EMS: Erik & Matt Show
After hours style conversation focused on the hidden and often overlooked parts of first responder life. Discussing everything from continuing education and home life to health and wellness.
EMS: Erik & Matt Show
Immunocompromised Patients Podcast
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In this episode of the Erick and Matt Show (EMS) we discuss the immunocompromised patient. These are very common patients, and they can have mortality rates as high as some of the worst trauma patients. We will discuss how to recognize and manage these high-risk patients.
That's a good way to put it. Yeah, getting sepsis is almost as deadly as getting shot in the head.
SPEAKER_01These immunocompromised patients are at increased risk over the general population.
SPEAKER_00You are listening to EMS. With your hosts, Eric XC and Matt Ball.
SPEAKER_02Well, Enrique?
SPEAKER_00Yes.
SPEAKER_02Mateo. Mateo?
SPEAKER_01Is that? Yeah, yeah, yeah. A lot of the folks that I've met from Mexico, they've called me Eddie. Eddie? Eddie. Eddie? Eddie. That's what I'm saying. Really? Yeah, I don't understand it, but actually this this is.
SPEAKER_02I mean, I would think Enrique would be Eric in Spanish. I would think. I don't know.
SPEAKER_01Oh, well I just when I say Eric, they say Eddie. Oh really? I guess. I mean I I I know in Scandinavia my name came from the the name Harry.
SPEAKER_02Eric came from Harry?
SPEAKER_01Yeah, that's the that's the origin of the name Eric.
SPEAKER_02Well, how do you say it in Scandinavian?
SPEAKER_01Oh, I don't even know.
SPEAKER_02Oh, maybe that's it. I'm 100% Swedish. I can't speak Swedish. I've never even been to Sweden. I do have some people that were missionaries in Sweden and speak fluent whatever Swedish. They would always do that when they didn't want anybody else to know what they were saying. It was a couple, and they would always, you know, and it yeah, it's an interesting language.
SPEAKER_01We have a language we speak when we don't want people to know what we're saying. Uh it's like a the family kind of a thing. You have your own. It's kind of like pig Latin in some ways, but it's not Pig Latin at all.
SPEAKER_02Well, there's that case. I don't know if you've seen that documentary on Netflix about that girl, the crash.
SPEAKER_03Yeah.
SPEAKER_02And then her and her mom apparently speak some form of they call it carny language, which apparently it's actually a thing. Really? That they call it Carney language, but they on their like phone calls and stuff, apparently they'd use this language, and she did it like when the police were interviewing her, she started talking to her mom in this weird pig Latin-y kind of language, and everybody was trying to, what is this language? And then somebody finally like, Oh, it's actually like Carney language. Interesting. So, how did you guys come up with that?
SPEAKER_01Well, it's I it's actually something I brought into the family. My friends and I, a lot of my college friends played baseball, okay, and they had this language they used that they would talk to each other. So the person standing on first base had no idea what the first baseman was saying to the pitcher. Because he would speak in this other language where you kind of just mix up the consonants and vowels and whatever. So we have that. We'd we uh taught the taught the family. Eventually the kids picked up on it from mom and I talking, right? Dev and I we would talk and then Well, she speaks Canadian. That's true, she does. That's her second language. But the kids started to learn it, they got so smart. That's funny. Now the kids speak it better than anybody. Really? And I can't keep up. Yeah.
SPEAKER_02That's I wonder how close that is to like that Carney language thing.
SPEAKER_01Yeah, you basically uh it's uh we called it ears language, is what we would call it. And so you'd say uh um ears-eye, ears have, ears ab, ears I whatever. That's it.
SPEAKER_02That sounds exactly like what they were doing.
SPEAKER_01Oh yeah, yeah. So it's if you when you hear it, it's like uh like if I said um uh I'm hungry would be ears I, ears am, ears on greerzy. So you it's hard to when you know it's a good thing. But when you start to talk fast, you you'll get lost and you won't be able to understand it.
SPEAKER_02That sounds very similar to the language they were talking, so I wonder if it's the same thing.
SPEAKER_01Yeah, I wonder if it is. That's interesting. Well, you know uh we are way off topic. It's okay. It's okay. You know, we're we're um so we're gonna talk about a population of patients today that that uh are pretty common. In fact, a lot of people may not fully appreciate how common they are, this immunocompromised patient population. If you do a Google search for it, they'll about six to seven percent of patients six to seven. That's right. Is that why you did that? Yeah, the number's actually six point six. Yeah. Six point six percent of Americans are uh considered immunocompromised. But that's not true though. Uh about twenty percent of Americans are elderly, which would be immunocompromised by their advanced age. The young. And the young, another population. You got you can add dialysis patients to this, you can add patients who are septic, you can't.
SPEAKER_02Yeah, what's their criteria for calling somebody immunocompromised?
SPEAKER_01I think this would be somebody with a condition that makes them chronically immunocompromised. Yeah, transplant patients. We'll talk about them later, but it's actually a lot more common. And uh and in some of the research we done, I thought it was interesting that I uh see if you can figure this out. Okay. What state in the United States has the most elderly patients or the highest population of elderly patients? What state?
SPEAKER_02Who I percentage wise. Percentage-wise. I would think probably Florida, a big high retirement area.
SPEAKER_01Absolutely agree with you. That's exactly the first place I went.
SPEAKER_02Did I get it?
SPEAKER_01That's not it. It's not Florida. It's not Florida.
SPEAKER_02Do I get a second guess?
SPEAKER_01Yeah, give a second guess. See if you can get one of the three states that were ahead of Florida. Okay. None of them I would have predicted. So Florida's the top five. I would even think maybe Texas because the weather's here. Yeah, a lot of people warm. It's not that.
SPEAKER_02All right, I'm lost. I only get two.
SPEAKER_01Number one was Maine. Really? Number two is West Virginia, and number three was Vermont.
SPEAKER_02Oh, so it's just a percentage. So those are smaller states.
SPEAKER_01Yeah, there may be more elderly people in Florida. Right, but it's based on the percentage of gross population. Yeah. It surprised me because I thought I would have thought, yeah.
SPEAKER_02Florida. Warmer states, not those are all northern states.
SPEAKER_01Yeah, that's interesting. I didn't think about it from that standpoint, but yeah, that's interesting.
SPEAKER_02But I do have family that live in the Northeast, and people from the Northeast do not leave the Northeast.
SPEAKER_01Yeah.
SPEAKER_02They stay there.
SPEAKER_01So this immunocompromised patient population is huge. So why does it matter to us in EMS?
