Prolonged Field Care Podcast: Tourniquet Conversion
Prolonged Field Care Collective
[{'start': '7.919', 'end': '12.719', 'text': 'Welcome back to the PFC podcast. The'}, {'start': '10.880', 'end': '15.200', 'text': 'views and opinions you are about to hear'}, {'start': '12.719', 'end': '17.920', 'text': 'are the speakers and do not necessarily'}, {'start': '15.200', 'end': '21.080', 'text': 'reflect those of anyone else. Now on to'}, {'start': '17.920', 'end': '21.080', 'text': 'the podcast.'}, {'start': '22.160', 'end': '26.880', 'text': 'Welcome back to the PFC podcast. This is'}, {'start': '24.240', 'end': '29.199', 'text': 'Dennis and today I am with Jamie. How'}, {'start': '26.880', 'end': '32.719', 'text': 'are you doing today? Doing great. Glad'}, {'start': '29.199', 'end': '35.200', 'text': 'glad to be here, Dennis. All right. Um,'}, {'start': '32.719', 'end': '38.239', 'text': 'so just jumping into it today, I want to'}, {'start': '35.200', 'end': '39.680', 'text': 'talk about tourniquet conversion. Um, I'}, {'start': '38.239', 'end': '42.399', 'text': 'mean, we got conflicts all over the'}, {'start': '39.680', 'end': '44.520', 'text': 'world. Another one just kicked off uh'}, {'start': '42.399', 'end': '47.680', 'text': 'day ago in'}, {'start': '44.520', 'end': '50.039', 'text': 'Israel and I I promise you tourniquets'}, {'start': '47.680', 'end': '53.360', 'text': 'and tourniquet conversion going to be'}, {'start': '50.039', 'end': '56.480', 'text': 'important. So, if we could just starting'}, {'start': '53.360', 'end': '60.520', 'text': 'off, uh, what is the difference between'}, {'start': '56.480', 'end': '62.960', 'text': 'tourniquet conversion and tourniquet'}, {'start': '60.520', 'end': '66.000', 'text': 'replacement? Yeah, Dennis, this is an'}, {'start': '62.960', 'end': '69.920', 'text': 'important distinction right up front.'}, {'start': '66.000', 'end': '72.320', 'text': "Conversion is essentially you're making"}, {'start': '69.920', 'end': '74.560', 'text': 'positive efforts either because you'}, {'start': '72.320', 'end': '77.280', 'text': 'controlled hemorrhage or you determine'}, {'start': '74.560', 'end': '79.759', 'text': "that the tourniquet isn't necessary to"}, {'start': '77.280', 'end': '82.240', 'text': 'actually remove that tourniquet, right?'}, {'start': '79.759', 'end': '83.840', 'text': 'convert it to some other type of'}, {'start': '82.240', 'end': '86.640', 'text': 'hemorrhage control. That could be a'}, {'start': '83.840', 'end': '88.880', 'text': 'direct pressure dressing. It could be um'}, {'start': '86.640', 'end': '91.600', 'text': "you've achieved vascular heistasis by"}, {'start': '88.880', 'end': '93.520', 'text': 'surgical means. But in other words, you'}, {'start': '91.600', 'end': '94.960', 'text': 'have found a way to control that'}, {'start': '93.520', 'end': '97.280', 'text': "bleeding or the bleeding doesn't need to"}, {'start': '94.960', 'end': '100.079', 'text': 'be controlled with a tourniquet anymore.'}, {'start': '97.280', 'end': '102.479', 'text': 'Okay. I mean, could that also be you you'}, {'start': '100.079', 'end': '104.240', 'text': 'bought a shitty tourniquet from Amazon'}, {'start': '102.479', 'end': '106.240', 'text': "and it's failing and now you're"}, {'start': '104.240', 'end': '109.280', 'text': "replacing it with something that's"}, {'start': '106.240', 'end': '111.280', 'text': 'actually effective? Sure. Yeah. So,'}, {'start': '109.280', 'end': '113.520', 'text': 'replacement. Yeah. So, getting to the'}, {'start': '111.280', 'end': '114.720', 'text': 'point of replacement, replacement is'}, {'start': '113.520', 'end': '117.439', 'text': "something's gone wrong with your"}, {'start': '114.720', 'end': '121.040', 'text': "tourniquet