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
Pediatric Foreign Bodies Podcast
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
In this episode of the EMS Podcast. Erik and Matt discuss pediatric foreign body obstructions. This is a very common call we get and most of the time the obstruction has cleared before we arrive. But what happens if it doesn't? Tune in while we discuss the management of these patients.
The more common things that a kid might do is to stick something in their nose or their ears. Or their mouth or their mouth.
SPEAKER_03And mom and dad refuse transport. No, he'll be fine. She'll be fine.
SPEAKER_00Listening to EMS. With your hosts. Eric X.
SPEAKER_03You kind of had an interesting call the other day. You were doing a ride out or something? Mm-hmm.
SPEAKER_01Yeah, I did. It was a very interesting case.
SPEAKER_03Very interesting.
SPEAKER_01I did. Well, it was kind of funny. So I was on a ride out, I got there to the station, and the guys want to share a story with me. Um one of our guys, um, we his name's Chris. Okay. Uh he um uh was they were called to the waiting room of an ER because a kiddo got his finger stuck inside the hole of a cymbal like the played drums with. Exactly. And um the ER called because they couldn't get it off. And they thought, well, the fire department, they'll have some sort of a grinder they could get it off. So they called 911, our guys show up. The grinder's not a good idea. They knew enough to think this is gonna burn the kid's fingers. So one of the guys, Chris, got the idea, hey, let's grab the tin snips and cut it off. Yeah, work perfectly. And so they put a label on the handle and they called it a symbol remover. I thought it was kind of funny. We took pictures of it and then they put it into the engine as in new inventory, like new new. New tool. New tool in the in the in the engine. Uh or the triple.
SPEAKER_03One of them will probably RD like some kind of a special tool and retire a multimillionaire creating some tool that does that.
SPEAKER_01Anyway, so they're literally just telling me about this call they had had earlier that day in the morning. And while they're telling me the story, and I'm literally downloading the picture of the symbol, which we'll show here somewhere, um we get a call to another ER for a finger of an eight-month-old stuck in the handle of a measuring cup.
SPEAKER_03All within eight hours, it was yeah, short period of time.
SPEAKER_01Yeah, yeah. Whatever, same shift. And I talked to Chris on the way out there. He's like, How many times has this happened in your career? He's been around for a little while. It's happened a couple. I don't know, 15 years or whatever it was. Never happened before. And it happened twice in the same shift within a short period of time.
SPEAKER_03It's funny how those calls happen like that. Or just you know, you get these small groupings of things.
SPEAKER_01It is funny. That's funny. Well, these types of situations with kids, you know, they get their finger stuck in a measuring cup hole and they can't get it out. If you don't, it could cause some serious injury or tourniquet to their finger. That's exactly right.
SPEAKER_02And then the swelling makes it worse.
SPEAKER_01It's just it's like a vortex, and then the finger, you know, if you don't fix it, could cause permanent damage. Absolutely. So definitely a good thing to go to the ER for, but um, don't grind off a symbol, it'll burn the finger.
SPEAKER_03But I bet those guys loved going to the ER to save it. Oh, they loved it.
SPEAKER_01And they went again, they were so happy.
SPEAKER_03It was a different ER, though.
SPEAKER_01Different ER. Yeah, but same group of guys. Nice joke. And they pulled the labeled symbol remover out of the truck, which they really had a place for and as a joke, and now here they've used it twice in one day.
SPEAKER_03That was funny. That's hilarious. I love those stories.
SPEAKER_01So, what we're gonna talk about today is kind of an interesting topic. Um, some of my more favorite things to deal with in the ER, actually. Uh pediatric ingestions and foreign bodies.
SPEAKER_04Okay.
SPEAKER_01Kids typically uh get a little curious at this age and they stick stick things or eat things they maybe shouldn't eat. Uh and we're not going to talk about everything, it's not a comprehensive list, but maybe some of the more common ones you may encounter.
SPEAKER_02Yeah.
SPEAKER_01Um, which could be important. In fact, we in fact uh just recently was talking to a firefighter, and you and I were just talking. And there's some things that you'll learn here today that you may not know, which could help in a refusal kind of a situation.
SPEAKER_02Absolutely.
SPEAKER_01Just to equip the parents with the knowledge of knowing, hey, this is one of those really bad things. Uh you've got to be very careful.
SPEAKER_03Don't worry.
SPEAKER_01They're gonna poop it out. It's okay. Yeah. Um, so let's start off with uh what we're gonna call they ate what? What do kids eat?
SPEAKER_03Oh, they put well, I don't know if eat is the right word, but put in their mouth.
SPEAKER_01Put in their mouth, yeah.
SPEAKER_03Yeah, yeah. I mean, I've known that I've been called out numerous times for like pennies, yeah, uh, coins, things of that nature. Kids are crawling around, you know, toddlers crawling around on the floor, they're mobile for the first time. They see something shiny on the ground, and what do they do? They pop it in their mouth.
SPEAKER_01That's right, yeah. The uh and most of the time, really nothing to worry about. Unless the kiddo shows signs of a choking hazard, right. They're drooling or they're having trouble breathing because it could have gone down the windpipe, right? So these could be an airway foreign body, which requires emergent action. But typically a kiddo that swallows a penny will just pass that penny in the stool. Um but uh but again, something a lot of people really worry about.
SPEAKER_03They're gonna pass that penny in the pool.
SPEAKER_01In the stool, I said in the pool. Yeah.
SPEAKER_03Just look for a little shopping thing the next time he poops in his diaper.
SPEAKER_01Uh no, it's it's typically one of those things we don't have to worry about. But if your kiddo has swallowed a coin and they're drooling or they're having any signs of respiratory distress, that's a five alarm fire. We gotta really be careful with those things. You know, another one, one pill um can kill is a good mantra to remember. Because you know, the pill that grandma takes every day, dose for that weight.
SPEAKER_03Yeah, and a two-year-old gets a hold of it at fifteen kilos, twenty kilos.
