Episode 358: Dr. Mario Rugna & Kirk Smith RT: Using the Vent on 911 Calls Should be Standard

Added: 2026-05-12

[00:00:00]Quick disclaimer before you listen. The World's Oasis Medic podcast is an educational and commentary platform produced and recorded by me. What we say on here is not endorsed by any of our employers, and we are not speaking on behalf of our employers. Our commentary is our own. Finally, remember to follow your local protocols. I have two guests today. I have Kirk from Hamilton. He is a respiratory therapist with Hamilton.

[00:00:24]He's been on the podcast before and you've heard me talk about him. And by the way, thank you for the invitation of the Phillies tonight, >> but I couldn't.

[00:00:31]>> One of these days, one of these days, we'll get it.

[00:00:34]>> And and just I'm not getting paid by Hamilton. I'm not sponsored by Hamilton.

[00:00:39]And your invitation was not on behalf of Hamilton. This was just >> Kirk and Mike are buddies and we were going to go to a base, >> have some fun. Yep.

[00:00:49]>> And then from all the way in Florence, Italy, we have Dr. Mario Runa.

[00:00:55]Yeah. Perfect, Mike. You're great. Yeah.

[00:00:58]The channel that we did work >> perfectly. Yeah. Yeah. Yeah. You are you're an Italian.

[00:01:02]>> Thanks for having us on, Mike.

[00:01:04]>> Yeah. No problem. And doc, what kind of physician are you?

[00:01:08]>> I'm an emergency physician. I work mostly preos now. Uh I come from a a long experience in emergency room and now I work just mainly to the hospital uh everywhere because I work in my dispatch center as a coordinator uh for the educational program and uh in the rapid response vehicle where I'm now uh and uh the helicopter service. So okay almost everywhere out of the hospital now.

[00:01:36]>> What kind of helicopter are you guys in?

[00:01:39]Uh AC 145 the Airbus.

[00:01:43]>> Oh, nice.

[00:01:44]>> Nice to fly when I worked at Christian.

[00:01:46]It's great.

[00:01:48]>> Yeah. Yes. I think it's the best for for our region to to emergency because you can land almost everywhere.

[00:01:54]>> It's really really great helicopter.

[00:01:56]Powerful and great.

[00:01:58]>> Do you have one or two pilots?

[00:02:01]>> Uh just one pilots because our base is uh is not night base. So we we are on duty just during the day.

[00:02:09]So at night do is it standard to have two pilots?

[00:02:12]>> Yeah, in Italy is the you are obligated to have two pilots for night flight.

[00:02:18]>> Well, there you go. Maybe that's why we have so many crashes at night in the United States.

[00:02:23]>> Yeah, but we are moving toward the United States with our regulation European regulation because more and more you can fly during the night with just a single pilot.

[00:02:33]>> I don't agree for many many reason. Yeah, with night co vision and just one pilot with special operation is it's too risky for our job.

[00:02:48]>> Do you do you do IFR flights? Is is everybody IFR certified? Your pilot?

[00:02:53]>> Yeah. Yeah. Yeah. We we we have IFR and uh visual too flight but we can uh fly instrumental too in some particular places.

[00:03:06]Little trivia before we get started.

[00:03:08]Kirk was in a helicopter crash and has survived. You told me one time at the bar, you're like, "It was a hard landing." And I was like, >> I said, "What you just described was a straight up crash. You describe it as a hard landing." But another story for another day. So >> Kirk, tell us.

[00:03:26]>> Yeah. Yeah. Hard hard landing is the right word, Kirk.

[00:03:30]>> That's what it was. I mean, that's the way I looked at it because, you know, we all walked away. The patient had no idea what was going on and we just auto rotated and right before we got to the ground um teased it up a little bit and flared it up and >> we just kind of we were lucky that it had rained for a whole week um because you know everything kind of sunk in and softened things a little bit but it happened really really fast and um you know >> yeah you did pee how do you know that the patient had no idea what was going on for something >> I'll just tell you this we had plenty of battery and plenty propall on board.

[00:04:05]>> All right.

[00:04:05]>> Okay. Perfect. That's >> a good way.

[00:04:09]>> That's what I mean by that. That's what I mean by that.

[00:04:12]>> Yeah. Yeah. Yeah.

[00:04:14]>> We we landed in a corn field. So, you know, we're in the middle of a corn field. You know, it was August, so there's corn both sides of everybody and all of a sudden, you know, we land, we're we're getting everything together.

[00:04:24]There's a whole long story to this, but I I just say Daryl and his brother Daryl came from two separate corners of the cornfield and met us all where the helicopter was and got us out of the cornfield and, you know, to hop on another helicopter.

[00:04:39]>> All right, Kirk, why are we here today recording? Why have you brought this Italian doctor to the podcast?