SPEAKER_02Well, because uh it goes along with one of the most risky patients that we s oftentimes take for granted because it's not the sexy patient, and that is the septic patient. Septic patient. That we sometimes, again, we take it for granted, people, oh, this isn't that big of a deal. You know, they kind of downplay the importance, but extremely high mortality rates, especially in immunocompromised patients.
SPEAKER_01In fact, you and I are preparing for we're doing a uh we're uh speakers up in Boston soon, uh well relatively soon, Boston. Yeah. And one of the topics they requested that we covered was sepsis. Yeah. And so in preparation for that, we learned some very interesting things. There's nothing more deadly in the hospital than sepsis, and there's nothing that costs the hospital more than sepsis.
SPEAKER_02And what are most patients in the hospital, whether it's permanently or temporarily, they're all immunocompromised. Probably first the majority of them are right. They are sick or they just had a surgery or whatever it is.
SPEAKER_01Yeah, being sick uh can make you immune. Yeah, all those, you're absolutely right. So it's uh this is a real important uh patient population for us to be aware of. And it I think it can the reason why we thought this would be a good podcast is that uh or at least the good content for our uh curriculum like you can watch this for CEs. Uh is that a patient population like this can be missed if you don't get uh the a thorough history. And if you miss it, you could potentially cause harm to these patients because it's been shown in literature that early identification, early treatment saves lives.
SPEAKER_02And I think that it's very uh complacency is the problem here because these are you know the older people, which is the majority of the patients that we go on, the falls, the sick people, the nursing home calls, and you go, Oh, we're going back to the nursing home again for the third time today, and I get it. But at the same time, these can also be some of the patients that are most at risk. And that we could have the again, it's not gonna be the cool trauma, or we're not gonna be activating the STEMI or you know, something like that. But we could have a dramatic impact on patient outcomes with this patient population. So it's very important that we understand it.
SPEAKER_01Yep, the the elderly population is super susceptible to these things, and that's why we're talking about so being immunocompromised, um, you know, as the name implies, you've got a compromised immune system, and the immune system's our defense. Yes. So for some reason, soldiers. That's right. Yeah. It's kind of like leaving your doors unlocked at night or your your your security systems failed. Yeah, your gun's not loaded. Nothing more useless than an unloaded gun. That's right. Anyway, yeah, so uh that's a I think a good analogy for for an immunocompromised patient would be like you uh, you know, not having a security system or leaving your car doors unlocked or open.
SPEAKER_02Yeah, you're leaving yourself, you know, in my neighborhood, the police, which I'm very thankful for actually, I live in a smaller town, and so the police will actually drive through our neighborhoods at night, and I've actually got they will actually go drive around through the neighborhoods, and if your garage door is left open, they will kind of come in and they'll leave you a note on your car saying, Hey, we stop by at three o'clock this morning, and they will actually check door handles and say, like, hey, your car door handles. And so I mean, first off, it's nice that they have a presence in the neighborhood, and it's also nice, and I like to pass that along to my wife and daughters and say, See, lock your doors anyway.
SPEAKER_01Well, those police officers, uh law enforcement, it's it's like those white blood cells. They're circulating through our blood just like those sensors are circulating through our community stuff out. It's a great analogy that you just brought up. And so a patient, yeah. A patient could have uh a neutropenic condition or a condition where they don't have a lot of white blood cells, which makes them immunocompromised. That's right. You know, uh the elderly population is immunocompromised for a lot of different reasons. Right. Chronic conditions, medications, age, age stage alone.
SPEAKER_02Yeah, their systems don't work as efficiently as they used to. Yeah.
SPEAKER_01That's right. So um and then of course, on the flip side, super young, uh, they're gonna have an immature immune system. Part of what our immune system depends upon is being primed and exposed to things so we can uh develop uh a robust immune response that would defend us from uh potential invaders.
SPEAKER_02That's why it's good to let your kids have a fever, folks. If you're a young parent, don't throw them on antibiotics all the time, let them build up an immunity.
SPEAKER_01That's right. Yeah, letting the body fight off an infection is important. Yeah, it's that's the way we're designed.
SPEAKER_02I mean, it's it's the yeah, exactly. Anyway, I was gonna go off on another topic. But yeah, you gotta let them fight a little bit. A little bit of a fever is not a bad thing. That means the body's doing what it's supposed to do, right? The immunocompromised patient's not gonna have that defense system, so you should actually be thankful that your body's working properly and that you do have a fever because that tells you my immune system is working, and you don't want to suppress it by constantly taking antibiotics. Sorry, I don't know.
SPEAKER_01Now there are some conditions. No, it's good, uh, but there are some conditions where a regularly functioning immune system can be harmful to you. Correct. Sometimes people have an immune system that's ramped up, like with rheumatoid arthritis, an inflammatory con inflammatory condition. So we will take medications to ramp down the inflammatory response just so we're not flared up all the time. By doing that, though, you are opening yourself up, you're immunocompromised. And that's why on those commercials, oftentimes, they'll say, you know, at a million miles an hour, you know, the risks at the end of things and all the side effects of this medication. And oftentimes they'll recommend do not take if you have tuberculosis or had turbulence.
SPEAKER_02Or they'll say do not take if you're immunocompromised.
SPEAKER_01That's right.
SPEAKER_02Another big risk. Yeah, exactly.
SPEAKER_01So that's what immunocompromised means. You've you've got your defense mechanisms are down, and there are a lot of reasons why you can have a defense mechanism that's down. You know, there are a lot of I mean, our skin, for example. Um, our skin is part of our defense mechanism. Yeah, there are different levels of immunity. Largest organ in the body. Largest organ in the body. You have a you've got a large wound, or you've you're you've got a skin condition, a burn, or whatever, that can make you susceptible to infections. Um you know, even um, you know, the you you start getting down into the cells, you have a blood problem, you that that's gonna limit your ability to fight off infections because of that. And you know, you're you're malnourished. I mean, there's a lot of different reasons why pathophysiologically you could be hampering your immune system, putting you at risk for an infection, which again, like we talked about before, um, can have a really high mortality rate.
SPEAKER_03Yeah.
SPEAKER_01And we've talked about this, I think, uh, but do you know how high the mortality rate of multi-organ dysfunction syndrome is in the hospital? Oh gosh. I wouldn't expect you to know this. I would say between twenty and thirty percent. And clinically it doesn't really even matter, but it's size eighty, actually.
