the, just think about the level of preparation to be an [00:33:30] NFL football player is just, I mean, those guys, I'm sure it's, yeah. 12, 16 or more hours a day Yeah. Prepping and then on game day, they still make mistakes. Yeah. So for us to think that. Oh, we, I, I've trained on this enough. No, you haven't.

Especially when a kid's life's on the line. There's no way you could sit there and say that you've trained enough for that situation, you know? So, anyway, just a thought that popped into my little brain. 

Erik: Well, you know, uh, actually, I, I love it that you brought the [00:34:00] football analogy in. There's, there's something about prepping and training that, that really equips you to be able to handle the game day changes Yes.

And obstacles that you encounter. Rudy Giuliani, I've told you this before, said the best way to prepare for the unexpected is to over prepare for the expected. Yeah, and I think the same thing is true for kiddos when we treat them, we're over preparing. We practice and we practice for those things that might happen that we don't expect.

Yep. I remember when I was [00:34:30] coaching football, one of my favorite parts of coaching where I felt like I could shine as a coach, we may not win the game, but as a coach, I could change the tactics and the strategies at halftime. To better compete against the team now that I've seen them. Mm-hmm. And I can make adjustments.

Matt: Mm-hmm. 

Erik: And then, you know, we, we were down 21 to zero in the first half. Right. But in the second half we shut them out. We lost 21 to 14. But man, I, I, as a coach Yeah. I felt like we really won that second half. Yeah. And I, and I think [00:35:00] it's true with, with pediatric. You know, patience. Mm-hmm. You, you start out, you think you know what you're doing.

You may have to pivot like, wow, I thought this was seizure, but no, no. Yeah. I don't think that's, yeah. And you pivot. Yep. I think not getting so stuck in what you think it is and anchored, like we talked about. And being willing to pivot and, and know, adjust your way of thinking. Mm-hmm. And not be too prideful.

Mm-hmm. And humble yourself a little bit. Yep. And, and, uh, take care of that patient first. That's why we're there. 

Matt: I'm laughing a little bit [00:35:30] because it's, you talked about the seizure patient and I remember we made a call one time, seizure call, uh, 18 month old fire apparatus had got there first, and myself and my partner walked in and as we were walking in, they were disrobing the kid. Mm-hmm. Getting ready to put it in the bath. So what do we automatically think when we think a 18 month old having a seizure? It's febrile, right? Febrile seizure. Kid's got a fever. That's 99% of the time, right? That's what it's Right. [00:36:00] So I'm walking in, they're taking the onesie off the kid and they're getting a tub ready to cool it off a little bit.

And I'm like, Hey, what was the temp? And they're like, oh, it was like 98, whatever. And I'm like. So why, why are we, why are we trying to cool the kid off? Like it didn't have a temperature. Mm-hmm. It hadn't been sick, but they got so locked in on, well, it's an 18 month old that's having a seizure. It's gotta be febrile.

Like, no bro, they don't have a temperature. Mom is saying the kid has not been sick. They're not hot to the touch. Yeah. There's something else [00:36:30] going on here. And sure enough kids started seizing again. Right. And so now everybody's freaking out because yeah, now they thought, oh, we'll just take the, take the onesie off.

We'll cool the kid off. It won't have any more seizures. We're heroes. We can go back and eat ice cream. Right? Yeah. Now it's like, oh, crap, I've gotta do algebra and figure out Yeah, how much versed, I've gotta get this kid, right? Mm-hmm. So, yeah, preparation is huge because they will turn on you in a heartbeat, but that brings up the point of don't get the blinders on, right?

Yep. You've gotta keep like mm-hmm. Just because. [00:37:00] It's this. Nine times outta 10 doesn't mean the 10th time it's gonna be the same thing. Yeah. You have to be ready to, like you said, make that transition. 

Erik: Yeah, no, you do. I had a similar situation in the ER not too long ago. I think I may have told you this story.

Mom brought in limp, limp, 4-year-old kiddo, um, into the er. Bang on the ambulance bay doors and here she is. Yeah. And now I'm in room four and I got this four. 

Matt: No call. No time to prep. Here you go. I'm responsive. 

Erik: No idea what's [00:37:30] going on. And again, like we talked about before, you know. Okay. Um, what do I know?

Yeah. Uh. Get some information, start assessing the kid. Work of breathing. Yes. Looking at that appearance, looking at the appearance, circulation, the circulation, looking at all these things, and you start to get some historical clues. And it started to move towards seizure and it started to make more and more sense, but uh, the SATs didn't look good.