[00:04:45]>> Well, I just think now Mario has a lot of experience. He had a lot of prehosp experience. Um I have you know essentially seen some of his talks and it really is kind of um you know following what we're trying to do here in the United States which is bring mechanical ventilation into the EMS space. Um you know there's a lot involved with that you know obviously um you know whether it becomes leadership there's financial responsibilities there's education which is the biggest thing but just to kind of bring light because we are making some some headway you know little by little. Um, and I'm not just talking about Hamilton themselves. All the ventilator companies are kind of bringing this to light because I think it's something, you know, as an RT. This has kind of been true and dear to my life, you know, for the past 25, 30 years. I've taught medics, I've taught nurses, u mechanical ventilation, and there is some upfront stuff, but it's not a mountain that they can't overcome. Um, so, you know, Dr. Dr. Rema has some great experience of you know training implementing um mechanical ventilation in EMS and I just thought it would be great to have him on and you know talk about some of the successes and then maybe some of the you know the things the pitfalls you need to look out for if you're going to implement that.

[00:05:59]>> All right doc take it away.

[00:06:02]Yeah, I I just basically think that uh less is not more but less is just less then because you know when you talk about the prehosp emergency medicine you just think about less less be keep it simple keep it simple but sometimes we are too simple and for patients is not the best way to do this is was a dream that I had uh mechanical ventilation on the field from the beginning of my career uh where we had almost nothing just about by our hands to ventilate patients. And for me always it was a crime. It was a was terrible cuz the worst patients in the worst ambient uh you ventilate by your hands. Uh so it's it's like going in the in the night without lights in a foggy foggy night uh with your fast cara. So it's it's not good for the patients. It's not right for the patient. It was a dream is a long story started more than 10 years ago and uh now here in Florence finally uh in Tuscanany I can see uh we probably reached the a good a good level of ventilation in the field.

[00:07:12]>> How did you this is a very niche passion topic for you. How did you develop such a passion for bringing mechanical ventilation into the field?

[00:07:23]Uh >> yeah I I I developed my passion for my failures.

[00:07:29]>> Sure.

[00:07:30]>> So so >> spoken like a true professional.

[00:07:33]>> Yeah. A good example of this the first time that I failed an airway when I was a young physician. I said okay this is something that I have to learn and then I developed a passion for airway management in the field. Uh and then after uh after hardware management I said and now what we do everything to manage the in the best way in the best uh way we do with we can for the patient and now what hands like this blind no way. So the next step is uh manage the airway uh and then ventilate mechanically ventilate the patient.

[00:08:19]>> So how long do you guys essentially you know obviously the BVM you know I still say you know it's going to be hard to ever you'll never replace that. There's always a place for a BVM. At what point, you know, is there a timeline that you say, "Hey, I want everybody on the ventilator within 5 minutes, 10 minutes, 15 minutes.

[00:08:37]Is there a timeline you try and >> I think that in prehosp you can't have a time. It depends where you are, which uh team you have, but uh as soon as you can.

[00:08:52]I'll tell you what every >> I'll tell you what every paramedic I shouldn't say every nine out of 10 paramedics in the United States are going to say. Why do I have to lug that thing into somebody's house? Can't I just wait till we bring them out to the ambulance? What do you think about that, Doc?

[00:09:10]Uh this is that's a matter of um uh mentality and dimension and technology because uh all the technology that we have that we use most of the time they're not developed for us. We uh just passive uh just passive customers and we uh just have uh technology developed for our our environments and we take out of the hospital. So now we have technology and we have to change mentality because we have the technology that we can bring at the fifth floor without elevator because in Florence we are all like this. It's not like in US or most of the Europe in Flores we we develop our life in age without elevators and we have good ventilators transport ventilators so we can bring in the house the patients we have to change the mentality because from the first step you have to treat your patients in the best way you can >> okay you you in your in your writing it seems like you are even advocating which I I don't know if it's common in Europe, but it's I don't think it's very common in the United States to use a ventilator as a bag valve mask without an ET tube.

[00:10:32]So, in a non-intubated patient.

[00:10:35]>> Yeah.

[00:10:36]>> And Kirk, I know you've mentioned that about using the vent just with a mask to deliver ventilations.

[00:10:43]>> Yeah. Yeah. We did that in the back of the truck. And I got you Drew Costino was the first guy to ever kind of throw that out to our critical care team. We obviously went through progression if we had somebody in respiratory distress. Um we would put them in the progression of obviously high flow then we went non-invasive. We always had a backup rate automatically in. So if the patient then decompensated went apnneic or whatever you were already in a kind of a good spot where I essentially have you know uh non-invasive positive pressure ventilation already being instituted as a backup rate to kind of catch me while I was getting my tubes and everything ready. So it was it was helping with the preoxygenation. We all saw the preoxy study that came out. So we were already, you know, I hate to, you know, say we were already kind of doing that because we only had, you know, when I was doing critical care, we had two people in the back of the truck. So hands were limited, resources were limited. And this all came out during a code that we had. And we had another doctor that was really kind of screaming of why we did not give EPI every 3 minutes. And you know, he didn't understand the the limited resources we had in the back of the truck. We had one person on the chest doing chest compressions. The guy that was doing the airway, which was me, was the one responsible essentially for getting the meds out, getting all the equipment out while they were banging on the chest. And we flip-flop. So after that incident, we essentially then, you know, he kind of said, "Hey, why don't we, you know, try a workflow change that might help you out the next time the scenario kind of pops up." So that was essentially what we changed in our workflow uh to move forward.

