SPEAKER_04 0:01

Especially these kiddos. Yes.

SPEAKER_01 0:02

They can code on you very quickly if you don't resuscitate.

SPEAKER_04 0:06

Tell a hundred stories of uh uh little kiddos that uh were sick and uh ended up being sepsis, some sort of an infection.

SPEAKER_00 0:19

You are listening to EMS with your hosts, Eric Axe and Matt Ball.

SPEAKER_01 0:27

What's our topic today, Enrique?

SPEAKER_04 0:30

Enrique, yeah. I think that today's a commonly missed thing, but a common thing we see. Uh you know, you you'll have a a baby that's just not feeding well or seems more tired or lethargic, it's not acting right. Missing sepsis is a common cause of a sick kid. And a scary patient, when you see a sick kid as like a lifeless sack of potatoes, it's scary.

SPEAKER_01 0:55

And we don't normally think, at least I didn't normally think of when I thought of sepsis, you always kind of think of the older nursing home patient. That's like the typical patient that pops into your head, not the like you said, the young lethargic kid. You're thinking the sepsis isn't one of the first things on your brain. That's right. It should be, it should be one of your differentials for sure.

SPEAKER_04 1:16

And and those and those the younger, younger, but like neonates, like little kids, they're they're almost I mean, you can should consider them immunocompromised.

SPEAKER_05 1:24

Yeah.

SPEAKER_04 1:25

So there's a lot of different factors to a sick kid. So yeah, so we're gonna talk about the pediatric sepsis.

SPEAKER_01 1:31

It reminds me of the office when Dwight says that I never get sick. Well, if you never get sick, then you have no antibodies. So that's but that's like, I mean, literally, because little kids they have no antibodies, right? Because they haven't really been exposed to anything.

SPEAKER_04 1:45

Didn't he didn't he say something about like if he could have a superpower, he'd want to lower his cholesterol or something like that?

SPEAKER_01 1:51

Well, he I he had one thing where he was like, I can raise and lower my blood pressure at will. Why would you want to raise your blood pressure so I can lower it? Classic, classic show.

SPEAKER_04 2:01

That's classic.

SPEAKER_01 2:01

Anyway, you have no antibodies, Dwight.

SPEAKER_04 2:04

No. And then we need antibodies. But you know, with sepsis, the adults get a lot of the and like you mentioned, the the nursing home patients. Yes. They get all the press. Yes.

SPEAKER_01 2:12

Um, and they're the most common for sure.

SPEAKER_04 2:14

They are the most common. But and you know, the problem with kids too, some they can't communicate. Right. You know, and they can't they can't tell you, you know, I'm having, you know, feeling body aches or uh and so they can go for a while. And they and because kiddos compensate so well, sometimes we're not seeing them until they've fallen off the edge. Right. So we we titled this lecture Um a uh Tiny Humans Massive Compensation. Sorry, podcast. No lecture, no lecture. Lecture's a bad word. It's a curse word in the firehouse. So pretty common.

SPEAKER_01 2:48

Yeah, yeah, yeah, yeah.

SPEAKER_04 2:49

You probably can tell a hundred stories of uh uh little kiddos that uh were sick and uh ended up being sepsis, some sort of an infection. Um I think it's good to set the stage with you know the most common kinds of infections that kiddos get.

SPEAKER_05 3:04

Yeah.

SPEAKER_04 3:05

Either bladder, lung, or skin.

SPEAKER_01 3:07

Yep.

SPEAKER_04 3:07

And skin would include ears and throat and stuff like that.

SPEAKER_01 3:10

I'm gonna default to respiratory every time though.

SPEAKER_04 3:12

Yes.

SPEAKER_01 3:12

Just because to me that's probably the one that's gonna I hate to say kill them the fastest, but that's the one I'm gonna be most concerned with. Yeah, you know, is the kid having that respiratory compromise and be real aggressive with the treatment. And that's what we teach, you know, all of our providers. But like you said, they compromise really well, right? But then when they they don't have the reserves, and once they fall off the cliff, they fall off the cliff. There's no you know, slow roll into circling the drain.

SPEAKER_04 3:39

When you have a really sick kid, we can support their respiratory system by giving them some supplemental oxygen, even intubating and breathing for them. Yep. Uh we can we can fill their tank a bit with some fluids. Yep. Even, you know, in some municipalities will give antibiotics to treat the underlying cause. Yep. Uh lungs are very common. One of the ones that we will miss, but you know, in the pre-alcipital environment, uh, you know, you're not going to test the urine. But a urinary tract infection is very common, uh, especially with the kiddo that's potty training and learning how to wipe and all that's really easy to cross-contaminate. Sure. Much more common in females than males, of course, anatomically. But uh, those are the ones that uh I know in the ER can, you know, you get this kid that comes in with a fever and vomiting. It's amazing how often it's uh urinary tract infection. Um so it's it's uh it's certainly common, but in the in the ambulance though, you get called to a uh a kiddo that's not doing well, um fever, whatever the the call is.

SPEAKER_01 4:38

Difficulty breathing, yeah.

SPEAKER_04 4:39

Yeah, those are those are relatively common calls. But it's gonna be one of those things. Yeah. It's 99% of the time. And then that small percentage of the time you're dealing with, and we'll talk a little bit about them, but like meningitis or maybe even a you know, some sort of a GI emergency, like appendicitis or something like that.

SPEAKER_01 4:55

Unless they have some congenital thing going on.

SPEAKER_04 4:57

That's true too.

SPEAKER_01 4:58

You know, which again, like we talk about in all of our pediatric stuff, you know, talk to mom and dad. You know, they're the experts on what's going on with this kid. Get a good history because, like you said, the patient can't tell you anything. You know, obviously if they're four or five, but if they're, you know, babies one, two, they're not gonna be telling you what's going on.

SPEAKER_02 5:17

No.

SPEAKER_01 5:18

Right? They're probably not gonna be very happy. They're maybe gonna be crying if they're not crying. Obviously, is a good sign. They're not crying, they're very lethargic, that's a bad sign.

SPEAKER_04 5:26

Bad sign.

SPEAKER_01 5:26

As mom, you know, how long has this been going on? Ask about diapers, yeah, fever. Have you been giving Tylenol and Notrin? Because you might check a fever and the kid doesn't have one. And then you take sepsis off your diagnosis. Well, mom just gave some Tylenol before you got there. That's why maybe the kid's epheberol now.

SPEAKER_04 5:42

And a lot of these immunocompromised folks can't even mount a fever. So you you know, a fever is not a requirement for sepsis, it could be hypothermia as well. So that's a good point.

SPEAKER_01 5:54

Is how our protocols are worded.

SPEAKER_04 5:56

Yep. And the other big part of it is the compensation. So, you know, I think this might be a good place to remind our friends of what is the definition of sepsis? It's when the body can't meet the demands. Right. Uh well, that's really septic shock, I guess, is we can't meet the demands.

SPEAKER_01 6:13

It's a cascade. Yeah.

SPEAKER_04 6:16

But sepsis by definition would be uh almost it's really more about the body's response to an It's like anaphylaxis.

SPEAKER_01 6:23

Exactly. It's an over, it's it's I've always said it's like using a a nuclear bomb to blow up a mo an anthill in your backyard. That's a little overkill. You killed the ants, but you killed the ants, but you killed the rest of the area too. Right, right. Yeah, it's overkill, right? It's this it's again like an anaphylactic response. It's its body basically attacking itself and it's like, whoa, slow down.