Vitals weren't looking good, kiddo wasn't looking good, not seizing that we could [00:38:00] see, but I thought, well. This is probably a seizure, so let's prep the airway drugs. 

Matt: Mm-hmm. 

Erik: And we'll watch for some improvement because if this kiddo is postictal right now, we should see some improvement. Mm-hmm. But I wanted my nurses to get all the meds ready for intubation.

Mm-hmm. Potentially if we needed to protect the airway. 

Matt: Mm-hmm. 

Erik: And over time, over the next few minutes, which felt like an eternity mm-hmm. We started to see the kiddo looking around. Okay. And I was like, okay, I'm feeling better. 30 minutes later the kiddo was up, sitting up and talking to mom. Sure. [00:38:30] And, and totally fine.

And. Transferred for pediatric seizure. Yeah. Uh, we did our workup appropriately and all that. Sure. But the point is though, is that sometimes you just gotta slow your roll a little bit. Yeah. And not be too quick to act. Yes. Uh, it wouldn't have been bad necessarily to quickly intubate that kiddo because based on what they look like, they should be, could have justified doing it.

Right. Right. But that doesn't always mean it's not always the best thing for the patient. Right. Right. Get a good history, get a good idea of what's going on with the [00:39:00] patient, and then watch them carefully reassess, reassess, reassess. Well, and that's 

Matt: like you, like we said at the beginning, like, you know, what's your appearance?

Mm-hmm. What, what do they look like now if that kid was. Not breathing and had blue lips, you'd tube the kid right away. Right, right. Because it's like, okay, yeah. This is obvious. The kid's not protecting its own airway. It's not breathing currently. We gotta get an airway in. Yeah, right. But that's where experience comes in.

It's just where like everybody freaks out when they see that limb kid, but it's like, okay, hang on. Like is it breathing? How is it [00:39:30] breathing? What's the appearance look like? What's the cap refill? What's, you know, let's listen to lung sounds. We've got some time here to look at some things before we freak out.

Just go doing something we don't necessarily need to do. Yeah, that's uh, Jerry Wells said that, I think he said that in our podcast. Love that guy. Yes. Yeah, but he, I'll never forget that he is pulled up on a big, huge fire on the highway and he goes sometimes. Mm-hmm. Something so big. You just gotta get out and just take a deep breath and go, okay, this is what I gotta do.

And that's where those checklists kind of come in handy too. Like, okay, I [00:40:00] gotta do this, I gotta do this, I gotta do this, do. 

Erik: Yeah, exactly. It's very important what he say. We practice civil, we've been talking about. Is that a good idea? Let's do it.

Matt: Alright, so you're gonna quiz me. What are we doing here?

Erik: Yeah, let me, uh, I'm gonna, I'm gonna throw a couple pediatric patients to you. Okay. Um, it was actually same shift. And we will paint a picture as if they were, you know, you responded to their home. 

Okay, 

so dad and daughter, is this the 

Matt: same time or I'm doing one at a time. 

Erik: Oh, do, well actually they came in at the same time.

Matt: Yeah. For you. They came in at the same time. Okay. 

Erik: And so we can talk actually about [00:40:30] multiple. 

Matt: So I'm at a house and a bus crashes. 

Erik: So first patient, 7-year-old was wrestling around with dad, coffee table, glass, coffee table broke while they were roughhousing. And, uh, the 7-year-old got stabbed in the abdomen, left upper quadrant with a piece of glass.

Okay. A large, larger piece of glass. Okay. And, um, they ended up coming in by private vehicle. But, but I, what I want you to do is 

Matt: people that really should call 9 1 1 don't. 

Erik: Right? Right. So this [00:41:00] one I want go through your assessment. Yeah. Your doorway assessment of this, this 7-year-old patient. Like what type, what type of things would you ask me and I'll give you the information, 

Matt: right?

Like, so the call would come in as a stabbing, obviously that's gonna get everybody's blood pressure up a little bit. 

Erik: Oh yeah, that's right. 

Matt: Walk into the house. You know, I'm immediately. Looking for the patient, you know, and is my patient number one. Are they conscious? 

Erik: Right? Totally. The conscious talking to you seemed really well appearing.

Matt: Okay. They're so, they're a and O GCs 15. 