SPEAKER_02Oh, eighty. Wow, wow. So that's what I meant. There was eighty percent.
SPEAKER_01Yeah, of course. Well, well, you're right, though. The most run-of-the-mill sepsis patients don't have an eighty percent mortality rate. Right. This is that patient I'm intubating. All the organ systems are failing, they're bleeding from every hole in their body, they're in DIC. These patients have a clarify that.
SPEAKER_02I would have gone higher than twenty percent. I thought you meant overall septic patients.
SPEAKER_01By the way, what's the mortality rate of a shark bite, for example? Like what's what are the chances of getting.
SPEAKER_02Oh, I remember this. I I remember this from our trauma lecture. Uh the mortality rate from a shark bite, I would say 10%.
SPEAKER_01Yeah, it's really, really low. Super low. Lower than that even.
SPEAKER_02I know the fall from 60 feet, that was 100% mortality. That was the worst. Good, yeah, good memory.
SPEAKER_01I'm impressed. I have a few good numbers. Uh uh But the uh I was surprised that uh, you know, usually it'll come down to the last two. Like a lot of people will switch up the first eight of the top ten. Yeah. But the the the one and two uh were a fall from sixty feet and it was a gunshot wound to the head.
SPEAKER_02Yeah, right.
SPEAKER_01Well, you got about a ninety percent chance of dying if you get shot in the head. Yeah. But the fact that sepsis was close when you're in multi-organ dysfunction, you know, syndrome.
SPEAKER_02That's a good way to that's 80%. That's a good way to put it. Yeah, getting sepsis is almost as deadly as getting shot in the head.
SPEAKER_01Yeah.
SPEAKER_02The worst of the sepsis, not just yeah, any sepsis.
SPEAKER_01You and I could go in your hot tub and and uh have a hot tub thing. Oh, I thought you did.
SPEAKER_02No, I don't have a hot tub.
SPEAKER_01Oh, it's a pool, sorry.
SPEAKER_02I got yeah.
SPEAKER_01So you heat up your pool to a hundred degrees. We go hang out in your pool, yeah, and uh you know, we we would actually meet SERS criteria.
SPEAKER_02Sure. Yeah, right. It's all about context.
SPEAKER_01Yeah. We don't have the source of infection, but exactly. We may flag for sepsis, but we don't have I mean not flag for sepsis. Clinically shouldn't flag. Screen for SURS criteria.
SPEAKER_02It's like somebody's got a heart rate of 175. Does that mean they're an SVT.
SPEAKER_01Yeah. So you and I, we get sick, uh, pathophysiologically speaking, we will be able to mount an uh you know an attack or a defense against that invader. Yeah, and we'll probably be okay. We're relatively young.
SPEAKER_02Yeah. Well, I'm older than you now, currently, for the next few months or month. Oh, yeah. You're October.
SPEAKER_01Yeah, I'm October.
SPEAKER_02Yeah, I'm older than you for the next three months.
SPEAKER_01That's right. Well, we're basically the same age. I know. Basically the same age. And we are able to mount a defense against an invader, and and it doesn't knock us out, you know. Right. You're an 80-year-old in a nursing home, not getting a lot of great nutrition, maybe a bunch of comorbidities on meds and advanced age. You get the same infection then you might be going to the hospital for IV antibiotics or who knows what. So um anyway, so that's I think that's a big part of this because so that's really who's at risk.
SPEAKER_03Yes.
SPEAKER_01Is the uh the those immunocompromised folks are going to be uh more exposed uh to die of things that you know the average average Joe is going to be able to fight off.
SPEAKER_02So let's I think we should talk through like oh so who all would you consider immunocompromised? I would say the biggest patient population pre-hospital that we probably run that I would consider just broadly immunocompromised is the nursing home patient. I think you're right. Patient in a nursing home, not necessarily, you know, just based on their environment and they're older, which that's two factors that are gonna make them immunocompromised. Most of them are gonna have some sort of a medical issue. Um and again, I think that's a very common patient that we're running on. Um what else? What other patients?
SPEAKER_01Well, I'd look at the med list. I think another common patient population would be somebody who's taking a medication that would uh uh create an immunocompromised condition. Steroid patients. Steroids. Uh you know, patients up to the city.
SPEAKER_02Not anabolic steroids. Not every firefighter we know at the fire. On steroid testosterone.
SPEAKER_01Uh no, there's uh a steroid is more of a we uh it's uh it helps your adrenal gland. It helps uh you know, there's a lot of different things that these steroids will do, and they're different classes of steroids, but anyway, so you're on a glucocorticoid like uh prednisone, for example, uh that's gonna ramp down your immune system. Right. It's one of the side effects of steroids, but you're on it for a certain reason medically, uh, those patients. So you see somebody on a steroid, um, you see somebody on uh like a biologic, um, you know, the there's certain like rheumatoid arthritis, there's a ton of medications. They usually end in an ab, like adulinum ab or whatever it might be. Um and they uh these biologics suppress the immune system um so the uh uh the chronic condition you have isn't flaring up all the time.
SPEAKER_03Yeah.
SPEAKER_01But that again makes you immunocompromised because part of your immune system is that inflammatory response. So looking out for those medications, I think would be what I would say, Matt.
SPEAKER_02Yeah, and especially that that nursing home patient, you show up, they might be altered, they might have dementia um or not responsive at all. And so you have to go off of that med list that the you know the nurse gives you at the nursing home. And if you could be a superstar paramedic, if you're reading through that list to go, oh, you know, they're immunocompromised or possibly immunocompromised because they're on a steroid or whatever.
SPEAKER_01Uh so that's I guess another common one, like uh somebody's HIV positive, they're gonna be on immunosuppressants as well. That's the treatment for those. Right. They can live their whole a long, happy life on these immunosuppressants, but they do increase the risk of we have come a long way with HIV therapy.
SPEAKER_02We sure have a long way since thirty years ago.
SPEAKER_01Another common patient would be cancer patients. Uh very common, yeah. You got somebody receiving chemotherapy or uh radiation therapy, these things can make you more susceptible because they they knock your immune system down. Those new blood cells are very susceptible to these uh medications and these the the radiation treatments.
SPEAKER_02Yeah, yeah. Typically they will be wearing masks shortly after their chemo treatments. Yeah, for you know, depending they uh w a day, a couple or a week or something like that, they may be wearing masks. Um somebody that's recently had surgery could be susceptible to immunocompromised.
SPEAKER_01Yep, the diabetes and dialysis patients. I mean, there's a lot of different chronic conditions that can create a second. Eating disorder patients, that's right.