SPEAKER_04 6:45

COVID was a great example of this. You get that the coronavirus in, triggers your immune system, and it's a respiratory virus, so it attaches to the respiratory epithelium, and then it creates this massive cytokine storm in the body. And you end up, you know, you got World War III taking place on that one cell thick, you know, respiratory mucosa, the or the uh the alveoli, right? And and it's it it creates damage, inflammation, and that's really what killed people was the loss of of respiratory function. Yep. And you you're not you're not able to do gas exchange, you don't do well. So but with what's no exception with kids, um you know, when you have insepsis, your body's immune system creates a lot of problems. And those problems are manifest by what we see on the vitals.

SPEAKER_01 7:34

Yep. Which is important to know, like where the normal vitals, because you got a neonate that's not gonna have a resting heart rate like a 50-year-old. That's right. It's gonna be a lot faster. Yep. And so that's why it's important to know what are those normal ranges, right? You know, a neonate little kid, their heart rate's gonna be 150, 160.

SPEAKER_04 7:52

That's normal.

SPEAKER_01 7:52

That's normal. That's you know you and me? Yeah.

SPEAKER_04 7:55

Not normal.

SPEAKER_01 7:55

If I'm at 160, takes me to the hospital. If I've either done a really bad workout and I'm about to die anyway. No, but like you put that kid, like their respiratory rate's gonna be like in the 30s, probably. Right? So look at the kid, and we'll talk about the pediatric assessment triangle or ABCs, I like to say it. But um, yeah, look at how the kid's presenting. Yeah, you know, and look at everything in context, know what the normal vital ranges are for that age kid, and then you'll know if you're outside of that. Yeah, it's important.

SPEAKER_04 8:27

And and kiddos don't have a lot of the same compensation capabilities of an adult either with that little heart of theirs, that young heart. They little tiny. They really and we've talked about this with adults too. The first thing you see that changes is the heart rate, but they really have a limited ability to vary their stroke volume. They just it's all heart rate. It's all speed. That's right. So that's that's important to recognize. So when you get that kiddo that's not looking so good, knowing what the normal vitals for that age kid should be. I mean, a 12-year-old's getting close to being an adult, so you're looking for those more normal typical adult vital signs, but you got the neonate, you could have a heart rate, like you said, 160, and that's actually pretty dang normal. So it's nothing to worry about.

SPEAKER_01 9:11

Okay, we're good. Yeah, yeah. Yeah, but like asking mom, you know, what does the kid look like? Again, you get a one-year-old, you know, that's always a red flag that if you know you got five people walking into a house swooping this kid up, and they kick that kid doesn't get mad and ticked off, start crying, that's kind of scary.

SPEAKER_04 9:28

You know, that's a really good point. Uh, is what is what does the kid look like from the door? Yeah. Is this kid appearance? Yeah, what's the appearance? And we'll talk about that with assessment with the pediatric assessment triangle, but you know, there's a crying kid, it's a really healthy kid. It may be a little scary if you were new, like, oh no, this kid's crying. This is gotta be something wrong. But a more experienced paramedic's gonna know. I mean, that could be a problem there, but yeah, the very well could be. That's another thing I love about kids. They don't lie. Yeah, yes, something's bothering them. Yes, it might just be you.

SPEAKER_01 9:58

Yes, yeah, yes. Might not be a medical thing, might be an emotional thing, right? This gigantic six foot six, two hundred and fifty-pound guy picking me up like we're gonna be.

SPEAKER_04 10:07

We're monsters to these things. Yes, we're weird.

SPEAKER_01 10:10

Well, and yeah, I was gonna say, yeah, we they don't know us, right? No kid goes easily typically to somebody they don't know, especially when they don't feel good, right? They want mom, they want dad, they want somebody that's familiar, comforting them. You hand them off. So when uh I was in paramedic school and I went to paramedic school, we were down in the basement of this building. Those of you in Dallas know exactly which school I'm talking about. Uh but we would go up for lunch, they had a little cafeteria, we'd go up for lunch, and then we'd go back down to the basement to do class. And I was in class all day. My wife knew like I was in class, and the cell signal was hard to get in this building. Anyway, I had gone up and I got signal, and I had all these messages from my wife and missed phone calls. Very unusual. I knew like, oh, there's something's wrong. And our youngest daughter was like six days old, I think, at the time. So I mean she had just been born. And um, so I'm like, okay, something's wrong. Call my wife, Mike, what's going on? She's in the ambulance going to the hospital. Oh no. And I'm like, what's happening? And she's like, she wasn't feeding, she was real lethargic. Excuse me. She's like, I didn't know what to do. You know, call I'm like, call 911, that's what we're here for, right? So they were heading to the hospital. Luckily, it wasn't sepsis, um, it was actually acid reflux that had got her. Okay. Um, but it was just a scary thing. Little kid, you know, scary deal. Six days old. Six days old, little tiny little baby. Nobody wants that call, you know, this fragile little thing, you know.

SPEAKER_04 11:38

And they can turn quick. Yeah, exactly. You've got to be preemptive with them.

SPEAKER_01 11:42

Yeah, yeah. You gotta be aggressive, you gotta be on your game, paying attention. You have to be really good. It's like vets, veterinarians, uh-huh, they're such good doctors because none of their patients can talk to them. None of their patients can talk to them. Think about that. Yeah, they have to go based on their if they don't do a good assessment, if they're not really looking and listening and touching and feeling, it's hard to know what's going on, right?

SPEAKER_04 12:08

I agree. And I think emergency medicine too is in the whether you're in the ER or an ambulance, a lot of our sickest patients, it's like veterinary medicine. Yeah. Our physical exam, our history is so important. Yes. Patients not going to talk to you and tell you anything. No. Uh you gotta you gotta pick it up.

SPEAKER_01 12:23

Yeah, if they're unconscious, they're not saying much. Yeah, yeah.

SPEAKER_04 12:26

Fortunately, we have parents with these patients that are hopefully helpful. Yes. Um, but that's that's a big part of it. And the I think to finish off compensation, and you actually mentioned the respiratory system, and that's um it doesn't matter where the the problem is, where the infection is, that's part of the diagnosis of sepsis, but we depend so heavily upon our lungs uh to to oxygenate the blood to maintain the oxygen carrying capacity to fuel the cells to do what they need to do. The lungs become a very important part. So when you have a little kid and the lungs are diseased or having the the infection or whatever, maybe pneumonia, it hampers the body's ability to do what it needs to do, and they're breathing fast, their heart's going crazy. And it's just this cycle that's getting worse. Yes. And so eventually they get lethargic when they just get behind, they can't compensate. Yeah. And uh kids compensate, compensate, compensate, and then they fall off a cliff. Yeah. That's just the pattern for them. Whereas adults, you'll see them turn a corner and slowly decompensate. Yes. I mean, everybody's different, but that's typically what we see. Trevor Burrus, Jr.

SPEAKER_01 13:31

You're gonna definitely see a slower progression with adults than you will with kids. Right. So yeah, when you go on these kids, you know, keep sepsis as a differential, you know, and then be looking at your kid like do they look cyanodic? Yeah, you know, get them on some oxygen, you know, be aggressive with that oxygen therapy. I don't like to start IVs on kids unless I have to.

SPEAKER_04 13:50

That's a good thing.

SPEAKER_01 13:51

Um, but if I have to, I will for sure. And so you gotta get that IV, you know, and get some fluids going on those kids, uh, whatever your local protocols.

SPEAKER_04 14:02

And the fluids for you to do and the fluids are so fundamental, we gotta recognize when they're when they're in shock. When the and and it doesn't necessarily um mean that the fluids are gonna fix it. It's just gonna it's just gonna help them perfuse. Yeah, that's right. And we gotta fill up the tank. Yeah. And it now, we used to just dump fluids on people. That's not so m much in the literature anymore. I mean, we may get depressors sooner. Right. Um, but it's really important for kids though to recognize the signs of of sepsis or septic shock before they decompensate. Little kids you can look for retractions. That's a actually even before that with the history, uh, a couple things you can look for. You can ask mom, how many wet diapers?