Erik: Everything's normal for this [00:41:30] 7-year-old kid. Okay? 

Dad feels terrible obviously 

Matt: slowing down. So everything like, all right, everybody pumped the brakes, kid awake talking. So that's a good sign, right? Mm-hmm. Uh, so I'm assuming that, obviously, what's your skin look like?

Erik: Uh, everything looks great. Everything looks great. Great skin color. Great 

Matt: work of breathing. Looks fine. Work of breathing. Looks fine. Good skin color. You said? 

Erik: I remember the kid being a little bit nervous to be there. Sure. But everything Sure. 

Matt: And just got stabbed in the abdomen. Abdomen. So, yeah. She's probably not feeling good, so, so my initial impression is I'm good, like, mm-hmm.

Let's not freak out [00:42:00] here. We're good. Is the bleeding controlled. Bleeding controlled. Has the glass been removed? 

Erik: Dad placed a, uh, you know, like a, um, I think he had come in initially with a towel, but we have now in the nurse's assessment. Yeah. We had placed a four by four with the glass. Got removed. No active bleeding.

Yes. He took the, the glass out. Oh, dad did. 

Matt: Okay, so before we get there, okay, so large piece of 

Erik: glass. I guess if you were on scene, you could have seen the piece of glass. Sure. Yeah. But he described it as a large piece of glass, but it's hard to tell exactly how far the glass went in, which I remember trying to figure out, but [00:42:30] go ahead.

Yeah, we just subjective. Yeah. 

Matt: So the glass has already been removed. Yeah. So bleeding's controlled bandage of the wound, obviously you said upper left quarter 

Erik: never removed. Of 

Matt: Yeah. No. Right, right. The object. Yeah. We would not ever remove anything. Yes. And so if 

Erik: you, if you had do see a patient like this 

Matt: Yes.

We would stabilize that. Yeah. In place. Very, you know, carefully. Yep. And because obviously pulling it out could cause a lot more bleeding, so, but it's already been removed, so, but bandage. Um, you said upper left quadrant was where it was at? 

Erik: Yeah. Upper left quadrant. Yeah. 

Matt: So again, a little bit worried about [00:43:00] maybe a splenic injury.

Good. 

Erik: It's good to know the anatomy. That's good. Yeah. I'm glad you brought that up. Knowing the spleens here, what's on the right side? Liver. The liver there? Yeah. Yep. Two organs that with penetrating trauma, a lot of bleeding. A lot, yeah. Lot of bleeding. 

Matt: Yeah. So that would be my main concern is that she injured her spleen.

Erik: Yeah, 

Matt: right. Do I see a lot of blood on the ground? That's another thing. Okay. So not a lot of blood on the ground, so. I'm 

Erik: a lot of glass 

Matt: vitals are stable. 

Erik: Vitals look great. 

Matt: Okay. Her 

Erik: vitals are 

Matt: totally fine, so I'm sure she's probably in a little bit of pain. Right. Mm-hmm. Probably not overly comfortable, but vitals are all stable.

Yeah. She's alert and [00:43:30] oriented. I'm not overly concerned. Obviously, I'm probably gonna get an IV on this kid to give her some pain. Me management. Yeah. While I'm taking her to the hospital or while I'm in the hospital. 

Erik: Where would you take this patient? Like you? You trauma center 

Matt: for sure. Yeah. Trauma center that can deal with a, how old was she?

Seven. Seven? Yeah. Trauma. Trauma center that can deal with a 7-year-old with a penetrating abdominal wound. 

Erik: Exactly. 

Matt: For sure. Yeah, and, and again, I'm not, regardless of where you're at, I don't have to fly this kid. The kid's perfectly stable. Yeah. I've got the ability to manage her pain en route. Right. I'm watching her vital signs.

Erik: Let me ask you this. Mm-hmm. So [00:44:00] based on your assessment, what signs would you see that would concern you? It's like five alarm fire kind of stuff. 

Matt: Yeah. The altered mental status. Good. Yeah. Un yeah. Unconscious altered mental status. Mm-hmm. You know, poor skin tone. Uh, obviously she's pulseless or massive amounts of hemorrhaging.

I'm seeing evidence of massive amounts of hemorrhaging. Uh, a high shock index, right? Yep. She's got a super high heart rate and a super low sto blood pressure. Oh crap. 

Erik: We talked about this in our hemorrhage lecture, but the first thing that changes vital sign, right? The tachycardia. Mm-hmm. [00:44:30] If you're altered, you got organ dysfunction.