SPEAKER_01Overdose, and that could be really bad. Because you know, as you know, uh kidded kids have doses uh that are weight-based. Yeah. And so uh a full dose beta blocker or clonidine or a big norco in a in a little kiddo, a toddler, you know, um, you know, one to two years old. You know, grandma was loading up the pillbox and one of the norcos fell on the ground. Kiddo eats it. Um the kind of the some of the classic ones are those blood pressure medications, uh like a beta blocker or calcium channel blocker, um, some of those powerful, you know, blood pressure medications or or even the some of the powerful diabetic pills, um, some of the sleeping meds, pain meds, uh clonidine is another blood pressure med that um can cause a lot of problems in kids. Um so being aware uh of that as a possibility. We have a really sick kid and you can't figure it out. Yeah, what did they get into? Is there any way, mom and dad, that your kiddo could have got into some meds? Well, grandma was watching them. Yeah, maybe there was a pill on the ground. Yeah, and they picked it up and thought it was a Skittle.
SPEAKER_03Yep, yeah, and and ask, like, what prescription meds do you have? Mom, dad, grandma, whoever's in the house, right? Yeah. And go in and look, where were they at last, you know, and ask those good questions of mom and dad.
SPEAKER_04Yep.
SPEAKER_03Um, and then while your partner is doing a good assessment, like you say, if they're a beta blocker, heart rate's super low, kids really lethargic, okay. Well, this is you know, we pointing towards what we think's going on. But doing a good assessment, getting a full set of vitals, listening to lung sounds, right, on that kid that swallowed something, make sure there's not an obstruction of some kind there. Um but I would say any kid that's swallowed that or that you suspect has swallowed some kind of a medication, they need to be transported for someone.
SPEAKER_01Absolutely. Yeah. Yeah. And uh that's that's where I think when you have a situation like that is understanding some of these things can help you inform the parents properly so they know what they are potentially trying to refuse, right? And getting them to to buy in and to align with you can be very, very helpful.
SPEAKER_03Yeah, any household cleaners. I know like the Tide Pod thing was kind of a funny thing.
SPEAKER_01It can look tasty to a little kid. To a little kidfully.
SPEAKER_03Well, like fabuloso, that that uh floor cleaning or that cleaning fluid. Yeah. You know, the bottle is these bright, beautiful colors, and to a little kid that looks like fruit juice. The the liquid itself is, you know, whether it's greenish yellow or the purple one, that's the big one. Yeah. I mean, it looks like grape juice. You know, when you're walking through the aisle in Walmart, I've seen that before before I knew it was a I thought it was some kind of a juice, right? Well, some little three, four-year-old kid, they don't know.
SPEAKER_01They don't know.
SPEAKER_03And they just they're take a drink of that stuff. Oh man, that could be really bad.
SPEAKER_01Very bad. Yeah. It's the alkali in it that causes, you know, we all it seems like acids, everybody knows the acids are bad. But equally bad can be the alkali, the bases. They they're just the opposite of an acid, but they can actually cause just as much harm to tissues.
SPEAKER_03You know the anaphreeze thing? Yeah. You know how they used to it used to have a sweet taste to it.
SPEAKER_01Yeah.
SPEAKER_03You know, they've removed the sweet taste so less people would harm themselves by drinking uh I didn't know that. Yeah, anaphrize. Yep. Or like there were some people that were using that to kill other people. Yes. And because it had a sweet taste to it, and they didn't realize, well, apparently Ethylene glycol. Yeah, we had a conversation. I was talking to somebody at the station or something, and they said, Yeah, they've actually removed whatever the whatever the chemical was that was causing to have a sweet taste. They've actually taken that out so there's less people now that are using that. Interesting. Yeah, anyway. But that's another thing because it is, it's this bright, pretty liquid that a kid would see. Little kids, you know, don't know if dad's got it sitting in a measuring cup to do something with his car. Crazy things happen.
SPEAKER_01And actually, the it's you can actually determine whether or not that was the ingestion um by using a black light. Uh if you if you could somehow get to the urine or maybe the a diaper whatever, it will glow. Yeah. The ethylene glycol will glow. It's a phosphorescent. Uh so uh not just the detergents though, um and the medications, uh there are there are other ingestions, uh, you know, the alcohols, the isopropyl alcohols, uh some of these these other substances that can be ingested potentially, um, you know, you could end up with a kiddo looking very, very sick. And uh and and and even you know, what if it was an unknown ingestion, right? This is kind of my where I was going is you know, what do you do when you have a little kiddo that has had some sort of an oh you suspect some sort of an unknown ingestion? Um what types of things do you look for? Well, get your vitals.
SPEAKER_03I was gonna say, yeah, do a good assessment, right? Because that's gonna be part of your process of and it you know, for us as pre-hospital providers, we can ballpark and guess what they might have over or taken, ingested, but at the end of the day, we're just treating what we see, right? So if it's a respiratory issue, we're addressing the respiratory issue. Like if we think they got some kind of an opioid, maybe we'll give them some narcan. Yeah, but at the end of the day, like putting them on oxygen, maybe helping with some positive pressure ventilation if that's what's required. Um you're looking at the vitals. Is the heart rate super low? What's the bread blood pressure look like? Blood sugar, that's another one. Temperature, all these different things, right? Are pointing you to, okay, blood sugar's low, okay, I can do something for that. Oh, their respiratory rate's low, okay, I can do something for that. But that's at the end of the day, and obviously transporting because they get they're gonna need more definitive care to figure out what they ingested.
SPEAKER_01And when you're in a situation in a home and you've got this sick kid and nobody seems to know what the heck is going on, you can look around. Hey, that that's the pill bottles over there on the ground that grandma was or whatever, right? You you can see the potential for some sort of an ingestion where nobody suspected that. You do suspect it, so you're smart enough. Hey, uh I need a med list from every adult here in the house. Yep. Um because it it's a possibility you could have ingested a medication. W grandma, were you it looks like I see your pill bottle on the table. Is there any way you could have had any of your pills fall to the floor? And the kid grabbed it off the floor.
SPEAKER_03So gummies is another big one, especially that's right. Yes. They're very popular. A lot of people are taking, you know, CBD or THC gummies.
SPEAKER_04Yeah.
SPEAKER_03And to a kid, that looks like a piece of candle.
SPEAKER_01Absolutely. And in a little bottle. That tasted good. I'm gonna have another one and another one. Yeah. Before mom sees me, I'm gonna really get a lot of them.
SPEAKER_03All of a sudden you're going on a five-year-old that's tripping, shripping like crazy, and mom's wondering what happened. You know, this so yeah, good questions to ask, good assessment, good look around the house at what's what he put possibly could have gotten into.
SPEAKER_01And I think there's another resource you can call poison control. I think it's 1-800-222-1212 or something like that. Yeah.
SPEAKER_03It's such a simple number we didn't remember it.
SPEAKER_01Yeah, I know.