SPEAKER_02So just thinking more of the younger folks, right? We're kind of keep talking about the old and the very young, but you could have that teenage teenage patient or early 20 patient um that you know is suffering from a eating disorder. Yep. And that could cause them to be immunocompromised.
SPEAKER_01A lot of these cytokines and chemokines that are made uh, you know, to help with the inflammatory response, and not just those, there's many, many chemicals. Many of them are processed and made in the liver. So you have a liver patient, uh patient with liver problems. So they can also be immunocompromised, which is part of why that anorexic patient being malnourished would be because you're not getting the proteins you need, your body's not going to make everything. Right. It's gonna be in survival mode, and so you could be immunocompromised just because you're not getting enough nutrition. Yeah. Well, I think we kind of covered all those. That's a pretty thorough look at the different types of patients that could be potentially immunocompromised. Um, just having an infection can also um uh you know, you uh your body's so focused on a th an infection and you're you know, you it can actually create an immunocompromised condition just based on uh you fighting another disease, whether the disease has knocked you down and created a malnutrition and a weakness or uh yeah, if you have you could have everything safe at your house, doors locked, bedside guns loaded for those of us here in the state of Texas.
SPEAKER_02But you know, the guard dog and everything, but if ten dudes with bazookas come through the door, yeah, that's gonna be a little overwhelming. You're you're not gonna be able to handle that, right? So yeah, you get multi infections that are introduced into a body that's maybe has a healthy immune system, but it's just overwhelmed. Like I can't fight on ten different fronts at the same time.
SPEAKER_01Um you've used the word twice there. That was I think the key word is overwhelming. You overwhelm your immune system, it's just not gonna be able to fight off that next infection.
SPEAKER_02Even a healthy immune system. I think that's our point. Yeah.
SPEAKER_01Yeah. Um so in in addition to some of those other conditions like being sick and overwhelm your immune system. You know, I think what what we should probably talk a little bit about is the assessment. You know, you the EMS assessment. So when you're you're talking to your patient, you know, um sometimes we put on the blinders because we kind of know what's going on. This patient called for weakness and you got the fever, you've got the the vitals, and you're thinking uh you know, maybe you're thinking sepsis, right? Or um but sepsis is a spectrum of disease. But when you when you have an immunocompromised patient that is flagged for sepsis, it's like oil on a fire. The other problem too is uh oftentimes patients who are immunocompromised can't even mount a fever. So don't rely upon fever for your diagnosis of sepsis. Again, you don't have to have all of the service criteria to screen in. Um being very careful um when you're when you're looking to screen a patient for sepsis and activate, you may have an immunocompromised patient not even capable of mounting a fever.
unknownRight.
SPEAKER_01They're just altered.
SPEAKER_02And I get that all the time when I'm teaching or when I'm reviewing calls and I see like respiratory rates, you know, twenty six, heart rates one twenty, you know, all these things. But they were it. February, and they didn't call sepsis. And it was a nursing home patient that just had surgery three weeks ago. It's like this is screaming sepsis, but because they didn't have a fever, you didn't call sepsis on it. And so, yeah, I think that's a huge take-home point, especially maybe for newer EMTs, newer medics, that you do not have to have a fever. There's lots of reasons. Maybe they just took Tylenol, right? Or you know, something else to reduce their fever. Fever is not a necessary component for sepsis.
SPEAKER_01You can actually tragically too, which is worse, you can even be hypothermic. Which would flag you in. And that's um you get into those types of patients who are so immunocompromised that they um you know they're hypothermic in addition to all the other hypotensive things going on.
SPEAKER_02Now we're now hypoxic.
SPEAKER_01You're getting up now you're the mortality rate's going up. Yes. And then you and then you you start uh you get that uh patient in your ambulance and you missed it because there was no fever.
SPEAKER_03Yeah.
SPEAKER_01Um now we're delaying treatment. We're just increasing the the mortality rate just keeps clicking up, right? Yeah. Uh so getting them identified as soon as possible is the key.
SPEAKER_02Mostly follow your local protocols, but I think most heart rate over 90, respiratory rate over 20, um, you know, possible fever, presumed source of an infection. Um we, you know, oxygen, new onset of oxygen dependence. You know, normally they're not a COPD or something like that where they have HOMO two, and now this person that's never needed oxygen before is needing a nasal cannula to maintain 94-95%. Another thing that we've talked about numerous times, N title. If you have N title, put them on N title. I have had so many patients. I had one patient, uh, was an older female patient, um, called us out for a separate reason. Partner, everything, she was walkie-talkie, but she looked weak and kind of frail. Um but my partner, as soon as he started checking vitals, because I was talking to the patient getting the assessment, and he's like, her heart rate's like 140. Like, why is her heart rate so high? Right? Context. All right, she didn't just get done working out, she's older. Why is her heart rate she's in a calm environment? Why is her heart rate 140? But respiratory rate was fine, there was no other part of the search criteria. She was not a nursing home patient, she was at home. But the daughter did say that I don't remember if it was COVID or flu or something to that effect. So there was a presumed source of a possible infection. But the only vital sign that was off was the heart rate was 140. And so we get her out to the med unit, and I won't get too far into the story, but I was suspecting for a certain reason, I'm like, I think this lady might be septic. Yeah, and I threw her on N title. I her end title never went above 19. Oh wow. Could not get it above that was the highest end title reading I got. So I activated code sepsis on her. And uh started, she had terribly altered at all? Yep. She was what she was very kind of weak, but she was talking to me uh AO times four. Um I got a line on her, could only get one 20 gauge on her, it's all I could get without. I mean, she didn't need to be bone drilled, she was normo-tensive, blood pressure was fine, just the heart rate. Very good compensation.
SPEAKER_01Compensation.
SPEAKER_02Yeah, she was compensating very well. Um, but I did. I called a code sepsis and a nurse friend that if I said her name, you would know. And a younger doctor came into the room and I was given the report, and he asked me, he said, Why did you call code sepsis on this? And I said, I said, Listen, and this is what I tell people when I'm teaching. Like, my job as a pre-hospital provider is to look for signs. Like we've talked about, I don't have all the tools. I don't, I can't pull a lactate, right? Which is the definitive sign that somebody entitled though. Yeah, yeah, yeah. But you know, I looked at my entitled. So, hey, look, my job is to look for indicators that somebody might be having a STEMI, that somebody might be septic. And from what I could see, I think this patient could be septic. I started an IV, I did the best I could for her. She didn't meet my criteria for cephipine, so I didn't give her any antibiotics. Um, but if you're the doctor, you went to school for 12 years, I went to school for six months. So, but he's like, Yeah, I don't think she's septic, I think she's just got you know the flu or something like that. Take a guess at what her lactate was. I because I was curious. Well, and so I called this nurse later.