You've, you've gone beyond just hypotension. Now. 

Matt: You are no longer profusing the brain. It's very sensitive to changes in oxygen. 

Erik: Yeah. It'd be a bad sign 

Matt: that's. Yeah, that would be, yeah, that would be concerning. 

Erik: Yeah. I think, uh, the other things I might mention, um, if I was assessing a kiddo like this, that things that would concern me mm-hmm.

Um, you gotta, don't ever forget about non-accidental trauma. You gotta remember that. Yeah. Uh, and then, and then I would also say when you're, when you're doing your assessment is to, to look, if you're worried about hemorrhaging, is to remember the [00:45:00] conjunctive of those some just mm-hmm. Physical exam pearls that we've talked about Yeah.

And taught before. Yeah. It like the window into your, your, to your soul, blood, soul, like your, your tank, is it full or is it empty? Right. Yeah. So that'd be the 

Matt: only not one. I don't, I doubt that that's, you know, really taught. I know. I was not taught that in paramedic school. Let's do it again. Looking at that conjunctiva is probably something that not a lot of people are being taught as paramedics early.

Erik: That's right. One of the first places I'll look when I'm concerned about bleeding would be the conjunctiva. I had a GI bleeder patient that came in just last week on a shift that [00:45:30] I, um, really caught because of the conjunctiva was so pale. It wasn't, the chief complaint wasn't necessarily something like a bleeding, it was abdominal pain.

Matt: Mm-hmm. 

Erik: Um, but the concern was a perforated gastric ulcer that caused the abdominal pain and the bleeding had been going on for quite a while, and the patient was very anemic. 

Matt: Interesting. Interesting. 

Erik: Um, the lips. The, the tongue. Yeah. Lips. Yep. The palms, the creases in the palm. So while that patient, and I'll never forget, I was actually in the hospital, we weren't at their [00:46:00] home.

Mm-hmm. And this, like I told you earlier, they walked in. Yeah. But I was in there with the, our trauma surgeon assessing this, this pediatric stabbing. 

Matt: Mm-hmm. 

Erik: When. Bang, bang, bang and a bunch of chaos over by the ambulance bay doors. And your next patient was brought into you, uh, an infant. 

Matt: Were those gunshots or was that No.

Banging on the doors. Oh, okay. I was like, oh, no, that's a bad day in the ER. 

Erik: So this as an infant. Okay. Uh, you could see, uh, the, the, the, the jammies, this little onesie was were singed. Hmm. [00:46:30] Uh, this kid, uh, was brought in by law enforcement, had been involved in an accident, ejected from a vehicle. Mm-hmm. Uh, picked up by a good Samaritan on the side of the road actually.

And, uh, per report was on fire. The kid was on fire. The, yeah, the, the, the car, the, no, the kiddo. Oh, the, the, the pajamas were on fire. Um, and, uh, anyway, so here, here's your patient. They brought it into, uh, one of the, uh, let's just say. You bring it into the ambulance now, right? Mm-hmm. Yeah. You're on scene there in the [00:47:00] ambulance, your patient.

Um, what, what, how do you approach that emergent pediatric assessment? What do you do there, Matt? 

Matt: I'm assuming that this kid, again, appearance, mental status, is this kid unresponsive? Yeah, so airway is my number one concern. With the burns, uh, I'm assuming that they were probably in some car wreck as well.

That's correct. Um, so there's also maybe some blunt trauma that I need to be concerned about. 

Erik: Yeah. 

Matt: But highest priority in my has a pulse. I'm assuming 

Erik: pulses are there. 

Matt: So has a pulse. Yeah, but not how, [00:47:30] what's, what's my respiratory rate? Are they breathing? Uh, they're breathing, 

Erik: uh, not breathing great, uh, if I remember correctly, any, but no should or anything.

Yes. So yeah, singed burns, all of the exposed skin had, uh, signs of burns on the hands. So my number one 

Matt: airway, or my number one concern is I need IV access and I gotta get an airway and this kid right now, 

Erik: good. Yeah. You know what, uh, you know, we talk about pediatric assessment triangles and all that stuff.

Yeah. But in situations like this, yeah. You gotta know what to do right away. And that's [00:48:00] perfect. Matt, what you said is exactly what we did. Actually, Adam and I treated this patient together. 

Matt: That's a lucky kid to have two of you in that. 