[00:12:16]>> Totally agree. Uh because I I totally agree from the beginning when you have a respiratory dice you can you put in an invasive and then you have a pro oxygenation instrument so you have ants free and you can manage your resources in the best way you can. So definitely the machine does everything for us and when I can I let to the machine because I love machines because they have no brain. I put my brain on the machine but I need a machine.

[00:12:51]>> That's one thing you hear at least I hear from so many paramedics. They're they they feel the need to control the machine but the technology is so good nowadays. Let the computer in the machine dump off that cognitive load. So to your point, Kirk, you can focus on all the other stuff that you've got to manage.

[00:13:13]>> Exactly. And and that and and to that point, you know, just doing that, that's no different. You know, it's just putting it to what the machine's doing to what you would normally do. You know, when you have that patient, all you're doing is hooking up a a manual ventilator and now you're doing the positive pressure. But as we all know, we're terrible >> doing this. It's not consistent. It's very, you know, a lot of variability.

[00:13:36]And you know, one of those things people that have been to my workshops or education, something that was harped on me, variability leads to poor outcomes.

[00:13:43]You know, that was kind of how this was pushed through. So now we want to get something that is giving a consistent rate and a consistent time and it's using the knowledge that I already have in my head and just programming it in that ventilator and allowing it to do the work.

[00:13:57]>> Yeah. when you take out you evacuate the patients from the fifth floor you know let's take to uh volume guarantee and pressure regulated and take off the oxygen pre oxygenate well take off the oxygen and let the machine do the work and then you take care of the rest so that's the best way it lets do the machine control the machine because you know what is doing know what the machine is doing and then optimize is the physiology of the patient with the machine.

[00:14:32]>> What mode or I know Kirk, you've corrected me before when I say the term mode, but for lack of a better term since I'm a caveman brains paramedic. What mode or settings would you say to use? So, let's say I I arrive on scene and I find an unconscious patient who is irregularly inadequately breathing.

[00:14:57]So are you saying I in your opinion grab a bag valve mask immediately start ventilating them reposition the airway while somebody sets up the ventilator to take over not like bag valve mask ventilation. So then hook up the vent circuit to the mask and let the vent do the work while I'm holding a good seal.

[00:15:20]What settings would you use?

[00:15:23]>> Dr. Rogan, I I have my opinions. Do you have do you have opinions on your side?

[00:15:28]>> By level definitely two level by level pressure support whatever in noninvest it cuz you are holding the mask and wherever you are good you have leaks. So use noninvasive uh on uh two levels. So pressure support is fine and then with the backup. So so you follow the patience and try and look what happens.

[00:15:55]So the yeah and I think most protocols here in the United States anyway that I've seen from a buy level point of view they start at essentially an IPAP of 10 and an E of five and then you're going to adjust obviously for you know just the same thing you look at with a BVM you know chest rise and fall you know am I getting does my pulse socks look good does my end look good and then is my worker breathing you know you won't see an immediate fix but is there you know decreased worker breathing as I'm holding this they starting to it's synchronized with the ventilator, you know, but essentially it's just adjust, you know, start at 10 over five and then just kind of adjust from there, checking, you know, patient status.

[00:16:33]>> Yeah.

[00:16:34]>> Yeah. Check patient status and and volumes. If they make good volumes and the patient says it's good, ventilates, oxygenates, don't touch it. It's fine.

[00:16:43]>> And by checking volumes, just so everybody knows, would you be looking at the exhaled title volume?

[00:16:49]>> Yes.

[00:16:50]>> Okay.

[00:16:50]>> Yes.

[00:16:51]>> Yeah, definitely.

[00:16:52]>> Yep. XL totalize because you know that's going to pick up obviously your leaks you know it's going to you know obviously check that and give you some sort of I I've always said this you know a lot of times yeah I care what goes in but I don't care what goes in I want to know what's coming out you know the patient that was kind of what we always focused on >> in the on the way in is the machine on the way out is the patient so my care is on the patient >> yeah agree >> so you're saying if I pull up and I I'm I'm not questioning. I'm just if I pull up to one of those calls and the patient's breathing five, six times a minute inadequately, >> would you use by level or would you go for uh like a more like assist controller? What do you call it? SCMV plus mode on the Hamilton.

[00:17:40]>> Yeah, that's the SDM the the synchronized intermittent manatory ventilation. Yeah, that case could be a little bit different. you know, if they're agonal breathing, you know, I could, you know, I'm gonna start airing towards the side of probably intubating them, right? Depending on GCS, but, you know, could you use the ventilator?

[00:17:56]Absolutely. You know what I mean? You could use it in that fashion if you're comfortable with to kind of support them. And then if you put it in just an NIV ST mode with a backup rate that is going to adequately, you know, get a minute ventilation while you're hooking it up. And then theoretically, you know, if they don't spin around, then we're talking about, all right, I have a consistent positive pressure ventilation going in at a consistent rate if they're riding it while someone at that point, if I'm holding two hand mass CPR, somebody else should be getting ready, you know, getting getting all my equipment ready to roll. But yes, that would be consistent. But that, you know, let's be realistic here, you know, is that the current workflow? Absolutely not. You know, everybody's coming out with their >> totally different. People's heads are going to spin.