SPEAKER_01Make a good guess, and I know it's not a linear relationship, but 25 and then title to 25 is around four. So uh this now, I'm not sure exactly how steep the curve would be, but if you're below 20, I would say you're more than double that. I would say you could even be double-digit lactic acid.
SPEAKER_02She was, she was 16. Wow. Yeah, I texted that nurse friend of ours, and I'm like, I'm just curious, because I wanted to know like, was is this relationship between N title and a lactate? Is it pretty accurate? Yeah, her lactate was 16.
SPEAKER_01And did they end up diagnosing her with Oh, yeah, she went to the ICU.
SPEAKER_02I actually think she actually died a few days later. Oh she was extremely sick. Yeah, she went up to very well compensated, but yeah, 16. And I was like, okay. So that that one call sticks in my brain because I'm like, there is some truth, which I get that's one call, and all the data people are gonna be like, but data shows that yes, uh a la an end title of 25 is typically gonna correlate with a lactate of at least four, which is an indicator of severe sepsis, right? Two is a septic patient, four is a severe sepsis.
SPEAKER_01The most deadly thing again in the hospital, the most costly thing in the hospital, these septic, and that's why we're talking about this. And these immunocompromised patients are at increased risk over the general population.
SPEAKER_02Throw them on that anti. It doesn't hurt to get an anti weeks, right? Yeah, it doesn't hurt to do that. So use that as part of your assessment findings on these patients. But ask good questions too. Get a full history. Get a full history.
SPEAKER_01Every checkoff I do, it's always a tip that I'll give my new checkouts. Get a complete history. Yeah. You you you'd got a history, but you could have asked so many more questions. Now there's a time to load and go, and you get a really sick patient, but when you can get a good history, so helpful to patient management, you know, it may not help you every time. In fact, I told a recent checkoff this. I said, a full history on that motorcycle accident scenario that I had for you may not have really given you a lot of clinical information, but getting into the habit of getting a full history, it it's gonna it's gonna pay so high dividends down the line.
SPEAKER_02And it's never going to hurt you. No, it's never gonna be bad. There are times, like you said, on a motorcycle accident trauma. Yeah, if somebody's bleeding out, I don't care if they're a diabetic. Like I don't care right now.
SPEAKER_03Right?
SPEAKER_02If somebody can't breathe in their O2 sats at 70%, I don't care. I I need to do those things. But one thing that, and we've talked about this before, that I see most good doctors, most good emergency physicians that I have seen, they will always come in and do a good assessment. And I think a lot of times as EMTs and paramedics, we kind of take that for granted sometimes, yeah. Where we don't do that thorough good assessment, we kind of take for granted, oh, it's just grandma that fell at the nursing home again, right? And and they don't do that good assessment where physicians know I need to ask good questions, I need to do a good physical exam, I need to ask the right questions, because again, it might be that one question that don't that you don't ask that's the key to figuring out what's going on.
SPEAKER_01I I love the Swiss cheese analogy. That's right. Where uh you know, uh getting a good history. If if you were you've done this many times, you're giving me a patient, right? Yeah, you deliver a patient to me in the ER. You took a history, and you're gonna not gonna remember everything, right? No. Um and I'm not gonna remember everything. Right. But when you line up your history with mine, you might remember something I didn't think to ask, vice versa. Yeah, you might learn something, I might like, oh shoot, I forgot to ask that. I'm glad he did. Right? I didn't ask about blood thinners, or I didn't ask about immunosuppressants. Oh, this patient's on chemo. I thank you. Yeah, and the problem is that patients, when they tell one person something, they think suddenly they told everybody in the healthcare continuum their story.
SPEAKER_03Yes.
SPEAKER_01So there's a misconception too, sometimes with patients. It might be because they're sick or whatever, tired or whatever, embarrassed. Yeah, but uh getting a good history is a big part of the assessment and not missing some of these potential risk factors of immunocompromise patients. Yep. So it could change your management, it could save a life, knowing if the patient is immunocompromised.
SPEAKER_02And if you're a new EMT paramedic, use your sample, use your OPQRST. Those are good tools to help you so you don't miss anything.
SPEAKER_01So that's the assessment, so you get a good history. I like physical exam. Yeah, like I think the history would be the subjective information from the patient. Correct. Some of it's objective as far as history goes, but what we can get from a patient without them talking to us. I mean, this is veterinary medicine now. You could get stuff on physical exams that could really clue you in. Absolutely. Uh whether it's a skin exam.
SPEAKER_02A med port. Medport very well. Are you a cancer patient?
SPEAKER_01Yeah. That skin with radiation therapies is really classic. It's like a plastic sort of a feel. Uh you've got that patient with uh you know surgical you know, scars responsible. Dialysis, indwelling lines, exactly, yeah. So a physical exam can be very important too. And that would include the lung exam, the the uh very common source of infection for folks. So you got that patient that's a cancer patient uh that's dealing with uh you know bladder cancer, for example, that's on immunosuppressant therapy or chemotherapy, um, and you're doing a lung exam, be common for them where you and I would fight off that lung infection, they're not going to be able to mount that sort of a a response and would end up being more susceptible to developing a pneumonia.
SPEAKER_02I'm also thinking of those chronically ill kiddos, the sad ones that you know typically you'll get moved into your neighborhood. You know, they have a nurse or an LVN that that's an in-home care nurse and they're trached, you know, and they're up in bed. I mean, talk about immunocompromised, they're like the definition of immunocompromised. All kinds of sources of infection. They're bedridden, so they're prone to having bed sores. Oh you know, yeah. And they're obviously their body's not working correctly, so another another patient population.
SPEAKER_01Yeah, and those are part of those red flags, right? I mean, we we can be in these situations where we're uh, you know, not not just on medications or whatever it might be, all of these things give us the clue, hey, yeah, be on the watch. This is a this patient's at risk. Really, I I think again, early early identification, early treatment's the key. Yeah. And if we're not noticing red flags, then we're gonna have delayed care. Correct. And delayed care hurts people. So I think we're all on the same page.
SPEAKER_02Yep, yep, yep. Yeah. Viral signs, we touched on that a little bit.