SPEAKER_03Sorry, poison control people. Everybody I think most people, if you don't have poison control's number programmed into your cell phone on your ambulance, you should.
SPEAKER_01We had it on the wall. Uh I mean, it would anytime it was.
SPEAKER_03It's in our protocols, like, yeah.
SPEAKER_01And it's a good idea too to get their input. They start they'll follow the kiddo uh in the way.
SPEAKER_03Well, and you can give them, hey, these are the symptoms.
SPEAKER_01Exactly.
SPEAKER_03That's what's and and they'll kind of go through their system and type it in, and however they do that, and they'll say, hey, this looks like this type of uh an overdose or an ingestion, and you can do this for it. Or you know what, they're probably gonna be okay.
SPEAKER_01And you'd be surprised what pills can cause cardiovascular collapse in a little tiny body uh when it's dosed wrong. Properly dosed, it actually can help with the blood pressure or whatever, but man, if you overdose on a med like that, you can c absolutely collapse. Yeah. And so that's another thing to to uh definitely be aware of. Um I think that's that's I think that's basically it for the the uh ingestions. There I mean many other potential poisons and things like that that could be ingested, but uh being aware of what kiddos can do potentially, just out of curiosity, um, is something to to be can you know be aware of. Yep. Yeah. Um so the next part we got here is they put what where? It's amazing what kiddos can do or what they I mean, I hate to say that, but get stuck in a zipper. I mean, there uh there are a lot Well actually it's uh what was I start with that? I think that's one thing I taught my baby doctors when I was in attending in the emergency room. Cut the zipper. Well yeah, well yeah, the sometimes you know mom and dad don't know what to do. It's okay because it's kind of you know, the little Johnny um zipped up the onesie and got his penis stuck in the yeah, in the zipper. It's not uh it's not uncommon actually, if it's something I've no, it happens for sure. It definitely happens. And it's not just kids, by the way, too, it's adults.
SPEAKER_02Yeah.
SPEAKER_01Um and uh seems to me, based on my experience, there's usually some intoxication involved where they're zipping up the zipper to go to the bathroom and just things didn't weren't timed quite right.
SPEAKER_03And it can it can be every guy listening right now is just like Yeah.
SPEAKER_01No, but but it's uh it's actually a pretty simple thing to do. But I've seen people transferred to other hospitals to f have these things fixed and just yeah, it's walk them through your your fix.
SPEAKER_03You know, most people are trying to, okay, we gotta do all this and we've got to pull this and try to unzip it out and all this thing. What's your fix for it?
SPEAKER_01Well, that's a good question. So follow your protocols. And I I know for me as a medical director, I've told my guys if they um well in conversations I've told them this, but um there's this part of a zipper that's called the central post. And uh the zipper is actually like two flat pieces of of of metal, usually in the s shape of a light bulb, you know, the zipper. But the two flat pieces of uh of uh metal connected by one post at the end. You can see it if you look at your zipper again. That that's called the central post.
SPEAKER_03That's the piece that you have the two at the base of the zipper, yeah. Right? You got kind of the male and female part, and the the male is the central post that you slide that in, then you start zipping it up, right?
SPEAKER_01I think well, uh I should we should have a picture of this. We should. We'll we'll find a picture of a central post and put it in there. If you look at the if you look at a zipper zipper right there on your sleeve.
SPEAKER_03But that won't have a central post, will it?
SPEAKER_01Yeah, they all do. So that thing you see there at the top.
SPEAKER_03I can't because your gigantic hand is in the way.
SPEAKER_01That's the cent center post. Let's put a picture of a zipper up here. Okay, we'll find a picture. We'll label that. Yes. That center post is holding the two halves of Oh, center okay, I'm sorry.
SPEAKER_03You're talking about the part that you're actually zipping. The part you zip is the part. Okay, okay.
SPEAKER_01That's usually the part that gets stuck in the room.
SPEAKER_03I was thinking of the the two pieces that are coming together.
SPEAKER_01Oh, yeah, no, no, no. Yeah, you're talking about Yeah, the center post is the part on the zipper you're you're holding. You'll see it now, but it holds the two halves of the zipper. So if you put your hand out there, Matt, that's the the zipper. Here's the zipper pieces that are. Yeah. So this this is the this is the zipper here that goes over the top of that. The central post is here. Yeah, I gotcha. Right? So that center post there, that's what you you you cut that with a pair of tin snips, it comes apart, and it's the the they're free. Got it. It's actually a pretty simple procedure to do, and I'm not saying that you should add this to your protocols or anything like that, but it is certainly something that can be done. And I know for my guys, like a patellar dislocation, I've helped reduce do certain things. It may not be in the protocols, but I can help walk them through it in a phone call.
SPEAKER_03We have it in our protocols.
SPEAKER_01Yeah. Oh, you do? Oh, that's cool. I didn't know that. Um but uh this this probably would never be in a protocol ever, but um it's certainly something. Uh in fact, it reminds me of that story. We didn't tell the story yet, did we? Which story? The one with the symbol? Did we talk about that? I know we talked about it before, but did we do it in the podcast?
SPEAKER_03Yeah, you opened with it.
SPEAKER_01Did we?
SPEAKER_03Yeah, you just went on the write-out and uh yep.
SPEAKER_01So those tin snips we use for that would be perfect for cutting that center post. And so that's what I would instruct the guys to do. Uh and then and and it would just come right off of the whole thing just falls apart after that. That's smart. But but that's not a good thing.
SPEAKER_03All right, so we've talked enough about the beans over the Franks, so let's continue.
SPEAKER_01Yeah, so um well, we'll go from head to toe. So the more common things that a kid might do is to stick something in their nose or their ears. Or their mouth or their mouth. Yeah. Yeah. And uh in an airway foreign body, those are the ones we really worry about. But as far as things in the ears or the nose, there's not a lot that can be done um in the pre-hospital environment necessarily.
SPEAKER_03We've got to back up. Yeah. Because we talked about things we swallowed and we didn't talk about the two most important things.
SPEAKER_01That's gonna be the end. Oh, that's at the end. Okay.
SPEAKER_03A race that lasts five seconds. No, I'm just kidding.
SPEAKER_01No, no, no. We can we can't. No, no, no. We'll talk about it at the end.
SPEAKER_03I wanted to make sure that we talked about it at the end of the day. Definitely we do. Yeah, okay. Yes. We'll touch on that at the end.
SPEAKER_01I think so.