[00:18:37]>> Oh, absolutely. Oh, they'll totally spin. Oh, absolutely. Absolutely. But, you know, if you're talking about giving, you know, consistent um mechanical ventilation like that, that would be the answer. But everybody's going to grab the bag. I mean, we've all seen it.

[00:18:52]>> Um and they're going to give varying pressures. You know, that's just been the acceptable thing. And it's a workflow thing. You know, who's grabbing the ventilator? Nobody. Everybody's grabbing the the BBM. They have the mask, they have the airway, they have etc. So this would be >> and even us and even us and even us kick probably the next patient we're going to grab bag but we have to dream big for our job. So uh this is something that is the current practice probably most of the current practice but we have to look forward to dream big >> and this is not the best way the way we do and we know that there is another way so we have to go to that and we have to do it more and more to I completely agree I I knew we were recording this podcast and I knew what we were recording about I won't give the details because still a fresh call and I don't like talking about fresh calls cuz everybody could figure out what I'm talking about. I ended up innovating the the kid and beforehand I'm watching a very experienced firefighter who I very much trust perform bag valve mask ventilations on this kid and I was like my god >> he is inadequately ventilating this kid. Just looking at the mask seal, the technique, the rate, the way he's squeezing the bag, I was like and this is a good provider. So, I had to do some spot correction, but I was thinking it if he's doing it like this, what is the rest of the world doing?

[00:20:21]Because where I work, we don't have doctors prehospy. We we just a paramedic is the highest level of care. And a lot where I work and in many parts of the country, there's only one or two paramedics on a call. and others are EMTs who doc I don't know if you know in the US it's about a 100 hours of training to become an EMT.

[00:20:44]>> Yeah. Yeah. Yeah. I know.

[00:20:45]>> What do you do with the What do you do when you have to bag valve mask somebody? Most paramedics go, "Well, this is an EMT skill. I'm going to hand this off to the EMT to do while I'm getting ready to do advanced life support stuff." And it's one of the most important things and it's probably inadequately done. Uh Mike, I understood this when I saw George Kovox teaching 3 hours back mask ventilation and he said guys when you this is a basic skill but this is not for basic providers 3 hours just on back mask and if you think of our normal and medium courses we just say okay you know how to do it that's it.

[00:21:32]Yeah. No, you're you're absolutely right because anybody who has gone to paramedic school and has gone to an O, granted I went to paramedic school 21 years ago and I remember going to the O to do my first inhibations, I was all excited about it. I had been an EMT for five, six years. I come home and my wife who's now who was my girlfriend at the time, she was like, "Oh, how were how was the O?" And I was like, "The innovations were fine. The hardest damn part of being in the O was the freaking bag valve mask ventilation. Apparently, I've been doing it wrong all these years.

[00:22:04]And if you want to destroy yourself uh consideration uh bag val mask with the entire C chip and try to make all squares I don't talk I don't I don't mean numbers I mean squares waveforms breathe by breath and you look at the entire CO2 and whatever it happens around you you going to lose the square back mask is something that we have to do in the best way for for a short time whenever we can use the ventilator and two hands. Thumbs up.

[00:22:44]Mask seal is huge.

[00:22:47]Invariably, somebody would ask and I think I know that the answer is no. But if you are using the ventilator as a bag valve mask, you can't just strap it to the head, right? You have to hold a mask seal.

[00:23:03]if you're using that fasting.

[00:23:05]Absolutely. Yeah. Yeah, I would agree with him.

[00:23:08]>> So, Kirk, with the with the backup mode, let's say you're working as a respiratory therapist on the unit and patient stops breathing, the backup mode kicks in, and you go, "Oh [ __ ] they stopped breathing." How how effective are those ventilations just with the masks strapped to the patient's head?

[00:23:29]>> Well, it all has to do with steel. you know, every time we ever had anybody in non-invasive, they were always at a 30° angle when we could, you know, obviously. So, what would I would have to do in that situation, and it happened to me, you know, a handful of times, >> you know, I'd have to make sure, you know, you usually have a good seal. Um, and then you have to go up on settings.

[00:23:48]So, you might have to go up on your iPad to a total of 20 over five or whatever the oxygenation is. I would hyper oxygenate them. And then I would also crank up the rate while I was getting my airway stuff together. Um, so having a plan in, but a seal, you know, that's that's give or take, you know, that that it's good one patient, you know, it might not be good the next. So you got to make sure that's sealed. And if I don't have a good seal, you know, the first thing I would do was, you know, there I'm taking the resources and a body out, I would use the two hands and see if I can fix it that way. You know, you just do your troubleshooting, you know, case by case. Um, but you know, after that patient, you do have to go up on settings because now you have now you're pushing against a diaphragm.

[00:24:28]Nothing's moving. So, you're gonna need higher settings, which is ultimately just about every ventilator's backup is going to give you some sort of a higher B level pressure when it goes out of non-invasive.