or you're making an effort to"}, {'start': '117.439', 'end': '122.960', 'text': "to replace. Put a tourniquet uh that's"}, {'start': '121.040', 'end': '126.399', 'text': 'either going to do a better job or save'}, {'start': '122.960', 'end': '128.800', 'text': 'you some tissue. Um because again, the'}, {'start': '126.399', 'end': '130.800', 'text': 'mantra under care under fire is high and'}, {'start': '128.800', 'end': '132.239', 'text': "tight. And so, you're going to have a"}, {'start': '130.800', 'end': '134.959', 'text': 'lot of really strong people putting'}, {'start': '132.239', 'end': '137.280', 'text': 'tourniquets on really high. Um, and'}, {'start': '134.959', 'end': '139.599', 'text': 'those might those bleeds might be'}, {'start': '137.280', 'end': '142.720', 'text': "amenable to a tourniquet that's closer"}, {'start': '139.599', 'end': '144.720', 'text': 'in proximity to the actual wound or the'}, {'start': '142.720', 'end': '147.680', 'text': 'source of bleeding. So, save your'}, {'start': '144.720', 'end': '150.000', 'text': "patient some tissue and you're going to"}, {'start': '147.680', 'end': '153.200', 'text': "replace that tourniquet with one that's"}, {'start': '150.000', 'end': '155.840', 'text': 'more proximal or closer to the injury.'}, {'start': '153.200', 'end': '157.680', 'text': 'Yep. Perfect. Perfect. You know, just'}, {'start': '155.840', 'end': '160.400', 'text': 'make sure you know, you have to'}, {'start': '157.680', 'end': '162.000', 'text': "visualize that injury. Um, it's getting"}, {'start': '160.400', 'end': '164.000', 'text': 'colder now, so people are going to start'}, {'start': '162.000', 'end': '167.040', 'text': 'wearing more and more layers of'}, {'start': '164.000', 'end': '170.000', 'text': 'clothing. Get underneath there. Uh, find'}, {'start': '167.040', 'end': '172.000', 'text': 'where the actual injury is and then just'}, {'start': '170.000', 'end': '175.840', 'text': 'go a couple inches, two, three inches'}, {'start': '172.000', 'end': '178.720', 'text': 'above that. Correct. Great point, Denn.'}, {'start': '175.840', 'end': '181.200', 'text': 'Cool. Um, but getting into actual'}, {'start': '178.720', 'end': '183.519', 'text': "tourniquet conversion. So, we've done"}, {'start': '181.200', 'end': '185.040', 'text': 'the care under fire thing. weaving.'}, {'start': '183.519', 'end': '186.400', 'text': "Hopefully, we've done some kind of"}, {'start': '185.040', 'end': '189.519', 'text': "tourniquet replacement where we've"}, {'start': '186.400', 'end': '190.280', 'text': 'gotten it to the skin a few inches above'}, {'start': '189.519', 'end': '194.159', 'text': 'the'}, {'start': '190.280', 'end': '196.000', 'text': 'injury. Now, some time has passed.'}, {'start': '194.159', 'end': '199.599', 'text': "Hopefully, we've gotten the patient away"}, {'start': '196.000', 'end': '203.959', 'text': "from uh the X and now it's time to"}, {'start': '199.599', 'end': '208.560', 'text': 'actually think about conversion.'}, {'start': '203.959', 'end': '211.040', 'text': 'So, the guidelines are are pretty vague'}, {'start': '208.560', 'end': '215.040', 'text': 'when it comes to that. It says less than'}, {'start': '211.040', 'end': '218.560', 'text': '2 hours or, you know, if the operational'}, {'start': '215.040', 'end': '220.480', 'text': 'environment allows, which I got to be'}, {'start': '218.560', 'end': '223.360', 'text': "honest, when there's gunshots going off"}, {'start': '220.480', 'end': '226.400', 'text': 'or explosions happening in my vicinity,'}, {'start': '223.360', 'end': '228.280', 'text': 'I can constantly justify pushing that'}, {'start': '226.400', 'end': '232.080', 'text': 'longer and longer and'}, {'start': '228.280', 'end': '234.879', 'text': 'longer. Why do I need to when do I need'}, {'start': '232.080', 'end': '236.400', 'text': 'to uh convert this tourniquet? Like,'}, {'start': '234.879', 'end': '239.040', 'text': "he's stopped bleeding. I've essentially"}, {'start': '236.400', 'end': '242.000', 'text': 'saved his life.'