SPEAKER_03Continue on. Up the nose.
SPEAKER_01Yeah, up the nose and ears. So it's common for kiddos to put um, you know, jelly beans or um, you know, little bits of food, peanuts, legos to little toys.
SPEAKER_03Army soldier, yeah.
SPEAKER_01Up the nose. And typically, well, the dangerous thing there is aspirating those types of things potentially. Um but in the ear, though, we have to uh what we get worried about is like a peanut being a biologic um is more at risk of causing an infection than a than a Lego or something like that, or an earbud or something like that. Um and again, those are uh really easy to remove. You just have to be careful not to damage the eardrum.
SPEAKER_02Right.
SPEAKER_01Um but that's something that we are. No, no, I think so. But but when you have somebody refusing care though, right? Uh I would be far less concerned about some Lego as opposed to, yeah, you know, we were eating and Johnny put a bit of uh you know chicken in his ear. Whatever. I don't know, but something biologic like that, or a piece of food or peanut or whatever.
SPEAKER_03Those something that's gonna break down over time.
SPEAKER_01Yes, and that decomposition, or actually a real story um is a snail in in the ear. Um in that particular patient is now deaf because it was handled differently. Did they intentionally put the snail in the kiddo's just being a kid and putting a tiny little snail in their ear and the ER doctor was going to remove it and uh ended up damaging the ear. The kiddo is now deaf.
SPEAKER_03Oh wow.
SPEAKER_01That's terrible in that ear.
SPEAKER_03Yeah, I've heard a lot of cockroaches.
SPEAKER_01Yes.
SPEAKER_03That's a big bug crawling in the ears.
SPEAKER_01I have had those 300-pound the most manly man you see ever come in crying, screaming, the bigger they are three babies. And and then I can look in the ear and there's a little bug in there. You know, I mean it it's miserable. I I've never had a bug in my ear, but I'm sure it's normal. And I've had some burrow in through the eardrum too. So you can see how this could be really miserable.
SPEAKER_03But how why do you how do you let it wait that long? Well, you know, Well, I got something in my ear. It's getting it's coming out.
SPEAKER_01Well, if they crawl in, right, they get in there quick, and then you start putting your finger in there, and now they're really freaked out. There's only one way to go. Anyway. That sounds like a horror movie. But uh, I've had some of these kids come in, and and mom says, Yeah, Johnny says he's got a sore ear, so uh thought we'd come in and make sure it's not an ear infection.
SPEAKER_03Johnny's on his mom's Q P C P, by the way, folks, not the ER. I'm sorry, go ahead.
SPEAKER_01And I go in and I look at the ear, and this kiddo's got a bug staring back at the end. You see a yeah, you see a cockroach butt. Oh my gosh. Mayflies seem to be the most common ones to me. Really? They fly in there and anyway. But ear form bodies, nose-formed bodies, pretty common. But the the the biologic stuff, the the insects, the food products, those are the ones we've got to be more careful of. And obviously, this is more of something that's going to be definitively cared for in an ER with the right tools. But you can though equip mom and dad, though. It's like, hey, listen, the ER has got all the tools to help your kiddo. With this being a, you know, a f a piece of a chicken finger, or whatever, I don't know. Uh something like again, it's biologic, right? Uh that's something that's going to need to come out soon.
SPEAKER_02Yep.
SPEAKER_01Um and likely antibiotics as well, potentially, depending on the story. But and uh the it's the other thing too, as an ER doc, we always look in the other ear.
SPEAKER_02Yep.
SPEAKER_01You're right. You always check the other ear and uh check the nose too, right? Yep. Because it's usually not just one thing.
SPEAKER_03Check everywhere, yeah. Uh but those didn't you have a story of something got put in one side and he was complaining of one side, but it was actually there was something on the other side.
SPEAKER_01Yeah, yep, that's exactly what happened. Was complaining of something on one ear. I got that out, and then we just checked the other ear. Oh, there's another Lego. Yep. Another Lego in the other ear.
SPEAKER_03So yeah, always do a good full assessment. And those are like you said, that's where oh Moss, oh, that's you know although I would say I can't see a lot of parents knowing their kid has some foreign object stuck in their nose or their ear, yeah, not wanting their child transported to the hospital.
SPEAKER_04Yeah.
SPEAKER_03That would be pretty unusual.
SPEAKER_04Yep.
SPEAKER_03Um so but at being educated and telling them, like, hey, yeah, this is a piece of organic material that is gonna break down because cause problems we need to go. Um or this is a Lego, still need to go. Yeah.
SPEAKER_01You know, but um And they usually do, and and that's fine. Um now when we get down south now, it's still the curiosity sometimes. The kiddos will put things in their vagina or their their rectum or or their penis and stuff like that. So um there's a couple things to be concerned about here. Yeah. Um kiddos who are putting things in their rectum or in their penis or their vagina, you wanna, you've got, especially when it's a little kiddo, yeah, you've got to think about the potential for this kid being abused. Yeah, that's right.
SPEAKER_03That is unusual behavior for a you know, any child, that's unusual behavior.
SPEAKER_01It's one thing to be curious with your bone body, and then you know, mom's looking at Joey's penis and he was playing with that, maybe did something that irritated or something like that, or whatever. But uh but uh anytime the genitals, even though mom's story about Johnny sounds pretty reasonable, you've gotta think about the potential of abuse. So anytime oh, I think uh my daughter she got the shampoo lid in her vagina or something. I don't know. I'm just making up a story. Right, right, right. The these types of stories that you hear, you've gotta think about abuse. Form bodies in the genital area. Not normal, yeah. That's something that's a red flag. And we gotta ask some tough questions.
SPEAKER_03For no other reason you're transporting, obviously, if there's something still stuck in there, that they need to be transported to the hospital, and then you know, you're gonna express and the nurses and physicians in the ER are even if you're not you don't have your uh what am I trying to say? You don't have your spidey senses up that something's wrong, right? Hopefully the nurse, the physician or something's gonna be like, that's not normal for a five-year-old to be putting things in areas that shouldn't be having areas or things put in, right?
SPEAKER_01And things things do happen, but we can't assume that. Um with uh we've talked about this in our child abuse lecture. Yes, that's why it's important. Some form you know, sticking a lego in your ear is one thing, right? But when you're starting to put stuff in your penis or your things like the the we gotta we gotta be very careful with those things. So anyway, enough about not accusatory either.
SPEAKER_03Like, yeah, we're not gonna be accusatory. But we're gonna transport, relay our concerns, go from there.