[00:24:42]>> Okay. Doc, have you >> Oh, please go ahead.

[00:24:46]>> No, no, no. It's okay. Have you found or have they been able to measure less ga less gastric insulation when you're using a ventilator as a BVM?

[00:24:59]>> Uh yes, it depends. We are working so much on mask seal with one operator because we changing so much. we don't use anymore in our teaching course many many years the uh C grip but we chang it with the other more efficient grips to uh take to less leaks and less insulation of the uh stomach and with the two operators with the two thumbs but even when you use a ventilator as a back bag mask you still have gastric crystal >> so then you need >> the the the most common uh troubleshooting when you intubate the patients you ventilate after having even with the super careways there is a stomach uh insulation so you have to detect >> don't tell ER doctors in America that >> why >> yeah no >> we always had a protocol if we were ever like buy level if we were getting anywhere close to 20 um we had to drop an OG or an NG or something like that and open that up to to atmosphere was you know anytime we were close to the 20 range is when we had to implement that to kind of alleviate.

[00:26:17]>> Yeah.

[00:26:18]>> 100%.

[00:26:20]>> Yeah. prehos >> for us. Remember the the the last S stacks stacks bre even when you back mask cuz when you intubate and you can't ventilate the patient you can't really uh ensure a good ventilation do stack words is the most common >> yeah we we really should we do a very poor job in the US EMS of ventilating patients and then intubating them and not putting an OG tube in. We really do need to do a better job of any patient we tube should get an OG tube >> and medics like doing skills. I don't know why you wouldn't do it. It's another another tube to stick in a hole.

[00:27:02]Why wouldn't somebody want to do it?

[00:27:04]>> Yeah. And I mean it really makes a big difference. It's easy. It makes it can make a big difference when you know when that belly and you do have a lot of a lot of air and you know just like you said I didn't realize it all the time you know and then you know sometimes would be the last thing we would do and then all of a sudden it was like voila we just released all that air and now we're ventilating and if you if you measure the compliance and you see with stuck grates you see this is this is the worst set I ever had and then with just a gastric niggastric tube. Wow, it's incredible. It's incredible.

[00:27:42]>> First, >> okay, so let's let's talk about another thing with the Hamilton and again emphasizing I'm not being paid by Hamilton, but I am a believer in the product. Doc, is that are you guys using Hamilton?

[00:27:57]>> Yes. And some other models of ventilator. I'm not paid either from >> Okay.

[00:28:02]>> So, I'm just a great fan of the machine.

[00:28:06]I love uh yeah I have two or three other models of ventilator the vimman the i liquid model t60 in my in my field in my environment I use a lot of ventilators I love abbleton uh but there are many good ventilators now >> what are your thoughts on ASV >> in 20 years that we use able 21 on my helicopter probably we changed the ACB for emergency incubated patients uh twice.

[00:28:44]So it works in emergency it works and you have to have a good reason to change it something that works well. Sure.

[00:28:53]>> You need to have sometimes I go on the logs of my ventilator and I look at some try to change ASV and then you come back to ASV.

[00:29:06]>> Gotcha. Yeah. No, I always say if you're going to pick up a patient who's already on a ventilator, match the settings. If it ain't broke, don't fix it. But I think for those of us in the prehosp environment, if you're intubating a patient, ASV is a great mode to put them on. Once you drop that too, Kirk, you want to explain ASV real quick >> for people. I think people know what it is by now, but >> yeah, the barriers I'm running into, just to get back to that, it's, you know, I I just spoke with a medical director last week with a big IF company and it's a lot of what I hear and it is no, no, no. I want my my teen to understand mechanical ventilation and ASV is just going to make it, you know, it's just going to make them stupid and they're not going to learn mechanical ventilation. My my what I'm finding is a lot of, you know, with just saying it out front, the medical directors over top, they don't understand that I'm going into these places, I'm teaching mechanical ventilation from a basic level. And these are people that have been using vents for, you know, 10 years. They are not understanding the basics of mechanical ventilation in regards to basic vent strategies or basic oxygenation strategies that I trying to teach it a different way that you know your p your your team really doesn't understand mechanical ventilation. I'll give them that base knowledge of you know the basic knowledge of it but I used ASV to teach my team how mechanical ventilation should be done. So I did it in the reverse a little bit because you know in my experience the knuckle draggers are going to be the knuckle draggers you know I can't change your behavior you know but what I can do is you know take the eye out of it and you know if you use this mode you could keep it very simple and it can teach you basic mechanical ventilation strategies if you're willing to allow the ventilator to you know you would understand what the vent is actually It is not a set it and forget it. You just you have control of CO2 over minute ventilation. But what I think is more important that to to free up that cognitive load, you can now concentrate obviously on your patient. But what I think is underutilized here is, you know, PEP and FiO2, which are to me really important things that are underutilized in the United States when you're talking about, you know, BVM or mechanical ventilation. But it allows you to focus on things that you normally wouldn't focus on and understand that the vent is doing is working with the patient, not with you, with the patient.