SPEAKER_02 14:47

Yeah.

SPEAKER_04 14:48

Because if you're not making urine, um your body's reabsorbing in and because it's behind. Yes.

SPEAKER_01 14:53

So and you gotta think they got little tiny bladders, so they're peeing a lot.

SPEAKER_04 14:57

Yes.

SPEAKER_01 14:57

So if they don't have eight to ten wet diapers over the last twelve hours, that's probably low. Oh, they've only had one or two wet diapers all day. Yep. Okay, that's yeah.

SPEAKER_04 15:07

It's not a diagnosis, but it's certainly you remember that's one of the flat the red flags. Yes. Uh mom says not feeding well. Yeah, normally she'll breastfeed blah, blah, blah a number of times. She's just not she won't eat. Uh that's another problem with kiddos, especially the little ones, is they're they really are are uh mouth breathers. Right? And if they've like firemen. Yeah knuckle draggers. Yeah, no. Just kidding, just kidding. So when you're when you're feeding and you're not breathing well, you c you you it requires them to breathe through their nose, and and if they're not able to do that for whatever reason, they've they they won't feed. And then they then they're now they're not getting the nutrition. And and again, it just adds to the whole constellation of sepsis and when they're gonna decompensate.

SPEAKER_01 15:51

Yes, until that infection gets fixed. Right. It's just gonna keep cycling downward.

SPEAKER_04 15:55

Yeah.

SPEAKER_01 15:55

And so early recognition of that is important.

SPEAKER_04 15:58

Really important, yeah. So in the ER, that's what I'm looking for. I'm asking these questions. How are they feeding? How many wet diapers? Are w are they up to date with their immunizations?

SPEAKER_01 16:06

Oh, yeah, good question.

SPEAKER_04 16:07

That's another good one to ask.

SPEAKER_01 16:08

Yeah, because nowadays there's a lot of parents that are, you know, and I'm not making any kind of a statement about vaccinations, but I'm just saying you have more parents now that are not getting their kids vaccinated for things that we've been vaccinating kids for for decades.

SPEAKER_03 16:23

Yeah.

SPEAKER_01 16:23

And so, you know, everybody's entitled to their opinion, but we're seeing things that we haven't seen in a long time that can cause these issues.

SPEAKER_04 16:30

We've been benefiting from what's called herd immunity for a long time, where you know, certain people decide they don't want to vaccinate. Well, they benefit from the the herd sort of thing. The herd doesn't get as that is immunized, and so that we're not seeing these diseases because of the herd immunity. But as more and more people aren't vaccinated, we're seeing uh some of these diseases pop up that hadn't popped up historically for the last few decades.

SPEAKER_05 16:54

Yeah.

SPEAKER_04 16:54

So that's a good thing to ask, just to be aware, just so we're we're you know, they're at risk for certain things. Yep. So that's a good thing to do with history. And then on a physical exam, uh, I think there are a few things. If it's a little tiny baby, the fontanelle is a great way to check the fluid in the tank. If it's sunken, that's uh it's not a good sign. If it's bulging, it's not a good sign. Right. So those are the things we want to do.

SPEAKER_01 17:15

Temperature, I would, you know, for a neonate, you know, I would be getting a rectal temp. You know, if I was really concerned, I I want to get that rectal temp um on that kid. Make sure you use the red probe, they're correct for one.

SPEAKER_04 17:28

It reminds me of our our uh the pediatric fever lecture. We're uh measuring our temperature.

SPEAKER_01 17:34

But you're measuring my temperature, yes. Yes, I was, yes. Yeah, there's lots of different ways you can do that. I don't like the axillary ones.

SPEAKER_04 17:40

The oral, yeah. No, most of yeah, most of what we do in the ambulance isn't a real accurate way to get a temperature, but we do the best we can. Yeah.

SPEAKER_01 17:48

And a lot of these kids you can feel them. You pick them up and you're like, man, this kid's hot. And then two, mom's got them bundled up, yeah, you know, because they feel like that's which I get it. That's comforting and soothing for the kid, right? And it's soothing for mom, you know.

SPEAKER_04 18:00

So Especially when you're dealing with a toddler that's saying, Mommy, I'm cold. Yeah, you're gonna get some blankets. Well, when you feel cold, that's a fever coming on, right? Those chills are actually the body temperature going up. Yeah, you're pulling in heat from your environment. Your hypothalamus has said, let's raise the body temperature. Which again, I love to say this and educate parents, but uh, you maybe if you're hearing this, you can educate parents. A fever is not necessarily a bad thing. No, the fever's body doing its natural thing. Not only does it hamper the foreign invader and and make it tougher for them to multiply, it also ramps up your immune system, giving them more strength, so to speak, right? To do a more efficient job of fighting the disease. So you're giving your body the advantage with a fever.

SPEAKER_01 18:42

But you don't want it to get too out of control.

SPEAKER_04 18:44

No, that's true.

SPEAKER_01 18:45

Yeah. Once it gets too high, okay, yeah. You want to get that down.

SPEAKER_04 18:48

Follow your protocols. Yes. But a lot of times uh folks will call my firefighters will talk to me because I'll talk about fever and then I'll get a call. Hey, Joey's got a temperature of 102. Okay, tell me more, right? Well, he's playing Legos right now, um, but should I do something about the fever? You know, it's like playing Legos, yeah, exactly. Same temperature, same kiddo, hasn't eaten all day, yes, can't sleep at night. Red flag, red flag. Give him the tile. Yes. Give them the motor. I know there's some controversy with some of these meds, but get them comfortable so they can eat and sleep. I think the risk benefit there is certainly in the favor of the kiddo, getting some rest and sleep and food, nutrition. That's how the body heals. Yeah. Yep. Uh also on physical exam, we can we can look for in addition to the temperature, we could get to more vitals too, but is the uh retractions. You see retractions on a kiddo. Uh those are some belly breathing. Uh that will, you know, progress to costal retractions. Tracheal tugging. Yes, you get to the tracheal tugging or the sternal notching or whatever you want to call it. They uh that's a that's that's that's progressed retractions.

SPEAKER_01 19:58

Cap refill. Like look at them, look at the core. Cap refill's huge. It's huge, yeah. Look at the core, you know, do what you can do cap refill on their skin. Everybody goes to the fingers or the toes, but do it on their chest, do it on their abdomen, see if you get that return of color, you know. But yeah, if you have a slow cap refill, I mean I I look at that more than SPO2 on a kid. Yeah. I mean, I'm gonna because it's quick, right? I can look at that quick and go, how well is this kid perfusing?

SPEAKER_04 20:22

That's why it's such an important part of the pediatric assessment triangle. The the perfusion is huge, especially in sepsis. Yeah. Because when the body's compensating, it will shunt body blood to the core. You get that modeled kind of cool extremity, you know. But you you've got to be careful though, because if you really go into full distributive shock, you've lost the ability to vasoconstrict. So you can you can you get the extremities don't have to be cold. Um, and that's when you're really in trouble. Yes. Now your body's not compensating.

SPEAKER_01 20:50

Moving a little bit faster.

SPEAKER_04 20:51

Yes.

SPEAKER_01 20:52

Yes. That's where you're starting the IV on the kid. You're getting them on supplemental oxygen.

SPEAKER_03 20:56

Yeah.

SPEAKER_01 20:57

Yeah. You're you're definitely moving down that road a little bit faster. Uh circulation, we talked about that. We talked about breathing and then appearance. Again, if that kid's not crying, if they're lethargic, you know, that's those are all red flags.