SPEAKER_01And we tell the providers who we're handing off to what our concerns were. That's that's what I'm saying. Yeah, yeah, yeah.
SPEAKER_03We are not trying to remove any of those objects.
unknownNo.
SPEAKER_01We're just follow your protocols. Um the I think uh most of what we're talking about so far, these are just aware of a common thing that can happen to kids where we're aware of the way they're handled and treated, which can help us equip mom and dad, can help us th help them to understand what they're refusing care for potentially.
SPEAKER_03Yep. Um I got one for you from a medical director perspective. I mean, I know what I would do. Yeah. So here's even more of a red flag. Kid has stuck something in somewhere below the waist, right? Whatever. And mom and dad refuse transport. No, he'll be fine. She'll be fine. We don't they don't need to go.
SPEAKER_04Yeah.
SPEAKER_03As as the paramedic, I'm like, again, yeah, the initial thing is that they're putting something up there that's unusual to begin with. Now mom and dad are refusing. Why are you refusing to get your child help?
SPEAKER_01Yeah, I'd I'd be asking a lot of questions.
SPEAKER_03I'd be asking a lot of questions, and now I'm like, I'm calling my medical director. Yeah, you know, and you're gonna talk to the doctor. And then continue to refuse. Now I'm we're looking at a CPS report.
SPEAKER_01Exactly. And and if we're worried about the patient's safety, then we're mandated reporters here. And I think this is a universal thing federally, I think. If you're concerned about a possible child abuse situation, old and young, we are mandated to report, and so it'd be tough, but uh you know, sometimes you gotta look out for kids. And and the bottom line is we miss the majority of these things that happen. Yep. And for unfortunately, kiddos can end up in the morgue for some reason, and two weeks ago they were in the ER.
SPEAKER_03That's right. And their their abuser was continuing to or somebody called 911 two weeks ago and mom and dad refused transport on the kiddo.
SPEAKER_01Yeah, right. Yeah. Yeah. So be very careful with those. That's a great, great uh. Yeah, another red flag.
SPEAKER_03You know, again, that's that's two big red flags. Like, that's not normal, and that's very you know, mom and dad refusing when you're telling them because they called you for help, and you're telling them your kid needs to go to the hospital, and they're refusing that, that is a massive red flag.
SPEAKER_01And we learned about some trafficking stuff in our recent lecture, right, where mom was actually trafficking daughter. Uh that's terrible, terrible stuff, right? So you never know what level of evil you're dealing with.
SPEAKER_0363 percent, I think it was sixty-three percent of human trafficking victims at some point will interact with first responders. Yes. So a huge majority of people who are whether it's sex trafficking or labor trafficking, at some point they're probably gonna have some sort of contact with fire police, EMS.
SPEAKER_04Yep.
SPEAKER_03And so that's why they're starting to mandate this human trafficking lecture, is because we could have an impact on that doesn't look right.
SPEAKER_01And a significant portion of these these victims, these vulnerable patient populations are pediatric. Yeah. And so you get a kiddo in here that you're concerned about whatever it might be, and it could be a genital sort of a foreign body thing, who knows, that that clues you into wait, something's wrong here. And you know, as we see something, say something. See something, you say something. Yeah, very good. No, I think uh I think that's uh really important. Now, there are some some things to consider too. These these are some red flags, and I've seen them in the yard a number of different times. And recently I had a a firefighter call me uh because of an issue that we're gonna discuss now. That is just just a couple things that you know we want to be aware of because if you're not aware of the severity of these two red flag ingestions, yeah, um you could I mean these are surgical emergency type things. Yeah. And being aware of them equips you to inform mom and dad or whoever called 911 that this is not something to refuse. When they I mean, see, this is the beauty of a refusal, and this is what really gets me. So before we get into this, I'm just gonna briefly talk about refusals. ACDC. Just think ACDC, right? To make an autonomous decision, you have to have capacity, mental and legal capacity, to be able to make a decision for yourself.
SPEAKER_03I don't think firefighters or I I shouldn't say firefighters, I don't think a lot of EMS providers appreciate the the the gravity of that word capacity in the legal setting.
SPEAKER_01I agree.
SPEAKER_03I mean, they just don't, and they take it for granted that oh, it's just a refusal, you know, we don't have to really And a four GCS fifteen, they can refuse. Yeah, they got capacity. They're A know. That's not an assessment of capacity.
SPEAKER_01No, it is not. So if they have capacity, they can now hear what you say, understand it, and make a decision for themselves. That's right. So the AC is autonomous decision capacity, legal and mental. And then the DC is you gotta disclose the information to them so that they can communicate back understanding.
SPEAKER_02Yes.
SPEAKER_01Right? If right off the bat, if they're not AO for GCS 15, right, you know they don't have the mental capacity, they're not gonna have any autonomy. They can make a decision, so there's no reason to talk to them.
SPEAKER_03Being AO times four and GCS is 15 just shows that you have the ability to test for capacity. Yes. Not that they have capacity.
SPEAKER_04Right.
SPEAKER_03Right now you have to ask the question, like, okay, sir, you're complaining of chest pain, right? I'm encouraging you, I'm seeing changes on your EKG. There, you could potentially be having a life-threatening situation. You need to, I'm fine, I don't need to go to the hospital. Okay, you understand that I'm telling you you could potentially be having a heart attack and die in the next 20 minutes if you do not allow me to take you to a calf lab that can treat you. Yes, you understand what it means.
SPEAKER_01I understand that I could die, but I don't want to I do not want to go to the ER because I'm sick of the ER. Last time I went last week, same thing, chest pain, and I'm still paying the bills. And what's gonna be I'm not going anymore, and I might die, and I don't care.
SPEAKER_03I understand that. I understand that. But what happens? I want you to explain to me what I'm seeing changes on your EKG. You're having a heart attack. You understand. Explain to me the risks of not going.
SPEAKER_01I could die. Yes. My heart could stop beating, that's right. And you could be called back to my house for cardiac arrest. That's correct. And I absolutely don't want to go to the ER, and it's my right to refuse.
SPEAKER_03That is capacity right there. He's yeah, you just demonstrate competitive.
SPEAKER_01That's good. We want to try to care for patients and you want to push back a little bit and get them to help them to understand. So, with these situations and what we're about to talk about, I'm equipping you in a couple different situations where mom and dad might not be aware of the fact that this is a life-threatening thing for their kid.