[00:31:40]And it it's setting them up for success and and taking the human error out of it while everyone catches up from an educational point of view. Um, from a paramedic stance, >> I don't want the paramedics to be respiratory therapists.

[00:31:57]I want them to understand me the basics of mechanical ventilation, but more than that, I want them to be able to use the tool in an efficient manner.

[00:32:07]>> Yeah, >> this I I get I get wanting your paramedics to understand mechanical ventilation 100%. But that whole it's going to make them stupid is just inaccurate.

[00:32:18]>> And two, the paramedics got other stuff to worry about. Again, it's not set it and forget it, but you've got to start pressors.

[00:32:26]You got to titrate pressers. You got to give other meds. You got to be on top of your sedation. You got to do X, Y, or Z.

[00:32:33]You got to manage the 15 firefighters that are milling about the back of the ambulance.

[00:32:39]>> Yeah.

[00:32:39]>> Uh >> yeah, >> you know, I don't want the paramedics to like necessarily be nerding out over vent settings in the back of a situation like that. Just pick something that works and run with it.

[00:32:51]>> Definitely.

[00:32:53]>> Yeah. And then go ahead >> you have you have a a mode of ventilation that is physiology. This pressure is really uh sweet at this physiology and then you have uh even the target. So you have volume what you want more in emergency.

[00:33:14]So you respect our physiology for a really fragile patient and then you have your target reached automatically in a good way.

[00:33:25]It's perfect is the only way to use it to ventilate the patient in in emergency. No more volume.

[00:33:34]Pressure is like a PlayStation. You have to noology too much no. Yes, this is too much pressure regulated volume guarantee. If you have a minute volume guarantee, so you don't have to make even the ch the choice of the respiratory rate better.

[00:33:56]>> Gotcha.

[00:33:57]>> I always like to tell this story and you know how we ended up with ASV. So it was a mode we could not touch, we could not use. Um I came from a pediatric critical care background and you know I was the educator for the team. Um it was a mode we weren't weren't allowed to use. So all of a sudden you know we we reviewed 20 to 30 cases every quarter in regards to problems we've had as a team. And you know I was constantly doing remediation and and you know people were on 90 days etc etc. Well all of a sudden our QI numbers started going down. We went from 25 calls to about eight calls. And I'm like you know here I am patting myself on the back. I'm like, "Yeah, they're starting to listen to me. You know, everybody's paying attention." So, um, another six months goes by. I get a phone call from our medical director.

[00:34:43]Great guy. And he starts screaming at He's like, "I thought I told you this team's not to use ASV." And he was messing with me. I was like, "Yo, doc, I I didn't tell him to do anything. I didn't tell him to do anything." He goes, "Well, Kirk, I I I think we need to look into it." And I was like, "What's going on?" You know, he apologized for messing with me. He goes, "I'm messing with you." He said, "I think we need to look into it." So, the story was this. They had a 9-year-old asthmatic um who was basically status, almost silent chest, couldn't figure out settings. So, what the team had done, and these were, you know, I got to hand it to them. They were thinking outside the box, and this is what they were doing. They were putting patients into ASV and allowing it to figure it out.

[00:35:20]You know, what respiratory rate, what eye time, which was very important. And this is >> the point of ASV.

[00:35:26]>> Yeah. Yeah. Exactly. So what they were doing was and right before they got to the ICU because we weren't allowed to use that mode, if you go from ASV to a CMV mode, it mirrors everything it does and flips it over. So this is how they got away with it for 6 months. So they dropped the patient off at the ICU. Our medical director happened to be filling in that day and he put him on the servo ventilator, what we would normally put an asthmatic on, and the kid crumped. So they made some adjustments, kid crumped again. So he poked his head outside the door and was like, "Get back here."

[00:36:00]Well, right away I talked to the team afterward. They were like, "Oh my god, we're in trouble." He's going to know we didn't pick these settings just based off the knowledge he knew of them.

[00:36:08]>> So he turns on the vent, pulls up the last patient, there's the settings. He looks at it, he puts it in the servo, put the patient back on, and the patient starts doing better. And >> that's great.

[00:36:21]>> He absolutely looked at them and they go, "We know we're in trouble." because he he goes he goes, "How did you figure out those bent sets?" And they were like, "Uh uh uh uh >> we did the Otis and Means equation in the back of the helicopter."

[00:36:34]>> Yeah. So So really that was how you know cuz I was like you know I I wasn't taught it. It wasn't kind of rolled out.

[00:36:41]It was initially rolled out that you you know better than this you know this where you know once we were starting to use it you know I used it you know a lot as a tool. Um, you know, there were some basic non-sick vents that, you know, I could, you know, I could set that up with watching peak pressures, watching driving pressure, you know, watching plateau pressures, but to be honest in, you know, when we show up at the at at a scene or at a bedside if you're IF at a hospital, like there's a million things going on. And, you know, I'd rather I know it's working smarter. I know it's looking at plateau. I know it's looking at driving and it's going to do it. I use it as a tool somewhat you know as a crutch absolutely at times um you know it's a great tool in the toolbox and in EMS I will argue that 95% of the patients that we have intubated would do perfectly fine because what I'm hearing is I hear ASV as soon as it's talked about the first thing I hear about is what it can't do. I was like, you're talking about the grain in the sand of what it can't do. And then that's when you always have to have a backup, but you know, it's going to take care of 95, I'd say. Yeah. And this is just observational. I'm not going through any data or studies, but 95% of my patients, it got me right to where I needed to do in a safe in a safe ventilation strategy and mode.