SPEAKER_04 21:10

I would say that I think that's not given enough credit. Uh that that doorway assessment, you know, when you're looking at that kid, you can see a lot there. And I think differentiating between sick and not sick is really what we're talking about here. But that vital sign of just appearance is huge. And again, that's on the pediatric assessment triangle. That's why it's there. It's a big deal. Yeah. Is that kid tracking and looking at you? They should be a little leery of you and a little shy. I mean, that's normal. Maybe even cry when you go to put on the blood pressure cuff or the the even the pulse socks, right? They should be fighting you. They really should be. Yeah. Don't touch me. It's scary. Yeah. And then, gosh, let alone an IV, if that kiddo's not crying with I mean, there's there's a there's that kiddos having issues.

SPEAKER_01 21:55

Also, blood sugars. Blood sugars. Check that I mean, we're kind of touching on vital signs, check that blood sugar. You know, because these kids don't have a lot of reserves, glucose reserves. So you want to check that sugar, make sure they need if they need a little supplementation, get that sugar on board to give them energy right to fight through this infection that they're dealing with.

SPEAKER_04 22:11

And you know that you I'm glad you mentioned that because this is a another thing, uh, you know, to not uh you know, you see a kid with potential sepsis, it's good to dig deeper, don't just anchor on the fact we got sepsis.

SPEAKER_05 22:22

Yeah.

SPEAKER_04 22:23

There are some some things that can cause a rapid respiratory rate in a kiddo that looks sick that's not sepsis too.

SPEAKER_05 22:30

Yeah.

SPEAKER_04 22:30

Checking that blood sugar and it reads high in this kid who just, you know, we find out you know, he's got a type one, you know, he's type one diabetic. But the parents didn't know that. Yeah. But you got the kiddle that's breathing fast and and it ends up being uh a totally different disease process, which is oftentimes actually triggered by viral infections. Viral infections, like an uh you have an initial viral infection, and then uh the body and the immune system end up attacking the pancreas. And that's it's a common cause for type 1 diabetes. Yep. So it's um that's not sepsis, of course, but it can sure look like sepsis. Sure. Absolutely.

SPEAKER_01 23:06

And the treatment's kind of gonna be the same, right? We're gonna control the airway, fluids, yep, right? We're gonna give some fluids for a kid that's you know hyperglycemic, and we're gonna transport probably to a children's facility if we have that ability to do so, and obviously following our protocols, yeah. For you know, always I'm gonna always go to somewhere where that kid can be admitted. Yeah, you know, because whether it's sepsis or if it's new onset diabetes, they're probably gonna be get admitted and be there for a few days.

SPEAKER_04 23:31

Probably, yeah, ICU as well. Yes. Well, uh so as we talk more about assessment, right, and trying to figure out what's gonna put a kid at risk for having sepsis. Well, the little tiny neonates, like we've talked about, they have an underdeveloped immune system, and even the blood-brain barrier is not quite right, they're gonna get a full workup when they get to the ER. Those kiddos can be very sick. Yeah, they're immunocompromised, like we talked about. Yep. Some of the kids we see are chronically ill too, and they're immunocompromised because of some of their medications that they're on. So being aware of some of these things with medical history is important. Uh some of these little kids have DKA. I mean, sorry, diabetes already, right? So an infection can actually trigger a more life-threatening problem of DKA commonly um that will be triggered by that. So those are things to be aware of, I think, the risks. Um I think uh there's um there's all sorts of different pediatric diseases that can increase the risk for that. But but I think overall, uh being aware of all of the history that we talked about, putting yourself in a position where you're not gonna miss a pediatric sept.

SPEAKER_01 24:36

Yeah, I think just putting I would again, if I went back five years ago, I probably wouldn't have sepsis on my differential going to a pediatric call. Yeah. Right? Because again, you're thinking more the older nursing home patient. That's gonna be, you know, as soon as I get a sick person call at a nursing home, that's like number one.

unknown 24:53

Yeah.

SPEAKER_01 24:53

Not not even on there with a kid. So it's one one of the things to change, have that on there, even go into a difficulty breathing or something like that. Hey, they could be septic. Yeah, you know, keep that in mind.

SPEAKER_04 25:03

And I think uh I think another risk factor is part of our assessment would be the fact that these little kids, because of their body surface area to mass ratio is being off, they're really uh kind of hindered as far as thermoregulation goes. Yeah, you and I can thermoregulate pretty easily, um but a little kiddo can't do it as well as not as efficient, yeah. Yeah, so that's another issue. But so um but I think if you're looking at a kid and you're trying to remember all this stuff, it could be a little overwhelming, but just remember the the the the triangle.

SPEAKER_02 25:36

Yeah.

SPEAKER_04 25:36

Uh pediatric assessment triangle uh really that's an easy thing to remember. A B C.

SPEAKER_01 25:41

Airway breathing circulation, right? Or appearance breathing circulation, sorry.

SPEAKER_04 25:44

Well it's like the A B Cer. No, you're right. I mean, I well that's all I think that's that's kind of plays in this too. Yes. Um, but you're right. So as far as the appearance, first thing we look at from the doorway, you're looking at the kiddo, a crying kid that's fighting you or the bomb, good sign. Yeah. Uh the tracking. I mean, what's I mean uh it's normal for a a toddler to be crying and fighting you, but you know, a tiny little baby or uh maybe an adolescent kid, you know, there's probably don't know the difference. Right.

SPEAKER_01 26:14

Yeah. But then you're looking at again cyanosis. Yeah. Are they nice and pink? Right? Do you heat what's their capri fill? Good. You know, definitely throw them on the SPO2, see what that is, right? Listen to lung sounds, right? Yep. Listen to their heart. Does their heart sound like it's ticking good? You know, again, remember your normal vital signs.

SPEAKER_04 26:32

Yep. And work and breathing with retractions. How hard are they? You can see that from the doorway too. Yep. And you said that color of the skin, perfusion. I mean, you can see that from the door. These are a lot of these things are not rocket science. Right. Uh just we just cannot forget to identify how understand how important it is to identify a a pediatric septic patient.

SPEAKER_01 26:51

So we get this kid, we figure out this is probably sepsis. Right? What are you doing for this kid?

SPEAKER_04 26:58

Well, I think the first thing, and I think one of the hardest things to do is like how sick are they? Do they really need an IV or not? Right. One of the cornerstones for treatment for us in the ambulance will be, you know, obviously, regardless of whether you're BLS or LS, but I mean, we need to we need to get them some fluids. These kiddos can get dehydrated pretty quick. So if you have a patient that you feel like you need to give them some IV fluids to help them to compensate, you're gonna they're gonna need an IV.

SPEAKER_01 27:26

Just get the IV. Yeah. Explain it to mom, dad, whoever's there. You know, hey, look, we've got to get this IV on this kid. Hands, in my experience, are gonna be probably your best bet on a kiddo. You know, usually AC, you might be able to get one. Those are kind of they're not gonna usually have the forearm veins. Depending on the kiddos, depending on the kiddo, yeah. Usually hands are the kind of the go-to spot. Make sure you board it because they might rip that thing out.

SPEAKER_04 27:49

And if you need to, we got the IO.

SPEAKER_01 27:51

We do have the IO. Yeah. That's gonna be like, okay, yeah, we need IV access now.

SPEAKER_04 27:56

I mean you're thinking these are those kids. I mean, even in I mean, if you're gonna go into cardiac arrest, and we've talked about this in some of our other lectures, the number one cause for cardiac arrest in kids is respiratory. Yeah. And uh, if you're in a situation where you've got that kind of a kid, yeah, yeah, don't don't hesitate.

SPEAKER_01 28:12

No. So it's better than waiting and working a cardiac arrest, yeah.

SPEAKER_04 28:16

Yeah, distal femur.

SPEAKER_01 28:17

I was gonna say, hopefully most protocols have distal femur, not tibbias anymore. Yeah. I would hope so. I mean, tibias, if that's all you can get, but you should be able to get a femur on a kid, no problem.