SPEAKER_02Yes.
SPEAKER_01And equipping them with that information. Because see, mom and dad right away might be thinking, uh, you know, dad comes in the room, honey, why'd you call 911? We are not doing this again. We still are paying the bill for the last ambulance.
SPEAKER_02This is ridiculous.
SPEAKER_01We are we are gonna take our kiddo to the ER. It's fine. Yeah. Right? And then, well, hold on just a second. You know, I appreciate that. You've got the legal right to look after your kiddo, but I need you to understand what you're doing. And then you explain them. So one of the situations that you should be able to explain, and if you didn't know this before, now you know, right, is magnets. Let's talk about magnets first.
SPEAKER_02Yeah.
SPEAKER_01One magnet, no big deal. If you know for sure it was only one magnet, yeah.
SPEAKER_03That's that's a hundred percent for sure. Yes, and always safest to take the kid and go and have it go.
SPEAKER_01Yes, yes. And that probably is smart. But the what what they're gonna look for in the ER though, uh would be a second magnet. Yeah. If we know for sure they swallowed two magnets, um or at least two magnets, we could have a big problem on our handle. So if you can imagine two magnets going down the GI tract separately or whatever, um, if they weren't locked together initially, um, what could happen is later on in the GI tract, one magnet in that part of the loop of intestines hits another magnet in another loop of the intestines, and because they were in close proximity, they stick together in two different areas of the intestine. Those two magnets then will create ischemia in the tissue between the two magnets and over time could erode and cause tissue damage, even perforation. So that's why two magnets is a big deal. One magnet's not so much a big deal. Right. But if you have any kiddo swallowing magnets, best to transport them because you don't know.
SPEAKER_03Like I said, they can't confirm that he didn't swallow two or she didn't swallow two, either one.
SPEAKER_01And the great thing about magnets is that they show up on x-rays, too. So it's a really it's again, you know what? I know you don't want to go to the ER, but listen, this could be a surgical emergency and it's a really easy x-ray, and you know, it's it's good to get this done. This could save your kiddo's life potentially.
SPEAKER_03I would also recommend taking these kids to a pediatric facility if that's possible. I mean, in some areas that might be a two-hour drive, right? So maybe you can't do that per your protocols, but yeah, if you have the ability to take them to a pediatric facility, this isn't an immediate life-threatening situation. So taking them to the most appropriate facility because this kid's probably gonna get admitted.
SPEAKER_01Yeah, probably be admitted for observation, potentially. I mean, they're gonna do an X-ray. They may get discharged from where they're going. Um but the uh again, a potential surgical emergency, good information, you know, it's gonna guide your questions too. Is there any way it could have been more than one magnet? Is there any, you know, whatever. Those are really important questions.
SPEAKER_03Well, and then the bigger question is how do you know it was only one magnet? Well, I watched him do it. Well, why the heck did you watch him do it, dad?
SPEAKER_01Where to go, idiot? No. And again, I we can't forget about abuse, right? I mean, uh not that this is a form of abuse necessarily, but uh, you know, you're in the house and you see multiple kids running around, open you know, alcohol containers or whatever, and you're like, this is not an appropriate environment for a kid. Yeah. No. This might be uh the information you might need to help a kiddo that's not being treated properly. I mean, neglect is a force a force a form of abuse too. That's right. Uh the the second one I was going to bring up, which is is uh probably more common. I think so, because those button batteries, so the swallowing a button battery, it's the the chemicals within the battery are dangerous and can cause erosion of the mucosa of the uh GI tract. But um these um uh these button batteries, if you swallow one of them, uh they could look like a coin potentially, but they are a lot different than a coin. A coin, remember, we don't worry about those so much typically, unless they cause drooling or respiratory distress or whatever. But um but you have a kiddo um and mom says, I think they swallowed a coin. Look like a coin. Are you sure it's a coin?
SPEAKER_02Yeah.
SPEAKER_01How do you know? I watched him do it. Way to go, idiot. No, just I love that. You were so hard on people. That's true. Watching our kiddos, we can't have our eye on them all the time. And so um, you know, little Johnny got his hand on the controller or some sort of a device these days. A lot of them have those little button batteries. Oh, yeah, for sure. And they swallowed a button battery. Yep. Uh the kids are just very oral that way, and they just swallow things they put in their hands. And uh that is one of those things that has gotta go, it's gotta be seen, and we've got to get that out. Uh could potentially cause problems. So that's something to, again, to go to a pediatric hospital.
SPEAKER_02Yeah.
SPEAKER_01If you don't, they're gonna get those x-rays and likely send them there anyway for a while.
SPEAKER_03How are they gonna get it out?
SPEAKER_01Well, that's a good question. There's a lot of it depends on where it is. Um some of them can be taken out endoscopically.
SPEAKER_02That's right.
SPEAKER_01Um of them get stuck in the um uh the esophagus too. Because yeah, it's kind of depending on how big they are and how small the kid is. Um but some of them um can be surgical emergencies too. So it's really gonna depend where it's at where it's at. And that's up to those pediatric surgeons, right? I mean, that's um that's part of we're not gonna fix this in the ambulance, obviously. But again, this is good information for us to be able to share with Oh yeah, it's huge.
SPEAKER_03Yeah, because I mean you would think, you know, I I remember we got called out, and this was years ago, and it was a firefighter, not that didn't work for my department, but worked for a neighboring department. And it was so funny. We got called out for a choking, yeah. That's what the call came in as and show up and here's this big old, you know, the the quintessential fireman, right? You know, the big old muscle, and he is freaking out because his kid swallowed a penny.
SPEAKER_01Oh no.
SPEAKER_03And I was just I kind of I I I didn't want I didn't chuckle, I didn't laugh, you know. He was he was concerned about his kid, but it's so funny when the emergency is happening to you, it's totally different than I'm sure if he was on shift, he'd be thinking thinking the same thing I was thinking. But we were like, hey man, like we'll take him to the hospital, it's totally fine if you want to go, you can take him. It's probably okay too if you're you know, but he's probably just gonna poop it out. Because the kid was fine. I mean, the kid was running around playing, he was totally fine.
SPEAKER_01Different of the tripoding and drooling hundred percent, yeah, different, totally different thing.
SPEAKER_03But oh yeah, I I'll never forget that guy was he was so scared, like, hey, my kid swallowed a penny. Like, aren't you a per, right? The kid'll be fine.