[00:38:03]>> I agree. I think we have to we have to concentrate on teaching about troubleshooting more than how much is good as we know is is good but we have to concentrate our our teaching on how much uh what we have to do when it doesn't work.

[00:38:21]>> Yeah.

[00:38:23]>> Doc, what's your initial strategy for troubleshooting? Are there certain things you look at? Are there things you find out that are easy fixes most of the time?

[00:38:34]Yeah, most of the time my I something that I learned when there is an alarm on ASB don't do nothing. let the machine work because usually when there is a an alarm the machine is working and then fix by itself. But when it happens, something happens, I test on um volume graity pressure regulator. So I can change everything and the next step is detaching accumulator by hands, optimize the physiology and attach as again.

[00:39:14]>> Gotcha.

[00:39:16]What about you, Kirk? What are your strategies?

[00:39:20]>> Exactly. just kind of let the vet work cuz you, you know, any ventilator you're going to get alarms right from the jump.

[00:39:24]Um, and a lot of them are just while it's adjusting itself and getting to a baseline. Um, after you have it on and they've settled out a little bit, then you're you're just going back to the basics. You know, I just go back to chest rise and fall. I go to pulse socks. I go to end title.

[00:39:39]>> The ventilator itself, I think, you know, the one that does pop up in regards to ASV is um, you'll get ASV cannot meet target. Um most of the time that is just simply the pressure limit is set too low. Um I think you know it's and specifically in asthmatics um that that can be a whole you know another topic of conversation. Um but when we're talking about peak pressures everybody gets nervous around 30 to 35 in most patients. But if it's an aszmatic I let those crank out because that peak pressure that's in there is all resistance um at that point. But that's pretty much the limitation I do see with ASV. It's just ASV cannot meet target and that's just simply a a pressure adjustment as long as you know depending on the physiology.

[00:40:25]>> Yeah, that's another thing that paramedics are inadequately taught in the United States, not specifically about ASV but just more broadly. I told the class I taught this week, when you put somebody on the ventilator or you make a rudimentary change like you change the PEEP or the FIO, whatever, you've got to give it a couple minutes to work. It's not instantaneous. And just from years of going picking up patients on vents and seeing patients be managed with a ventilator, I told the class, >> you know how when you go to innovate or if you're teaching somebody how to innovate and you see their wrist start going like that, you know they have no freaking idea what they're doing >> and they're just like co they're just like cognitively vapor locked and you're like, "All right, take the linjoscope out and we need to recalibrate." I said the equival and everybody nodded their head because the paramedics are like I know exactly what you're talking about.

[00:41:20]>> If you see somebody start making a shitload of vent changes, that's the equivalent of that being tapped out.

[00:41:27]That's the equivalent of that wrist moving around.

[00:41:30]>> You got to give the vent.

[00:41:31]>> If you want to enjoy yourself, uh download the log of the ventilator with some of your colleagues and what they do in 10 seconds. They change everything.

[00:41:45]and they expect that everything change.

[00:41:51]>> I was going to I was actually just going to hit that exactly. I had a I had an agency that called me about 6 months ago and they're new to ventilation and they you know I went down and did the basic stuff but when chaos happened and you could tell when we pulled the log up you could tell when chaos happened. They were just trying to change, I think, the right button, but we were able to pull the logs and it shows every button that was pushed. They pushed every button until they got to the first one, you know, to the one that they wanted, you know, but they pushed 20 other buttons till they got to the right one that they needed to push. And it was just like relax a little bit, you know, and and keep it simple. Keep your your mind frame, keep everything relaxed. You just freaking panicked, freaked out.

[00:42:35]Obviously, I understand you're new in the vent, but you you know, you hit the silence button, the the manual breath button, the hyper oxygen button, the dim button before you actually ever got to the button you were trying to push. So, >> that just goes back to training and and just kind of relaxing.

[00:42:51]>> This kind of a funny story. We got the Hamiltons on the flight team and it was just as fate aligned that that same month. That's when I met you, Kirk. And then we went, you and I went out to a bar and we're just like shooting the breeze and I said, "Our bosses when we did the Hamilton training, somebody asked them, we weren't allowed to use ASV at first." And everyone was just like, "Fuck it. We're just going to use ASV and and blah blah blah." And they asked the boss, they're like, "Are you able to see what we do on the vent?" And the boss was like, "No, that's the one thing we don't like. Like, we can't go in and see what you did." And I'm sitting at the bar with you and you're like, "That is complete bullshit." that he's like they can very easily pull that log and see every knob that you touched, think about thought about touching.