SPEAKER_04 28:26

So I think the fluids is big and knowing you know, follow your protocols for how much fluid to give. Um and uh there's there's all sorts of different, you know, thought processes on this. Yeah. Um, but uh a good rule of thumb, you know, if you if you if you look at the well, you actually it depends. If you've got Brozlow or Anthevi, you're gonna be able to get a pretty good idea of what they're gonna need. Right. Um and again, uh depending upon the size, because these are weight-based fluids, right? Ideal body weight. Right. You don't you're not throwing a leader on everybody.

SPEAKER_01 28:58

No, yeah, exactly. Exactly. Yeah, think remember your you know, your one, three, five, seven, nine, ten, fifteen, twenty, twenty-five, thirty. That's a quick down and dirty way to remember uh what the ideal body weight for a kid of that age is. And so, yeah, give them a fluid bolus, again, depending on their size. Give them a little bit of fluids, get them on some supplement supplemental oxygen, you know, maybe some n title, if you can get a little end title on there, see what their entitles at.

SPEAKER_04 29:24

That's really good.

SPEAKER_01 29:24

Yeah, that would be a helpful tool to have.

SPEAKER_04 29:27

And don't, and I would say as you're making these decisions in the ambulance and you're looking at a kiddo that's tachycardic, but the blood pressure is normal, that's compensation. Right. We've talked about that with adults where um oh well the blood pressure's still normal, so we're probably early in the shock progression. But with kids, because they can compensate for so long, if you see a kid that's that's hypotensive now, you're whoa, you're you're behind the eight ball. Right. So don't wait for hypotension. Yes. You know, you've got to use your clinical non you know, sense to know that this kiddo is not doing well and is going to need fluids. Give it to them before they're hypotensive.

SPEAKER_01 30:05

H times two plus seventy, remember that. Yep. What is it? Yeah, everybody says a little bit different, but yeah. You're not looking for a blood pressure of 120 over 80.

SPEAKER_04 30:13

No, you can't.

SPEAKER_01 30:14

Basically, if you have a pediatric patient and their blood pressure is less than 70, you've got issues.

SPEAKER_04 30:18

Right. Yeah. And then don't forget too about mental status. Um listen to mom when she tells you her child is not acting right. Yeah. They may not be able to talk to you and tell you who the president is or how many quarters are on a dollar, all these questions. We might ask for mental status, obviously. Um, but listening to mom, she'll know. Yeah. She'll know. And this is true, I think, too, with those um those chronically ill kiddos that they may be chronologically 12 years old, but you know, you know, developmentally, they're six months. Yeah. Uh, those those children too, they they can't communicate with you, yeah, but mom can.

SPEAKER_03 30:54

Yeah.

SPEAKER_04 30:54

And said, no. Normally Joey, when he's happy, he does this. He's not doing that. He eats five times a day.

SPEAKER_01 31:01

He hasn't eaten at all today. Yeah.

SPEAKER_04 31:02

And I think that it's we've had other talks on this, but when you have those uh uh chronically ill kids, uh depending on mom and dad and the the history that they give, that that's a huge part of it. But sometimes we tend to be really scared with these types of patients. Yeah. And then we immediately think, okay, let's get an IV, let's let's we're gonna have to, you know, get to the pediatric hospital.

SPEAKER_01 31:25

More often than not, I would say, let's just go. Yeah. Just let's just go to the hospital.

SPEAKER_04 31:29

Let's go. Yeah. But these kids talk to mom and dad. It's like they you'll hear from them, no, no, no, no. I think I think I think Joey's okay. I I've seen him much sicker. Uh it sounds to me like this could be another one of his ear infections, or you know, often you'd be surprised. Yeah. A chronically ill kid with a G tube can also have an ear infection. And so uh anyway, so we don't want to be just because they're chronically ill with a G tube or think this horrible thing. Exactly. So now we're gonna intubate them and put in the eye. Confirmation bias. Yeah. Yeah. Yeah. So I think that's that's important. Get a full history. I always carry them may need it.

SPEAKER_01 32:06

I always take mom with me, mom or dad. I always take them with me. Because too, you get that kid in the back of the ambulance without mom or dad, they're not gonna be very happy. No. So and mom and dad's probably not gonna be very happy that they're out with their kid. And I'm I'm when my kids are literal little, you're not transporting my kid without me. You know, I'm we're gonna be there. So it's always better to take mom and dad, obviously, you know, do that safely. Um, but take them with you. Keeps the kid calm. I, a lot of times, especially if it's a baby, I'll give mom, if they need supplemental oxygen, give her that non-rebreather. Hey, hold this up to their face, that blow buy. It gives mom a job, will kind of calm her down a little bit, and boy, they will be diligent about making sure that mask is right where it needs to be.

SPEAKER_04 32:44

I'm glad you brought that. You reminded me of something so important and so common with RSV. Yeah. We gotta keep these kids calm. Oh, yeah. You you you start to agitate them too much and do too much, it's gonna create a bunch of problems. Yeah. The faster that kiddo moves air, crying, getting freaked out, screaming, the worse the problem and the barking becomes. Yeah. But you keep them calm, moving the air relatively slow because they're with mom and mom's arms, you're you're gonna be able to uh get that transport safe.

SPEAKER_01 33:15

I would say that's the best way to do it no matter what, because obviously this is not a good day for the kid if they're riding to the hospital in an ambulance. So they're gonna be freaked out no matter what. So having mom or dad there, caregiver, whoever it is there is gonna help the situation. Right?

SPEAKER_04 33:30

The RSV situation is the only time as an R physician I don't like them freaking out, and I try to do everything I can to calm them down.

SPEAKER_01 33:37

Where most of the time Do you just tell them to calm down? Yeah, right.

SPEAKER_04 33:40

Calm down.

SPEAKER_01 33:41

That works so good with my wife.

SPEAKER_04 33:44

If they calm down, you know, it's it's helps so helpful with RSV. Yeah. Some of these other respiratory issues. But when it's most of the other things, when I see a crying kid, I'm like, let them fuss.

SPEAKER_01 33:55

Oh, yeah, let him scream. Right. Yeah.

SPEAKER_04 33:57

Not with RSV. Yeah, no at all. I like the call. Let's find a way to calm them down. Yeah. Uh and and get mom in there. Well, like you said, yeah. All that stuff. That's that's really important.

SPEAKER_01 34:06

All right. So we did assessment, talked a little bit about treatment. Uh-huh. Yep, we've been talking about fluids. When would you innovate? When would you make the decision to innovate one of these patients? Well, I think I think that now this is. There's some factors you'd look at, I guess.

SPEAKER_04 34:20

Yeah, I think uh, you know, being able to assess whether or not they're protecting their own airway. You know, you get a kiddo that's so lethargic they're just you know, just uh literally like a sack of potatoes.

SPEAKER_01 34:32

Almost totally unconscious.

SPEAKER_04 34:34

Yeah, you need to you need to take their airway. Let's get them resuscitated, and then you know, eventually they'll they'll gain the mental function.

SPEAKER_01 34:41

What do you mean get them resuscitated?

SPEAKER_04 34:43

Well, go go deeper. Well, there's well, we go really deep on that.

SPEAKER_01 34:47

Well, yeah, but I mean I think that's important for people that have the ability for departments or agencies that have the ability to RSI and take patients' airways. I think it's very important to understand it's not all about like resuscitate before you intubate. And especially these kids.

SPEAKER_04 35:02

Yes.

SPEAKER_01 35:02

They can code on you very quickly if you don't resuscitate.

SPEAKER_04 35:06

Yeah, that's right. If you want to have a post-intubation collapse, then yeah, you don't want to you don't want to mess with that.