SPEAKER_01We did, yeah. That's and again, this the SURS criteria. I like QSOFA better, but um SERS is fine. Yeah, they're both simple. Yes, there are better systems out there. I think the uh the smart um um you know, uh screening tools probably better, but it's kind of complicated.
SPEAKER_03Yeah.
SPEAKER_01I I think though I like QSOFA uh better than SURS, and I think the literature says it's better too, but um the screening good screening tools are gonna catch a lot of patients that could potentially have sepsis.
SPEAKER_02I would say in good common sense. Yeah. Like use your common sense, yeah, right? That you look at this patient, they look sick, they're coming from a nursing home, they're coming from a dialogue, whatever the case may be, you know, and they just don't look good, and then their vital signs are meeting this criteria.
SPEAKER_03Yep.
SPEAKER_02Err on the side of caution.
SPEAKER_03Yeah.
SPEAKER_02Right? And activate. Because again, most protocols, you're gonna have a septic protocol and then you're gonna have your antibiotic protocol. They're not necessarily the same thing. Just because a patient is septic doesn't mean they're gonna get antibiotics.
SPEAKER_01The sickest ones should be getting antipsy.
SPEAKER_02The sickest ones should be getting antibiotics, and that should be pretty all your protocols.
SPEAKER_01Hopefully, your medical director is explicit in the protocol.
SPEAKER_02But fluids, I mean, there's not, you know, and a lot of these patients. Uh I know several years that these were a lot of patients that were getting tubed in the field, were septic patients, because they were, you know, in septic shock. And we're showing up. I remember one patient we had that was just totally altered.
SPEAKER_03Yeah.
SPEAKER_02And she'd been sick for days, and the family finally called when she was basically unresponsive.
SPEAKER_03Yeah.
SPEAKER_02And then we show up like, we gotta take this patient's airway. Like she is super sick.
SPEAKER_01Anyway. And and I guess to add to that, uh, I remember a patient you just reminded me of a patient that brought in by family from the nursing home. Shocker. They were irritated, no pun intended, actually, thinking she was in shock, and that's why she was altered. The family was irritated or well, the family was irritated that they were getting poor care at the nursing home. Oh, gosh, yeah. Which is a shocker. But um Don't blame them. I don't mean to be stereotypical there, but they were they were they were frustrated. I remember them bringing in mom, the grandma or whatever.
SPEAKER_02You know what? They were advocating for their mother, and I will applaud that all day. Yeah, me too. Yeah.
SPEAKER_01So they they put her in their vehicle and they brought her to the hospital.
SPEAKER_02Good for them. And they didn't call 911, double good on them.
SPEAKER_01Okay, right. So actually they could have come in by ambulance. Sure, yeah. I'm not 100% sure, but they at least they got frustrated that they hadn't done anything about grandma who's altered. And she'd been in the hospital multiple times for UTI, and so they were literally frustrated that they weren't treating this UTI, that mom's altered again, and that's a classic thing. Oh, yeah. Altered mental status in the elderly population, you gotta check it out. With a UTI, yeah. So they were convinced of sepsis, and her urine I remember is kind of borderline, it wasn't that impressive really, but she was pretty altered.
SPEAKER_03Yeah.
SPEAKER_01And on physical exam, I saw hematoma. She had a head bleed, big subdural. Oh wow. And so uh an altered patient. So don't forget, too, it's like uh it would be easy sometimes in a nursing home to put on those blinders for a sepsis patient, especially with what we're talking about today. But I think this is always a good reminder to you know, like in our cognitive bias lecture that we did not too long ago. Anchor. Don't anchor on a diagnosis. Don't don't uh don't rest your laurels on the information you get from dispatch. Don't don't let the family frame this thing for you. Yeah, all that these are things that our brain is always fighting against. And I think that's key. If you haven't seen the cognitive bias uh stuff we did, I think that's a that was a great lecture. But yeah, to circle back to immunocompromised, again, you get this septic patient, they can they could have something else going on too. Right?
SPEAKER_02So yeah, again, context is super important, right? Look at the whole picture, don't just zone in. Well, their heart rate's you know 130 and they got a temperature, they have to be septic. Like maybe they're hyperthermic, you know.
SPEAKER_01No, right, yeah, it could be a lot of things. Yeah, and that fever could be other things too. So I guess uh management. So how do we manage these these uh these patients? Well, I I think again the the patient population we're talking about is at risk for sepsis. So how do you manage a sepsis patient? Uh we've kind of already talked about this already, but well, follow your local protocols. Follow your protocols, but it's going to involve fluids. If they're sick enough, maybe some IV antibiotics.
SPEAKER_02Do you like LR over saline for these patients?
SPEAKER_01LR for sure. I do. LR, absolutely. It's now if you only have saline, use saline. Right. It's better than nothing, but LR is a superior fluid for sepsis. And and for DKA, uh, there's a lot of different conditions that LR is is uh much better for, where there's some that's like, well, either or. And there are actually some conditions where the DNS is is better. Uh so um, but for the purposes of this lecture, you're treating somebody who's immunocompromised that flags for sepsis. Yeah, um, the fluids are gonna be part of our our treatment. Don't give too much. Um, but but give give fluids according to your protocols. Uh, pressors are huge too. Um pressure. That's right. And and that's the tough thing too, because we're dealing with a patient population that tends to be old with these immunocompromised folks.
SPEAKER_02Do you remember that patient we had in the back of the ambulance at the nursing when you were riding that?
SPEAKER_01I do remember. We did some push dose pressors. We did.
SPEAKER_02We drew up a push dose pressure, got some lines going on her. Yeah, she was we didn't have antibiotics back then. She might have been a candidate for it, but that's right.
SPEAKER_01Yeah, we just started doing antibiotics for open fractures recently. And sepsis. Well, septic shock and severe sepsis is what we do antibiotics for.
SPEAKER_02Yeah, and then open fractures.
SPEAKER_01Yeah. Well, that's good. So let's uh let's practice a couple of these things, Matt. I got some cases here for us. Okay.
SPEAKER_02Um, we'll put each other on the spot here.
SPEAKER_01We'll discuss them. I think this will be good. So uh the patient uh you're talking to this patient uh at uh at home.
SPEAKER_02So we're not gonna don't throw it off too much, don't give it away too much.
SPEAKER_01And the the chief complaint is just fatigue.
SPEAKER_02Yeah.
SPEAKER_01Fatigue. That's it. So what what could that be? What I mean, if somebody who's tired, could be a million different things. It could be a million things. Yeah, I need to get more information.