}, {'start': '239.040', 'end': '243.599', 'text': 'Right? So the spirit of the TRIC'}, {'start': '242.000', 'end': '246.239', 'text': 'guidelines always goes back to the'}, {'start': '243.599', 'end': '247.280', 'text': 'tactical situation. Are you in an'}, {'start': '246.239', 'end': '248.640', 'text': "environment where you're creating"}, {'start': '247.280', 'end': '251.920', 'text': 'further risk to yourself and your'}, {'start': '248.640', 'end': '253.680', 'text': 'patient? So implied in your question is'}, {'start': '251.920', 'end': '256.160', 'text': 'we are now in an environment maybe with'}, {'start': '253.680', 'end': '257.759', 'text': 'better lights, better environmental'}, {'start': '256.160', 'end': '259.120', 'text': 'controls where I can really expose the'}, {'start': '257.759', 'end': '262.079', 'text': "patient. I can see what I'm dealing"}, {'start': '259.120', 'end': '264.400', 'text': "with. Um and I've provided for that"}, {'start': '262.079', 'end': '266.320', 'text': "hemorrhage control by other means. Now's"}, {'start': '264.400', 'end': '267.840', 'text': 'the time to convert that tourniquet.'}, {'start': '266.320', 'end': '270.199', 'text': "That's what the guidelines are talking"}, {'start': '267.840', 'end': '272.800', 'text': 'about when they'}, {'start': '270.199', 'end': '275.520', 'text': 'say based on your tactical situation or'}, {'start': '272.800', 'end': '277.280', 'text': 'as the operational situation allows.'}, {'start': '275.520', 'end': '279.520', 'text': 'Really, what I want people to take away'}, {'start': '277.280', 'end': '281.680', 'text': 'is you need to be pushing for that as'}, {'start': '279.520', 'end': '283.600', 'text': 'soon as you have resuscitated that'}, {'start': '281.680', 'end': '286.080', 'text': 'patient. Now, what does that mean? The'}, {'start': '283.600', 'end': '289.280', 'text': 'goals of resuscitation in a patient'}, {'start': '286.080', 'end': '292.080', 'text': "that's had tourniquets placed for reason"}, {'start': '289.280', 'end': '295.520', 'text': 'of hemorrhage or bleeding and they and'}, {'start': '292.080', 'end': '297.360', 'text': 'shock is a potential is your goal is at'}, {'start': '295.520', 'end': '300.000', 'text': "some point that patient's going to need"}, {'start': '297.360', 'end': '302.280', 'text': 'surgical management or we want to try'}, {'start': '300.000', 'end': '305.840', 'text': 'and replace that blood loss at a bare'}, {'start': '302.280', 'end': '307.360', 'text': 'minimum. So resuscitation is key as'}, {'start': '305.840', 'end': '308.960', 'text': "you're thinking about converting that"}, {'start': '307.360', 'end': '310.560', 'text': 'tourniquet. The very first question you'}, {'start': '308.960', 'end': '312.800', 'text': 'should ask is is my patient'}, {'start': '310.560', 'end': '315.120', 'text': 'resuscitated? The answer to those'}, {'start': '312.800', 'end': '317.280', 'text': 'questions lies in in is that patient'}, {'start': '315.120', 'end': '319.759', 'text': 'warm and non-coagulopathic? Have you'}, {'start': '317.280', 'end': '322.160', 'text': 'restored volume and the ability to get'}, {'start': '319.759', 'end': '324.560', 'text': 'oxygen to those tissues? You can answer'}, {'start': '322.160', 'end': '327.840', 'text': 'yes to those questions, which you really'}, {'start': '324.560', 'end': '330.960', 'text': 'should after about 30 minutes. Uh we can'}, {'start': '327.840', 'end': '333.840', 'text': 