SPEAKER_01 35:16

And SPO2, gotta get those sats up. Don't really want to be satting a kid that's or you don't want to be tubing a kid that's in the 80s.

SPEAKER_04 35:23

No.

SPEAKER_01 35:24

Gotta get those sats up.

SPEAKER_04 35:25

That's good. Resuscitate before you intubate. Yeah, thank you. That's good. And I think uh another common thing as we're managing these kids is that this isn't a load and go situation. I think it's important. I mean, we gotta we're gonna be transporting these kids, but do what you need to do now. You know, especially with the some of the things that that we need to do in the ER, we can do it here. Getting it done quicker is better for those kids.

SPEAKER_01 35:49

I think it depends too on where you're at, you know. Like if you're in a rural environment, because we always say, you know, you and I work in a kind of an urban area, right, where we're ten minutes from four different hospitals, right?

SPEAKER_04 36:00

That's true.

SPEAKER_01 36:01

But if you're out in the middle of Wyoming Let's get started.

SPEAKER_04 36:04

Yeah. Maybe in a helicopter.

SPEAKER_01 36:05

Or in a helicopter, yeah, and you've got an hour-long flight back to the children's center in wherever, yeah, you know, you need to get going.

SPEAKER_03 36:14

Yeah.

SPEAKER_01 36:14

Excuse me, because time is of the essence. And you can do these interventions en route. You need to be able to start an IV in route. You can get fluids in route, pressers in route. You know, hopefully you're not innovating in route, but yeah, I mean, it definitely depends on your location. If you're an hour out from that facility, obviously, if your kid's that unstable that you're taking an airway, I would assume your protocols tell you to go to the closest facility. Because even a small ER with a one physician and a nurse has more capabilities than we have in the back of an ambulance.

SPEAKER_03 36:43

Correct.

SPEAKER_01 36:43

And so take them to anywhere, uh, especially even in you're not moving, you're not in the back of a moving ambulance. You're in a stable, somewhat stable environment. They can get them tubed, they can get them stabilized, and you know, maybe fly them out if that's what's called for. So I think we always say like load and go or stay and play. There's different ways to say that. Really, a lot of that depends on where you're at. Yeah, if you're five minutes from a hospital, yeah, stay, get that IV, make sure you get your best opportunity. If you need to tube the kid, get the fluids, all that kind of stuff, and then start heading to the hospital because you're close. You got an hour-long transport, we don't we don't have that time. I can't spend 20 minutes on scene and then drive for an hour.

SPEAKER_04 37:21

That's true. And I think a lot of times crews, uh I think, and I've I've felt it before even in the ER. You just kind of want to get them out of the ER quickly. You want to get them out of your ambulance. Exactly.

SPEAKER_01 37:31

Yeah, I want to get out of here. This is not comfortable.

SPEAKER_04 37:33

But there are sometimes, especially I think more with cardiac arrest, which we're not really talking about today. Right. Is it's important to get that stuff done.

SPEAKER_01 37:40

Well, a cardiac arrest is different because there's nothing that you're gonna do in the hospital for that kid that I can't do. I mean, as a paramedic, right, that I can't do. There's same meds, all that kind of stuff. I can innovat, all that. So we know that working that problem on scene is better for the kid. Right. But when you've got a sick kid that needs antibiotics or whatever they need, you know, ventilatory stuff. You can do that enough. You can do a lot of that in a yeah, yeah, if your protocols allow you to.

SPEAKER_04 38:04

Yeah. And I think deciding how to transport to, you mentioned the helicopter. I mean, that you've got to that's a tough decision to make. Uh what when do I pull the trigger for this? I know for me, and the way that I've trained up our guys, uh, and and some of the places I'm medical director are really out there with in an hour-long transport's not uncommon.

SPEAKER_03 38:21

Yeah.

SPEAKER_04 38:21

And making that decision on whether or not we fly can take some thought. And sometimes they'll call for online medical control. Well, and I encourage them too, said if you're not sure, call me. Um call them.

SPEAKER_05 38:32

Yeah.

SPEAKER_04 38:33

Um so call the helicopter or call you? Call me. Yeah. Yeah, call me and then we make the decision together. Yeah. Yeah. And uh and if they did call a helicopter and they were wrong, I'll there's usually like we've talked about before, there's a context to this. There's a a decision that was made for a reason.

SPEAKER_01 38:49

You were doing the right thing for your patients. Yeah, do something for a reason. Never wrong in that.

SPEAKER_04 38:53

Yeah. So just don't do it because you're scared.

SPEAKER_01 38:55

Yeah, yeah, exactly. That's not a valid fear. We think that this kid needs to get to this facility quicker. That's the quickest way to do it. That's why we call the helicopter.

SPEAKER_04 39:02

Yeah. Done. So uh before we go over some common cases, uh, I thought it would be good to mention, too, one of the common problems, and again, difficulties with managing pediatric kiddos, is the the dosing errors. Because these meds that we treat with, whatever medication, like if it was a seizure or something or whatever, I mean, we're gonna be giving it medications. We've got to measure them out by weight with dose meds. This is when it becomes all the more important to do things correctly. Yes. That's where Antivi comes in, right?

SPEAKER_01 39:34

With the Yes, I we are not sponsored at all. We are friends with Dr. Antivi, uh, but we are not compensated in any way, uh, which is totally fine. But yeah, uh, that app is a phenomenal app, takes all the guesswork out of it. That's the whole reason why he created it. Um, and it just works fantastic. It's just a fantastic app. I can't promote that app enough, and I'll promote it for free till the day that I die. Because it truly, my paramedics are like, this is the greatest thing we've ever gotten. Yeah, I've used it, I love it. It just works.

SPEAKER_04 40:06

It takes something off like we said, the checklist.

SPEAKER_01 40:08

The fear that's gone. Yeah, the fear is gone. The fear of making a mistake. Yeah, yeah.

SPEAKER_04 40:12

It's like that's okay. I I can put my mental energy into these things. Yes. Right? I don't have to worry about the math here.

SPEAKER_01 40:18

But if you don't have hand heavy, let me give you a down and dirty way of drug calculations. Let's see. I am not a math guy, you're a brilliant math guy, my dad's a brilliant math guy, my father-in-law's, I'm surrounded by brilliant math people, and I can hardly spell math. So it's it's simple, right? You figure out the weight in kilos. Yeah. Okay, you figure that weight out, and then you take your desired dose over your volume on hand. Okay, Matt, what do you mean? Okay, what's my desired dose? I need, and I'll tell you exactly the call that I went on with this. Went on a call, a pediatric seizure call, showed up. Because it was an 18-month-old, everybody automatically went into it's got to be febro, right? So the uh the trucker, whatever it was, got there first. We showed up on the ambulance afterwards, and one of the medics is holding the kid, getting drawing a bath, getting ready to put this kid in a cooling bath, and I'm thinking, okay, it was febrile. I said, What was the temp? It was 98. Uh, did did the kid have a fever beforehand? Like, was there a nope? I'm like, okay, well then this isn't febrile. The kid is having another, it's not a febrile seizure, right? We need some benzos. Yeah, we gotta get this kid some meds, right? So again, got confirmation bias, got anchored on this, so got the kid out to the med unit, kid starts seizing. I never had an 18-month-old seize on me before. Now I gotta figure out, oh crap, how much Versaid do I draw up? Because that was the drug that we used at the time. And now I'm having to do math. And now I'm scared because I don't like math. And how much does the kid weigh? And oh my, okay. And I had in nursing school, I had a nurse break this down. This is very simple. So your desired dose is whatever your dose is, you do the mil the kilograms, whatever your protocol calls for, right? So let's say your dose is five milligrams, you know, uh, that you need to give to the kid, okay, based on your protocols. And then let's say that you have versed and it's 10 milligrams in two mls. It doesn't matter what the medication is, figure the concentration down to one ml. How many milligrams, micrograms, grams, or whatever it is per ml? Figure it down to one ml. So if you've got 10 and 2, that means you've got five and one, right? Five milligrams per ml, right? So then you just take my desired dose is five milligrams divided by the volume on hand, which is five, right? Five divided by five gives you one. I need to give one ml. Because at the end of the day, it doesn't matter what my dose is, I need to know how much do I need to draw up.