SPEAKER_02Yeah. So what's their history? What's their meds? What's their vitals?
SPEAKER_01Right. Well, as you continue to talk to them, they've got lung cancer. Ah. Lung cancer. They're on chemotherapy.
SPEAKER_02So they're gonna probably probably be chronically fatigued.
SPEAKER_01That's right. Yeah. Yeah. When did you get your chemotherapy? The patient condition right after chemotherapy is a whole lot different at the you know, right before chemotherapy. But yeah, you get this patient now, you know they're immunocompromised. This are they altered? I mean, they're one thing to be tired, nothing to be altered. Yeah. What do the vitals look like? So yeah, that's good. So that's kind of the learning point there, is is that these patients are increased risk for sepsis. And do you remember why these patients are increased that are on chemotherapy? Has to do with the blood cells. The chemotherapy is is gonna kill off those blood cells, so they're gonna be neutropenic.
SPEAKER_02Oh, okay.
SPEAKER_01Yeah, so that's the that's the learning point, I think, for that.
SPEAKER_02So they have less soldiers to fight off. That's what you're saying.
SPEAKER_01Yeah. Do you want to do the second one?
SPEAKER_02Sure. Uh well, let's see. So you get called out for a mildness of breath. Oh no. No, I can see it. Okay. Mild shortness of breath. Okay, mild shortness of breath.
SPEAKER_01Oh yeah, we talked about this in a previous podcast.
SPEAKER_02Exactly, in our hypoxic podcast. So very common. Very, very common. Yes. Shortness of breath. Yeah. We don't have a lot of so you get on scene. Lead me down the path. Okay, so you get on scene and let's see. We don't have a lot of. I'm trying to.
SPEAKER_01So they're breathing fast?
SPEAKER_02Yeah, so they're breathing kind of fast. Maybe their SPO2 is a little bit low.
SPEAKER_01Okay. Um hypoxic.
SPEAKER_02Maybe a little hypoxic, yeah. And then they tell you they just recently had a kidney transplant.
SPEAKER_01Ooh, there you go. Yeah. So when you have a kidney transplant, you need to suppress your flag. Danger, danger. You have to have an immunosuppressant on board. Yeah. Tacrolomus, or I think that's what they call it. Uh anyway. It doesn't matter. When you when somebody's had a transplant, uh, they're going to have to ramp their immune system down so their body doesn't attack as non-natable. Yeah, so that that's a great red flag. Uh you get a transplant, cancer, you transplant patient, cancer patient, somebody with uh on immunosuppressants for chronic condition. That should be a red flag to us.
SPEAKER_02Yeah, pneumonia, these type of patients. Yeah. I read the next one, sorry. Oops.
SPEAKER_01We'll skip ahead then. Okay. Uh no. Uh so let's see. So um, yeah, so you got a patient and uh um fatigue might be the complaint. Yeah. And uh you're asking them questions, and uh they you you ask specifically if they're maybe uh any uh if they're on any medications. Common part of the sample history, right?
SPEAKER_03Absolutely.
SPEAKER_01So you're asking about meds and you you're like uh most of the meds you recognize, but there's some weird ones on there.
SPEAKER_03Yeah.
SPEAKER_01And and uh how would you be able to I'm just let's just talk about this because this is an important one. Uh the medication, spoiler alert, is uh one of those uh biologics that's an immunosuppressant for rheumatoid arthritis, maybe. But you know, we don't need to memorize all these medications. Google it. Google it. You could look it up. You could go.
SPEAKER_02I have done that so many times on the back of an ambulance. Like, what does this medication do?
SPEAKER_01Or you could ask why they take it.
SPEAKER_02That's the other thing. Yes. What is this? But even at that, though, what they oh, I take it for my lungs. Yeah, that's it. Okay, but that doesn't tell me. Yeah, exactly. So, oh, I can't tell you how many times. First off, there's so many medications out there.
SPEAKER_03Yeah right?
SPEAKER_02It's important to know the classes of medications and what they do, um, but there's no way you're gonna memorize every single medication that's out there. So heck yeah, pull out your phone, your iPad, and Google that sucker and find out what it is.
SPEAKER_01And there are a lot of immunosuppressants out there with a lot of weird names, usually end with an ab, um, those biologics, and they can really create some potential risk for your patient. So that's good. That was uh case number three. So the the blunting the inflammat inflammatory response um by these medications can create an immune compromised patient situation. All right, try four. So good one. We talked about this. This is a common one that we gotta have this memorized in.
SPEAKER_02So you have a patient with hypotension.
SPEAKER_01Okay, so we are hypotensive and altered and and uh you're looking at uh He's got an adrenal sufficiency uh insufficiency, excuse me.
SPEAKER_02And an occult infection.
SPEAKER_01So they're probably on steroids. Yes. And when you're on steroids, you're blunting your inflammatory response again. That's correct.
SPEAKER_02Steroid patients. What are some common steroids?
SPEAKER_01Well, they're the common ones are glucocorticoids. So dexamethasone or decadron, uh prednisone or prednisolone.
SPEAKER_02Um I take decadron for my stero for my steroids, for my allergies when they get really bad.
SPEAKER_01Oh yeah. Well and by suppressing your immune system, it can really bring a lot of relief. Yes. The side effect of these things though is you're putting yourself at risk. Uh you can also it can uh decrease bone density over time. And there are a lot of different things that steroids can do um side by the way.
SPEAKER_02Yeah, but negative. With the with the good comes the the downside. With the pros comes the cons.
SPEAKER_01Right, right, right. So so anyway, all right. Last uh I think we have one case left. Is that right? One case?
SPEAKER_02Oh we should have one or two.
SPEAKER_01Oh yeah sorry we have two left yeah um so a dialysis patient how are they immunoc how do they get immunocompromised? Oh gosh.
SPEAKER_02Well they're almost constantly I mean they're getting fluid introduced to their body every couple days and they have a exact huge source of infection in their dialysis specifically.
SPEAKER_01Especially if they and they could even have a temporary dialysis catheter which can create in uh the chronic inflammation which can create a an immunocompromised patient. So uh no those are good.
SPEAKER_02Yeah the cau is it a CADI what is it that catheter I'm going back to catheter? No I'm talking about the acronym for the kind of infection I'm going back to nursing school which is about eight years ago. It's a catheter assistant catheter assistant yeah I think it was a CADI.
SPEAKER_01It's a fully associated and there's a catheter associated infection whatever I don't know.