Erik: And we intubated this kiddo right away. Yeah. And then as we were able to assess the kid further, then you're looking at, 

Matt: okay, we got the airway, we're good, we obviously we're gonna keep him sedated. Yeah. All that kind of stuff. Now we're looking at volume replacement. Yeah. Right. Burns mm-hmm. Trauma. We're doing a head to toe assessment. Does he have any other visible off injuries? Yeah. Extended abdomen. Mm-hmm. You know, any, what do my vitals look like, full set of vitals, all that kind of stuff.

That's where [00:48:30] I'm going from there. 

Erik: Awesome. Yeah. And I, and I, I, you did the, you did the first thing. Great. It's perfect. I mean, you have to, you have to do first things first mm-hmm. With these kiddos have to prioritize. Yeah. Yeah. And, uh, we did that. We got the fluids going. We were, you know, the full assessment.

We've, we found some other injuries mm-hmm. That collapsed lung and Yep. Um, we, uh, got the kiddo stabilized mm-hmm. To the CT scanner. Uh, had, 

Matt: did you dart it or did you put a chest tube on Tube. 

Erik: Chest tube, yeah. Adam probably did that. Yep. And, uh, we, uh, [00:49:00] um, ended up transferring this patient 

Matt: to a pediatric facility. Yeah. 

And let you know, we talked about what, what facility would I have taken that first patient to, yeah. Patient was stable, could. Take a ride, you know, 20, 30 extra minutes to go to maybe a pediatric trauma center, right? Yeah. This kid. Most protocols are gonna say, 'cause he's probably about to rest. He needs to go to the nearest emergency room to get stabilized.

Erik: That's right. 

Matt: Right. No matter how cool we think we are, that's correct. As paramedics, doctors have a lot more education experience and it's a more stable environment. And tools. Yes. They have nurses. [00:49:30] There's a lot more help 

Erik: get them stabilized right away. Then we can get them transferred to where they need, need to go.

Yeah. Uh, you're right that other kiddo, it's better to drive past some hospitals. Yes. 'cause even though the kiddo's stable, that kiddo needs to go to the or. Yes. And those surgeons gotta run that bowel. Yep. Gotta do that exam to make sure there's no intraabdominal injuries. Exactly. If you take 'em to another hospital, if there was something more serious going on, you're just delaying definitive care.

Yeah. This is where things are difficult. 

Matt: Oh yeah. There's some nuance. Transport decisions are not [00:50:00] easy. They take some practice, but yeah, those critical kids, it all goes out the window. Yeah, they gotta go to the closest facility, whether that's ground, you're five minutes from one or you're calling a helicopter 'cause you're in a super rural area and you gotta get these kids to a higher level of care.

Erik: Yeah. 

Matt: Fast. 

Erik: That's right. So remembering your assessment triangle. It's always good for pediatric assessment. 

Matt: Have some sort of system in place, whether it's Handtevy or using Broselow, you know, whatever system. Have a system in place to quickly be able to identify, yeah, dosages and things in [00:50:30] these kids.

Erik: And 

Matt: as I sneeze, go ahead. 

Erik: Bless you. And to know too when to get away from that typical assessment to know when it's time to take immersion to do something, right. Yeah. We talked about it. Remember we went hiking that day. Yeah. We were like, we were talking about go low and go stay playing. Yep. You know, and, and knowing when it's appropriate to do both.

Yeah. It's, uh, 

Matt: yeah. I'm not doing a full head to toe assessment on this burn kid. No. Like immediately like, no, this kid, if I take time to do that, the kid's gonna die. I have to control this airway right now, or I'm gonna lose it because it's a burn. It's gonna [00:51:00] swell up. He's gonna go into respiratory arrest.

I've got to do this right now. I'm not worried about if he's got a femur fracture. Right. I worry about that in a minute. I mean, that's my least. 

Erik: No, no, that's good. Well, we talked a lot about, uh. And the anatomy being different, the physiology being different with kids. We talked about the assessment with the triangle.

We talked about the Handtevy system and we practice on a few patients. Yep. Super important patient population. We gotta be really on point and good in practice like we talked about. 

Matt: Yes. Get this more into your system one thinking, not your system. Two thinking. And that'll help you perform better on the call.

Erik: So, 'cause [00:51:30] the best way to prepare for those unexpected calls is to over prepare.

Matt: That's right. See you the next one.

Erik: Be safe out there.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.