SPEAKER_03 42:41

Yeah.

SPEAKER_01 42:41

I can figure out the dose, I still need to know how much to draw up, right? So it doesn't, you take any number. If the kid needs three, three divided by five, that'll tell you the volume you need to draw. 1.2 milligrams, 1.2 divided by 5. That'll tell you the volume you need to draw up. You can do that on your, pull out your phone, figure out your dose, figure out the concentration down to 1 ml, plug the desired dose into the volume on hand, that'll tell you the volume you need to draw up every single time. As soon as I found that out, I was wanting to smack my paramedical instructors like, why didn't you teach us this from day one? Like dimensional analysis and all this. Like, what are we doing? Teach us this easy stuff. So hopefully you have an app like Hand Heavy, and Brazlo will tell you the dose, you know, per the weight.

SPEAKER_04 43:24

By height, actually. By height, yes.

SPEAKER_01 43:26

It'll still but it'll tell you how much you need to, but it'll just tell you the milligram dose. So you take that dose, get your concentration out, figure out how much you got per ml, do the math, and you're good. And it takes the scariness out of it.

SPEAKER_04 43:39

And that's what I like about Peter's system. And it's already prefigured. This is done. It's done. Uh Brozlow, they've compared the weight-based versus height-based. It's no statistical difference. Uh there may be some new studies out now that show that Peter stuff is better. I don't know. But it's better in my opinion. Yeah, I agree too. And and and with your hand, you've got hands. Yes. It's another just a Beautiful part of the system.

SPEAKER_01 44:01

Yeah, it's very simple.

SPEAKER_04 44:02

Yeah. So anyway, so I think that's something to consider when you have that pediatric kiddo, have a plan. Yep. Be familiar with the other thing.

SPEAKER_01 44:09

Yeah, be thinking about those dosages beforehand. Okay, we've got, you know, your notes will probably tell you it's a one-year-old, a three-year-old, or whatever. Okay, be thinking. Okay, if we got to give this kid Epi, if we got to give this kid verset or Adavan or whatever, right? What's my dose? Like, be ready for the worst case scenario on this kid. They start seasoning. Here's my dose. Boom. I can give it right away. Especially if you're given an IM dose.

SPEAKER_04 44:30

Yeah.

SPEAKER_01 44:30

You've got it ready.

SPEAKER_04 44:31

Absolutely. That's easy. Sorry, I'll get off my soapbox. I think that's a big part, and that's again why I think uh we're at risk for mistakes and causing harm. Because you're scared to the math. Yeah, you're scared.

SPEAKER_01 44:43

You can reduce fear through education.

SPEAKER_04 44:45

And it's one of those low frequency, high-risk type patients. So it's that's important.

SPEAKER_01 44:50

Reduce your fear through education.

SPEAKER_04 44:52

I don't think there's a lot more as far as treatment goes. I mean, if you guys uh if you're if you can use antibiotics, that could be something you can give. Yep. Um fluids, pressors if you need to control the airway. Airway support too. There's some other things you can do, supplemental oxygen. Yeah. But um and then transport to the appropriate facility.

SPEAKER_01 45:13

If you gotta and resuscitate before, you know, you got that patient that's maybe a little bit difficult to get their sats up with. You know, remember, these kids are breathing fast enough. They just need it's not a ventilation problem, it's an oxygenation problem, right? Yeah. So get that supplemental oxygen going, get a high flow, you know, nasal cannula on them, depending on the age of the kid. You know, give them a lot of oxygen, get that nitrogen washout on those kids is gonna buy you time when you go to tube these kiddos.

SPEAKER_04 45:38

Yeah. And I don't think we could say it enough how the pitfall of just thinking the kid looks okay. They look okay, well, they'll be fine. You know, they they will crump on you fast. Yes.

SPEAKER_01 45:48

Oh, their heart rate's fine, their blood pressure's fine. Yeah, now wait five minutes. Might not be. Yeah. So be ready for that crumping kid.

SPEAKER_04 45:56

So I think uh I think one of the common cases, I think one of the most common ones for me, I would say maybe that toddler that's been sick for a while, been in and out of urgent cares in the middle of the night, um you know, is not acting right, um, and they mom calls 911 and then brings them in to me right at two in the morning or whatever. So you're the paramedic on scene, you see this two-year-old sticking his head in the freezer, it's croup. Well, actually, it's funny that sometimes these kids look so sick at home. I've seen them, my kids have been that way. Yeah. You get them into the outside in the cold air and things. They feel they feel better. Yeah. But you get this kiddo, um, again, uh a very sick kid. The first thing you're gonna do is that pediatric assessment triangle, right? You're gonna get a good history, obviously, while maybe working together with your team. But what what does the what does the kiddo look like? What's the appearance? As you look at him, wow, this kid doesn't look right. They look like they're just limp in mom's arms. Right. I in fact, not too long ago in the hospital I had a mom just brought in a three-year-old just limp in her arms, totally unresponsive.

SPEAKER_01 47:02

That's lovely.

SPEAKER_04 47:03

Like you don't know like what is this, right?

SPEAKER_01 47:05

Yeah, is this did they get into something? Is this an overdose? We Christmas Day, I was on shift. Uh-huh. And we had brought in the entire Lord of the Rings trilogy. Yes, I'm a Lord of the Rings nerd. I don't care. I love that movie. I do too. It's my favorite, it's my favorite movie trilogy of all.

SPEAKER_04 47:21

That sound, anytime they talk about the Shire, that music they play. Oh, yeah. This makes me feel like that.

SPEAKER_01 47:26

I actually listened to that on YouTube.

SPEAKER_04 47:28

Oh, yeah.

SPEAKER_01 47:28

They actually have anyway, calling me down totally geeking it. It's very, it's very soothing. Anyway. Did you ever read the books? I have read the books, yeah. Tolkien, yeah. Yeah. I have one of a Tolkien quote tattooed on me.

SPEAKER_04 47:41

How did I not know this?

SPEAKER_01 47:42

Yeah, not all who wander are lost. Oh, yeah. Yeah, it's that is a Tolkien quote from the Lord of the Rings. That is fair.

SPEAKER_04 47:49

Anyway, so uh We should do a podcast just on Lord of the Rings. I love those movies.

SPEAKER_01 47:54

Let's do it. Um, Christmas Day, we were on shift. It was a slip, but I had brought in the Lord that we had planned. We were gonna eat good, we were gonna watch movies as much as we could. If we didn't get any calls, you know, it's hit or miss. I've worked Christmases where we're just running nonstop, and then this Christmas happened to be relatively slow. Actually, it was very slow. We were watching these movies afternoon. We're sitting there fat and happy, a bunch of firemen, Christmas Day watching a movie, and the doorbell at the fire station rings. And so we're thinking it's somebody to come by, you know, because people will come by, bring us treats or whatever. And I remember I walked around to the door and I looked through the window into our vestibule, and I see this guy holding this lifeless kid in his arms. Oh, the kid was like he was like maybe five or six, he wasn't a baby. And I just thought, I mean, the kid looked dead. And I just thought, oh dear God, please, no, not a dead kid on Christmas. Yeah, please, we don't not for this family, not for us, not for anybody. And he was a post dictal, he had had a seizure. Okay, and they lived very close, so they got freaked out. That's what that three-year-old was in the ER. Save me. Yeah, yeah. Sorry, but no, it just I'll never forget that call because I'll never forget the mind. As soon as I turned the corner, I saw this guy holding this kid. I thought that I thought the kid was dead. And I just thought, oh God, please, not on Christmas. Please don't do that to us. That's that would be terrible. Luckily, it was just a seizure, kid was fine.