[00:43:37]>> Yeah. And it's at the same time, you know, I get it. Everybody's like, "Oh, it's big brother." But, you know, obviously if you have a good QI process in place, you know, it's a great teaching, >> you know, trying to go back to what you're thinking. What you know, if if you know, now here we are, what would you do differently? You know, there there's Yeah, because hey, look, I I was in the same boat. you know, I was a, you know, early in my career, I made the same mistakes everybody here is, but it's just been repetition and obviously my, you know, it's my expertise, per se.

[00:44:05]Um, but, you know, we've all made those mistakes moving forward.

[00:44:08]>> Yeah.

[00:44:09]>> Yeah.

[00:44:11]>> Well, Doc, you got anything? Oh, go ahead.

[00:44:14]>> No, I just think that, you know, it's a great mode. It, you know, what I hear about it is I can't change this and I can't change that. when you talk about ASV and and I think you know I just go back to again what I was taught is it about you or is it about the patient and what's better for them and that's what you really got to think about and it's changing that mindset >> of you know I want control versus you still have control you're controlling the minute ventilation it's now picking the proper vent strategy based off that disease process and it's the same thing that the way education should come out because how it's working should be the same way let's say they have, you know, an insult during the call. You should be bagging them the same way that the vent is delivering those breaths, >> if that makes sense.

[00:45:01]>> Yeah.

[00:45:02]>> Yeah. Actually, I have highlighted right here your your quote, Doc, from the Hamilton article. It says, "Clinicians rely on a bag in their hands because we are humans," explains Dr. Runa. In the moment when you are out in the street with a young patient that is in cardiac arrest, you don't think about the volume that you inflate and you don't think about the respiratory rate. For many, the BVM is the literal metaphor for those touchandgo scenarios that highlight the gap between current manual practices and greater use of mechanical ventilation.

[00:45:33]>> Yeah. Yeah. Yeah, when we were cognitive lo I was just Kirk was saying and you was saying the the the the operator begging the kid it was a good operator with all the pressure inside you don't have uh the the skills uh your your skills they are at the lowest level. So if you have a machine, let's do the machine. Let's chest compressors. We love chess compressors cuz we are good chest compressor. We own training and we are perfect.

[00:46:04]>> Not >> do you like chest compressors? Do you like chest compressors?

[00:46:09]>> Yeah, I love them.

[00:46:10]>> Me and my nurse and nothing else in the desert around me. If there is a machine making the most important thing in cardiac arrest, let's do it. Is there a stigma against using them in Europe like there is in the United States thanks to the American Heart Associates with American Hearts Association, not just the chest compressors with the guidelines and new guidelines. They are really, really, really bad and they're trying to take ACLS at the lowest level in history.

[00:46:40]>> You ought to hook up with Dr. Peter and Tevy. I think you guys would have a lovely dinner together.

[00:46:44]>> Yeah, I think we are at the same level.

[00:46:46]We are really really agree with almost everything taking ACLS at the lowest level in history I ever seen in my career with those guidelines.

[00:46:58]>> True. Well, I'm glad to know that you use chest compression.

[00:47:00]>> I love them.

[00:47:02]>> And ventilators arrest dedicate more.

[00:47:08]>> We we still do you transport cardiac >> arrest for Yeah.

[00:47:14]>> Yeah. We we transport some some for for ECMO honestly more so because we don't have ultrasound yet in Pennsylvania and some of these codes we're unsure about.

[00:47:25]So until we get the ultrasound we're transporting some of these codes but you have them on the ventilator and you have the chest compression device going.

[00:47:37]You're just sitting there like just watching. It's really quite pleasant.

[00:47:42]You feel like the ultimate inefficiency.

[00:47:44]>> Yeah. So that's why the guidelines are so low cuz they don't understand that we work with machines. So we can do many many things reversible causes with transfer vagial ultrasound reversible causes with uh blood gas analysis uh you can do almost everything femoral artery uh puta everything because we have machets chest compressions and ventilation is no more a problem.

[00:48:12]>> Excellent. Well, do you gentlemen have anything else? We've been about 40.

[00:48:16]We're at 49 minutes now. I >> think we we definitely touched a good amount. Um, >> do you have anything else doc you want to bring up?

[00:48:23]>> Uh, many many things cuz we are at the same we are so agreeing with everything we talk about ACL trauma everything guys is so it's so good talking with you.

[00:48:33]It's really really interesting and that's there are many many things that I want to talk about probably next time.

[00:48:38]>> Yeah. No, I would love to like the ventilator talk was great. I would love to have you come back sometime to talk about cardiac arrest and trauma >> things like that.

[00:48:48]>> Let's speak. Let's talk about >> well great >> refractory.

[00:48:53]>> Well, I got your email. So, so it's it's it's going to be very very we have to understand that we have to go forward to make a ne next step. This is the basic and then we next step for our patients to save more lives.

[00:49:13]Great. Well, thank you for coming on all the way from Italy. And Kirk, you got anything to end with?

[00:49:20]>> Nah, thanks for having us on. Looking forward to the dialogue and, you know, obviously um you know, we're making strides little by little. I think, you know, we're we're providing better care um you know, as the years go by.

[00:49:34]>> All right. Well, gents, let me hit stop here.