SPEAKER_01Well, I think the last so we've talked about things that kiddos can ingest. We've talked about uh big things that put foreign bodies in different holes in the body. Yeah, and then uh the two we kind of focused on here, uh the button battery and the magnets was cool. Uh I think uh two more things. I think uh the potential to we talked about abuse, but there's also um the uh intentional ingestions in the pediatric population. I think that's also something that we have to we have to talk about this, only because the adolescent rates of depression and and suicidal ideation, younger and younger kids are are doing things to hurt themselves. And I think you know, uh like Tylenol, for example, Costco sized jugs of these pills, and it's just so accessible. And and kiddo knows that when I have a fever, mom you know, pulls the Tylenol out and I take a Tylenol and ten or whatever. They they can access these things and be very sick. And sometimes kids because of the age, they don't know how to talk about these feelings they're having. I've had I've had kids who are seven in the ER want to kill themselves. It's just uh it's an irrational thing and it's a sad thing. Um and I think the potential for intentional ingestions too, we have to think about that in our kids. You're looking at this, you know, I don't know, maybe a twelve-year-old and you're talking, wow, they look sick. What could this be? Mom and dad say, Hey, no medical problems. I you know, you've got to start thinking about is there any way they could have intentionally ingested anything?
SPEAKER_02Absolutely.
SPEAKER_01You know, it mom and dad may not realize how sad or depressed or angry their kiddos are. Yep. And uh what do they have access to? You know, it oh my gosh, the the Tylenol bottle's empty. Or whatever it might be, right?
SPEAKER_03So I think I remember that patient I brought to you that overdosed on Tylenol? No, tell me about it.
SPEAKER_01Remind me, remind me.
SPEAKER_03Uh you and one of our com uh one of our co no.
SPEAKER_01Oh, was that Adam? The other one.
SPEAKER_03It was it was his first tube.
SPEAKER_01Oh, that's right. That's right. I do remember that now. Yeah, that was uh that was a sick patient.
SPEAKER_03It was the sick patient, yes. Yeah, that was an interesting, interesting case.
SPEAKER_01When they do it right, nobody knows about it. But his vitals were finding it, yeah.
SPEAKER_03Everything was perfect, and we couldn't confirm. We had an idea that we thought it was this, but we didn't know for sure what it was because there was no the dad was like, I think this is what it was, but that kid's vitals were absolutely perfect. Heart rate, SPO2, respiratory, breathing fine, but he was just wouldn't respond to us. Yeah. I mean, eyes open, but would not talk, would not respond to us at all. It was a very interesting case.
SPEAKER_01And a lot of uh meds today and and things that people have access to, from gummies to all sorts of different types of drugs and you know it's yeah, the liquid, the um um vape liquids.
SPEAKER_03Yep. A lot of those are very, very powerful.
SPEAKER_01In fact, uh one of my friends was doing research on nicotine, pharmaceutical grade nicotine, one drop on his skin, he passed out. It was it's as you know, it goes through the skin so easily, right? Nicotine patches. Yeah. But anyway, all that's to say is let's not forget about the potential ingestion potential in a pediatric patient. Yes. It's not always accidental and it's not always abuse.
SPEAKER_03It's it's not always going to be an 18, 20, 30-year-old. It could be an eight-year-old that is considering suicide.
SPEAKER_04That's right.
SPEAKER_03Look for other signs, you know, like how does the kid interact exactly. Look for signs of cutting. Typically, they'll be on the wrists, on the forearms. That's where I've typically seen them. And a lot of times these kids, you know, depending on how you approach the kid, right, they might see you as a safe place.
SPEAKER_04Yeah.
SPEAKER_03And once you now, you also I would also caution that when you transport these kids, these are emotionally unstable kids. I would have two providers in the back of the ambulance, especially as a male with a girl. If I am transporting a emotionally unstable 12-year-old, 14-year-old girl for my protection and her protection, I want somebody else back there with me. So typically I'd, you know, if you have that ability. Now, some of our rural counties, it might just be two people and a medic, you don't have that. And I'm sorry that you don't for yours, but I actually one time I was on my own on a call. Well, it was just the medic. We got called out, and this was a young, young girl that had a lot of history and a lot of issues. Like one of the and I actually turned my cell phone and hit record. It wasn't recording her, video recording her. I was audio recording for my protect because I was like, I have no idea what this kid could say because she had already been making other accusations, not about us, but things that had happened. And I was like, I am back here by myself. There was no other adult that could ride with me, no police officers. Nobody else. And so I just hit my record on my phone, set it down. That way I have an audio recording. Again, I didn't obviously record, but it was just like, oh man. It can be scary. So if you have the ability to have a police officer, have a family member, if it's a safe family member, have another member of the crew ride with you for everybody's well-being and safety, that's always a good thing to do.
SPEAKER_01Yeah, I think that's good. So we've talked, I think, enough about the potential for abuse. We talked about that. We talked about the intentionality potentially. If there's a kiddo trying to hurt themselves for some reason, being aware of that. Um and then I think uh I think uh we we can't forget the basics of assessment.
SPEAKER_03Yeah.
SPEAKER_01And if we can stick to that, it can be so helpful for us. Yeah. The pediatric assessment triangle. You get you remember, um, and it and obviously a kiddo swallowed a uh a penny. You're gonna you're gonna catch some of these things with you look at that work of breathing. Yeah. I'm only hearing lung sounds here. Yeah, I'm hearing some strider, right? And then you with the potential of an ingestion. I mean, these kiddos could be s emergently sick, right? So um work of breathing. You've obviously got the skin, uh, you know, the the tone, I'm sorry, the uh uh the the uh color of the skin, right? And you get a kiddo that's uh ingested uh yeah, beta blocker or some sort of a blood pressure med and they're going into cardiovascular collapse.
SPEAKER_03I mean you walk in and the kids completely limp in mom and dad's arms, yeah.
SPEAKER_01And you said it before too, Matt. It's like if you've got a problem that you see, let's let's address that problem. We may not may not know what it is, but clearly they're short of breath here. Something's going on with the respiratory system. We need to address oxygenation, ventilation, whatever it might be.
unknownYeah.