SPEAKER_02Some the nurses out there will yell at me and say hey stupid this was a question on influx. Well I used to be on the hospital um committee on this thing we would see because this is a big deal right you do not want to get a hospital uh graded they're graded on that yes oh big time because that can cost you a lot of money and those CEOs and CFOs They're publicly reported grades.
SPEAKER_01Yes. And you've got to report these things when they happen yeah and the government will give you a leapfrog grade a safety grade based on these things.
SPEAKER_02Gotta be careful those pick line nurses and those people inserting that stuff gotta be careful. Yeah. Anyway sorry we digress no that's which is another but another infection source right?
SPEAKER_01Yeah.
SPEAKER_02These are all part of the same immunocompromised patient population.
SPEAKER_01Well I think to to kind of pull it all together um uh when when we consider a patient that's that we're seeing whether it's altered mental status or whatever it is having an understanding of their immune system's functionality is important. Patient with like that motorcycle patient I mentioned a while ago that patient is uh not immunocompromised.
SPEAKER_02Well actually if you think about it he is because he's a motorcycle patient he probably got some sort of a big abrasion. That's true. And so now he's got a m a wound that really susceptible to infection. Burn patients highly susceptible skin is a big part of our immune system. Yeah it's again the protection sorry.
SPEAKER_01No you're right though I mean it's hard to think of a of reason why based on some sort of an assault on the body's you know organ systems where you wouldn't have some sort of potential immunocompromise situation. But I guess my point is is like a even in a young person you know with no medical problems, you know you gotta be careful with these things because whether they may be malnourished or like you said road rash or uh even even massive hemorrhage.
SPEAKER_02Have a chronic medical problem they could have been born with.
SPEAKER_01Or yeah or on medications I mean there's a lot of different things that could happen um that could create a a situation where we need to be on guard. But I guess uh you know the most important thing to me and you may uh may or may not agree I think it's identifying the patients. Because if we don't identify them early we're not going to treat them. So I think being aware of these conditions that can create a problem with the patient's immune system, I think that's the big take home point for identification is the biggest the biggest part of it.
SPEAKER_02Because if you don't identify it you can't fix it or help it to be fixed, right? And you're just delaying that care whether it's you're not giving fluids or you're not giving antibiotics pre-hospitally to I'm not passing along pertinent information to you or the nurses at the ER and now I'm still saying them further and then all of a sudden it's an hour later and they get the lactate bat and they're like oh my gosh this patient's got a lactate six you know like that doctor not you know taking it for granted that oh I don't think they're septic and then gets the lactate back and hopefully pooped himself when he saw that going oh my gosh that paramedic was right and I was wrong. Yeah so not I love my doctors but sometimes people get their belief systems that oh this can't be that because I'm not seeing a fever. I'm not seeing too like look at the whole picture right do a good assessment look at what medications are on all these different things. It's I always tell people when I'm teaching that as an EMT as a paramedic when you're doing your assessment you're like a detective trying to solve a crime and more information is not going to hurt you. The more people the more witnesses you talk to the more camera footage you find the more evidence you can gather the more information you get about that crime is going to help you point in the right direction. And so like not asking a question is not helping you.
SPEAKER_03Yep.
SPEAKER_02Asking that question is not going to hurt you. It might be benign information that doesn't help you at all but it's not going to hurt you. I'll give you a prime example we had a lady one time lethargy every call we've talked about she just doesn't she feels weak. She doesn't feel good I've told this story before because it's stuck in my mind so much about and it's not that I was like this great paramedic but it was just doing a good assessment.
SPEAKER_03Yeah.
SPEAKER_02That it was during COVID we showed up at this lady's house older lady the family called she just doesn't feel good. She's really just drained and tired. All of her vital signs are perfectly fine except she's a little bit hypotensive and by a little bit I mean she's like right around 90. Nothing crazy. Normal for some people yeah heart rate was fine SPO2 was fine blood sugar is fine ephebrile she's alert and oriented but she's just kind of tired and felt this way for a couple of days and we're out in the med unit okay we'll run you up to the hospital probably thinking she's got COVID or something like that. And I had a newer paramedic with me and I was like you know what we've done everything else we had her on the four lead let's run a 12 lead on her and we're in and I'll never forget I'm they're doing the because I've got my new guys I'm training they're over putting on the lead and I'm talking to one of the guys on the truck who's in the door with the ambulance we're just kind of talking because I punched in we're waiting for the 12 lead to print out prints out she's having a massive STEMI huge STEMI and as this thing's printing out I mean I was like oh my god and so it was immediately like we need to go now and so but had we just been like eh this is just a sick old lady we don't need to and I'm not saying we do 12 leads on everybody right yeah but we had already looked at everything else we were back there I was training somebody let's run a 12 lead on her no complaint of chest pain no shortness of breath assessment is huge if you don't identify it you can't fix it.
SPEAKER_01Sorry No no no it's the same thing I I that's what we're talking about. This is part of the history this this they may be only complaining of fatigue. Yes but you get a full history it adds to the story of fatigue. It's not just fatigue it's fatigue they just got chemo. Yeah or it's it's not just fatigue it's uh the patient nursing home patient and you get their med list and oh they're on steroids. You actually reminded me of another medication we've got to be aware of too especially when you're looking for sepsis is the the uh the medications that can alter the heart rate like a beta blocker. Sure. Oh yeah oh yeah like well hold on we only have you know the heart rate's only seventy five heart rate yeah but uh they're on they're on a beta blocker which can blunt the body's response they're trying to compensate they want to compensate but because the medication heart rate's deceptively low it only has to get over ninety to really flag for it. But yeah you're right seventy five without a beta blocker it might be 110. So those are those are real medications that have a real effect and they can really affect the way that we would assess our patients and we might miss something.
SPEAKER_02Yeah so just do a good assessment check everything out don't get complacent you find those things again use entitle uh if you know your patient's immunocompromise that's automatically a red flag should be yeah if they have immunocompromise plus any of the SERGE's criteria I would be on high alert for them being septic right um get those fluids on board if you can give pre-hospital antibiotics do that certainly activate so that like you said passing along that information to the receiving facility hugely important a very common condition we can see in our patients that puts them at risk for some of the most dangerous conditions we treat in the hospital important content today that's right and what's the most important or what's the most important diagnosis?
SPEAKER_01What did you always say what's the what's the what's the most deadly diagnosis? What's the most commonly missed diagnosis the second one? Yeah that's what it was be careful.
SPEAKER_00Anyway be safe out there see you on the next one thank you for listening to EMS the Eric and Matt Show