SPEAKER_04 49:14

But the the the three-year-old patient that I mentioned earlier, those are those patients banging on the ambulance bay doors. Right.

SPEAKER_01 49:20

Yeah, freaking out.

SPEAKER_04 49:21

There's always something interesting that's coming in.

SPEAKER_01 49:23

At two in the morning, especially. Yeah. Yeah.

SPEAKER_04 49:26

So that so you're seeing the sick kid, you could go through your pediatric assessment trial, you're looking at the appearance of the kid, you're looking at the work of breathing, you're looking at their perfusion, looking at the skin. Is it modeled? You know, anyway. I think that's so important, that first step. Stay calm. Yes, that's a big key.

SPEAKER_01 49:44

Stay you're gonna be freaking out. Take a breath. Yeah, you start freaking out, everybody else around you're gonna freak out, act like you've been there before. Mom and dad are certainly gonna start freaking out. Yeah, reassure mom and dad. Now we're gonna get we have our visual assessment on this kid. Now we're going to mom or dad, whoever the case here is. Yes.

SPEAKER_04 50:02

What's going on? And while you're getting history, your partner's getting some vitals. We want to gather information. Get some information.

SPEAKER_01 50:08

As much as you can. Blood sugar. Get them on the heart rate monitor if you can. Get the temp. Listen to lung sounds. Get the temp. Get a rectal temp if you can, if it's appropriate, right? But talk to mom. Mom, how long is this going to go on? Check the fontanelles that on the peeds. How long has this been going on? Oh, just, you know, whatever, a couple days. Have they had a fever? Okay. Have you been giving meds for the fever? Have they ever had this before? Do they have any medical problems? Are they diabetic?

SPEAKER_04 50:33

What's the urine output? How many wet diapers? How are they feeding? Are they vaccinated? All these questions. Once you get a good history and a good assessment, a good physical exam, then you can move forward and think and even discuss with your team, right? Well, why don't we work on getting some IV access? This looks like one of those kids that's going to need some fluids. This kiddo's sick. Um or maybe they're not so sick, right? No IV guys, let's load, let's get them to the hospital as quick as we can. Do you know what a beer troll is?

SPEAKER_01 51:01

Go ahead. Do you know what a beer troll set is? No. Yeah, that's I didn't know either. That's we were talking earlier about fluid boluses on kids. That's what you use to give the appropriate uh the appropriate amount of fluids to the kids. A little beer troll set you hook up to your IV bag. Yeah, we did a video on it, or I did a video on it one time, but a lot of people have those. We have them in the ambulance. And I'm sure the nurses, right? Because as the doctor, you're probably not setting up the beer troll set, but um, but yeah, that a lot of people when I remember going through an ambulance like, what the heck is this thing do? And that's what it's for. You fill up the appropriate amount of fluids and it drips that much.

SPEAKER_04 51:31

Yeah.

unknown 51:32

Yeah.

SPEAKER_04 51:32

When we get a sick kid in the ER dropped on a trauma bay somewhere and just undifferentiated, mom's standing in the back of the room freaked out, she doesn't know what's going on. We'll get history from her, of course. But I think I think just staying calm and remember we've got to gather information. Now, if you're in a situation with you clearly see an airway emergency potential, gotta deal with that first. Deal with that first. But but gather information. Um and if it is that pediatric seizure patient, right? If you don't get that history, you might be intubating somebody that was in 20 minutes would have been totally normal. Correct. So anyway, it's it's a tough situation to be in. Yeah. But with pediatric sepsis in particular, like the case we started, being able to get the information in a calm manner, confident, right? You're gonna you're gonna be able to appropriately treat that kid, transport them to the appropriate facility where they can get what they need.

SPEAKER_05 52:23

Yep.

SPEAKER_04 52:24

Um the problems are is when we don't identify these things and we see, and I've been a victim of this too, uh, where you see a kid that's breathing fast and you think it's a panic attack, or it's this 10-year-old kid at school, they got to be like, Those little neonate babies having a panic attack. I was on a call with uh with our our firefighters. We had a a call to local middle school. I can't remember how old this kid was, maybe twelve or something like that, and she was just freaking out, right? And breathing fast, non-cooperative, just looked really, really sick. Um, that same patient could be a panic attack or it could be flora DKA. I mean, it could be a lot of things.

SPEAKER_03 53:03

Thyroid storm.

SPEAKER_04 53:04

Yes. Yeah, well, hopefully not. But yeah, no, you're right though. I mean, it could be a lot of things. Yeah. Keeping the blinders off, yeah, right? Uh really keep your mind off.

SPEAKER_01 53:14

Get as much information as you can get, right? Obviously, we're limited on the amount of diagnostic tools we have in the back of an ambulance, but again, check a blood sugar, check a temperature, get a blood pressure, get a heart rate, listen to lung sounds, like do all these things. Get as much history as you can from mom. Look the kid over head to toe, see if there's anything there. Heck, it might be a hair tourniquet. You never know.

SPEAKER_02 53:35

That's right.

SPEAKER_01 53:36

You know, we actually had recently had a pediatric case in. Did you because we just talked about this? Did you get one? A hair tourniquet? No, we didn't. I did not get one, but it was in my differential. Yeah, well, we've talked about it several times before. But it was that and it was actually one of my medics that brought it up to me. Was it because the kid was crying like kind of unconsolable, right? Yeah, yeah. And he looked at me and he was like, Have you thought about it? Have you looked for a hair tourniquet? And I was like, No, but because we had just got there, whatever. But I was like so proud of him because he had said that. I was like, There's not many paramedics that know about that. He and he he knew it because of I think it was his son or something who had one, and so now he had that experience stuck in his brain. Unconsolable kid.

SPEAKER_04 54:16

Oh, that's cool.

SPEAKER_01 54:17

Check everywhere, that's all I'll say.

SPEAKER_04 54:19

Look at the pants and look at the feet. Yep. Yeah, that's uh well, so I think the key takeaways today. This is a tough patient sometimes and easily to miss, and and there are the things that we do in the hospital, uh sorry, in the ambulance matter, especially with pediatric sepsis patients. Yeah. And then the transport decisions we make matter. All these things matter. Yep. Uh but I think the key takeaways, uh I don't know if I'm I'm imagining I'm talking to my all my FTOs right now. Like, what would I want them to know? Or if you're a new paramedic or EMT, what would I want you to know? Well, uh, how important the vitals are. I mean uh well actually your assessment. The assessment first. The whole assessment history is huge. Understanding that the uh the vitals on kids are different at different ages, but understanding how important it is to recognize when things aren't right. Yeah, because if the blood pressure is off, you're behind the eight ball.

SPEAKER_02 55:10

Yeah.

SPEAKER_04 55:10

Tachycardia is so important. Yes. And understanding that too. And then I think uh not only is blood pressure a late sign, but then just to remember too, is it early recognition of sepsis? And this is universal. Early recognition is what saves lives. That's what decreases mortality. Yep. Is delayed recognition is what kills people. That's right, especially little kids.

SPEAKER_01 55:31

Yeah, add it to your differential, have it on there when you're going on these calls. So good topic.

SPEAKER_03 55:37

Be safe out there.

SPEAKER_01 55:38

See you on the next one. Wait, we did that backwards. You did the basket? Oh well. Doesn't matter next time. That was fun.

SPEAKER_00 55:48

Thank you for listening to EMS, the Eric and Matt Show.