SPEAKER_01Um and so and then uh so what is it? What do you got? You got the uh work of breathing, you got the appearance. Yeah, the appearance pulses. So yeah. So the pulses well well, as far as pulses, I would put that as like perfusion, maybe. Yeah, right. And then appearance would be appearance. Right. Are are they lethargic? And you know, what's their I mean, is this nor it's normal for a three-year-old to be a little scared of you. They should be looking at you, like wanting to get close to Ma, right? That's right. But you get this kid that's not not looking at you, it's just lethargic. These are concerning signs of a kid though that could be high on who knows what, right? Intentional or whatever, accidental. So I'd uh one of the things that I've learned, and I know as an attending, talking to residents or new doctors, it's like sometimes when you're in a stressful situation, it's good to get back to your literally like ABCs. Yeah. Is is to really get back to the basics when you don't know what's going on, get back to the basics right.
SPEAKER_03What's the airway look like? What's the breathing look like? What's the circulation? Okay, let me listen to lung sounds front and back, right? Uh let me get a full set of vitals, what's the temp? What's the blood sugar? All the that's what I've said. Like you can't do too much of an assessment.
SPEAKER_04No.
SPEAKER_03It's like you can't do too much documentation, right? It's uh it could that one thing that you do could be the thing that is the answer to the problem. And you decide, man, I don't need to check their pupils, they're fine.
SPEAKER_01Yeah.
SPEAKER_03That could be the answer to the problem.
SPEAKER_01Right. Right. And I've seen people get lost in the weeds chasing down zebras. It's like, you know what, let's address in the ambulance here what needs to be fixed.
SPEAKER_03That's what I'm saying. Yeah. They're trying to figure out, well, what if it was this? What if it was that? Well, I don't know what it is, but right now the kids are breathing two times a minute. Yeah. Let's fix that first and then we'll go move on down the road. Or he's sadding 80%, right? Let's do something there.
SPEAKER_01Yep. And getting a thorough history is we could have probably spent another half hour talking about this, but you've you say this, and I love how you say this. It's like we're a detective. Let's get all the information we can on site from the bystander, from family members. Let's look around and see what we see.
SPEAKER_02Right.
SPEAKER_01Uh that information could be invaluable to me as an ER doc when I'm seeing a kid all cleaned up sitting in a hospital gown on this gurney in room four.
SPEAKER_03Yep.
SPEAKER_01So I think that is absolutely crucial.
SPEAKER_03Well, if nothing else, it saves time. Yeah? It saves you time. I come into the ER full history. And I can tell the nurse, you know, the receiving nurse, hey, this kid's got a history of this and this and this, and these are the meds he takes, and these are the allergies. Like, oh, that just saved you some time.
SPEAKER_01That's right. And mom is concerned that uh that he potentially ingested this battery. That's right.
SPEAKER_03Yep.
SPEAKER_01Oh, wait, hold on. What? Right.
SPEAKER_03Yeah. Hit the brakes. What's uh when they uh you well, you said they'll usually do they automatically go to X-ray if it's something that they swallowed?
SPEAKER_01Yeah, yeah, typically. Yeah, that's part of the general workup.
SPEAKER_03And then uh Is that where they're gonna find it is an X-ray, or do they have to not always find it?
SPEAKER_01Well typical, we we'll typically uh get an X-ray and extend it down. There's different types of X-rays we can order.
SPEAKER_03Yeah, right.
SPEAKER_01Uh and we're gonna want to see, you know, from the mouth to the anus. Yeah.
SPEAKER_03Which is outside the body, not inside the body.
SPEAKER_01Yeah. And just to see where it might be. Yeah. And to see how many there are. And uh it's not and uh it's amazing. I've seen people swallow utensils, I've seen people swallow knitting needles, I've seen all sorts of weird stuff on x-rays. Yeah. Those are typically adults with psychiatric issues, but um and then rectal foreign bodies too, we could do a whole nother podcast on that. Let's not with kids though. So to summarize, I think you know what we've been talking about so far. So we've um for uh the ingestions, be careful with the accidental ingestions, some of the common things we talked about, uh whether it's uh an alkali or or mom and dad's pill, because one pill can kill. Um those those things are important to consider. And then in these and in those ingestions, the button batteries are always bad. Magnets are bad too, potentially, if there's more than one. But like you said, it's hard to know. Right. And this equips us to uh inform mom and dad about a decision that they're making. And then, of course, the foreign bodies, we talked about those, beware of uh potential, you know, you know, rectal, vaginal, penile sort of you know, foreign bodies and you know, for potential abuse. Yep. Also um, you know, being aware of the fact that if they did put a some sort of an organic material in their ear, those have a higher potential for um uh infection.
SPEAKER_03Yeah, causing a bigger problem down the road as opposed to the Lego or the G.I. Joe, which they probably don't have to do.
SPEAKER_01Did you put a GI Joe in your ear?
SPEAKER_03No.
SPEAKER_01Have you ever let me ask you this have you ever done that as a kid? I never I swallowed a penny as a kid. Did you really?
SPEAKER_03No, I never swallowed anything.
SPEAKER_01I never my mom tells me the story. My dad shook me upside down by the feet.
SPEAKER_03He didn't know what to do. Probably would I my dad would have done that? I don't know. I just I guess You idiot. Yeah. No, I never I never not that I remember, I don't ever remember unless I did when I was like a little tiny baby kid. Yeah. But I don't remember ever uh swallowing or sticking anything in my ear or my nose.
SPEAKER_01I don't remember being shaken upside down, and maybe my dad didn't do that, but that's I think what mom told me. But you know, I and I don't remember swallowing uh a penny. But swallowing a penny.
SPEAKER_03Yeah, no, I never did any of those things.
SPEAKER_01No, but those things uh are common things for little kids. These are common potential things you might see with the pediatric population. Little kids can be uh these can be dangerous where normally uh certain things would not affect an adult as much. But man, uh a pill from grandma's pillbox, right?
SPEAKER_03Gummy but from big brother's gummy bag.
SPEAKER_01That's right. Ingestions, things like this, they can really wreak havoc on the physiology of a small body pediatric patient.
SPEAKER_03Yeah, always best to default, transport those kids, you know, take them to a pediatric facility, get them fully checked out because there's some things that we just can't check pre-hospitally, and for the well-being of that kid. Always best to take them in somewhere, and then again, always kind of have that abuse type situation on the back of your mind. And if you're seeing indicators, if you see something, like we said, say something.
SPEAKER_01Yep, and don't don't forget about intentional ingestions too. Seems like younger and younger patients are coming in depressed with suicidal ideation. Um sad but true time for these days. Yep. Well good lecture. See you on the next one. Be safe out there.
SPEAKER_00Thank you for listening to EMS, the Eric and Met Show.