'go into that in a little bit, but after'}, {'start': '330.960', 'end': '335.360', 'text': '30 minutes, you had best be thinking'}, {'start': '333.840', 'end': '337.039', 'text': 'about tourniquet conversion because'}, {'start': '335.360', 'end': '339.199', 'text': 'after 30 minutes, you probably should'}, {'start': '337.039', 'end': '343.280', 'text': 'have blood products on board. Does that'}, {'start': '339.199', 'end': '345.240', 'text': 'make sense? It 100% does. Um what goals'}, {'start': '343.280', 'end': '347.199', 'text': 'for resuscitation'}, {'start': '345.240', 'end': '349.280', 'text': "because you know there's kind of the"}, {'start': '347.199', 'end': '353.039', 'text': "combat ones like well he's got a radio"}, {'start': '349.280', 'end': '354.560', 'text': 'pulse. Um you know his mentating a'}, {'start': '353.039', 'end': '357.680', 'text': 'little bit better than what he was'}, {'start': '354.560', 'end': '361.039', 'text': 'before um before I gave him you know a'}, {'start': '357.680', 'end': '364.880', 'text': 'butt ton of ketamine um to control my'}, {'start': '361.039', 'end': '367.440', 'text': 'own heart rate. Um or kind of the ICU'}, {'start': '364.880', 'end': '371.680', 'text': 'thing of like well you know his urine'}, {'start': '367.440', 'end': '374.000', 'text': 'output is 30 to 50 an hour. um you know'}, {'start': '371.680', 'end': '376.639', 'text': 'tissue oxygenation is up you know all'}, {'start': '374.000', 'end': '378.560', 'text': 'those you know finer end points but on'}, {'start': '376.639', 'end': '381.440', 'text': "the battlefield I don't I don't have"}, {'start': '378.560', 'end': '384.639', 'text': 'those you know at best I got a you know'}, {'start': '381.440', 'end': '388.720', 'text': 'a manual blood pressure cuff and my'}, {'start': '384.639', 'end': '390.639', 'text': 'fingers yeah so great what I love about'}, {'start': '388.720', 'end': '394.240', 'text': 'this is the spirit of looking at the'}, {'start': '390.639', 'end': '397.400', 'text': 'whole patient uh so again implied in'}, {'start': '394.240', 'end': '400.240', 'text': "this question is you've achieved"}, {'start': '397.400', 'end': '402.080', 'text': "a security. So, you're in a secure"}, {'start': '400.240', 'end': '403.600', 'text': 'environment or a semi-secure environment'}, {'start': '402.080', 'end': '406.000', 'text': 'where you have some time to really'}, {'start': '403.600', 'end': '408.240', 'text': "assess your patient. What we're looking"}, {'start': '406.000', 'end': '410.319', 'text': 'for is all those measures you just said,'}, {'start': '408.240', 'end': '411.840', 'text': "Dennis. We're looking for, you know, is"}, {'start': '410.319', 'end': '413.280', 'text': 'the patient still shocky? Do they have'}, {'start': '411.840', 'end': '415.039', 'text': 'poor profusion? Are they cool and'}, {'start': '413.280', 'end': '416.720', 'text': 'clammy? Are they not ventating? Well,'}, {'start': '415.039', 'end': '417.919', 'text': "well, that's not a resuscitated patient."}, {'start': '416.720', 'end': '420.319', 'text': "I'm not going to have time to look at"}, {'start': '417.919', 'end': '422.319', 'text': 'urine output, right? But I can look at'}, {'start': '420.319', 'end': '425.680', 'text': "their skin and I'm fairly familiar with"}, {'start': '422.319', 'end': '427.280', 'text': 'my patients uh progression by looking at'}, {'start': '425.680', 'end': '429.360', 'text': "their skin and I that's something I can"}, {'start': '427.280', 'end': '431.319', 'text': 'appreciate over the course of that 30'}, {'start': '429.360', 'end': '433.599', 'text': 'minutes, hour, 90'}, {'start': '431.319', 'end': '435.400', 'text': 'minutes. Um are they getting better'}, {'start': '433.599', 'end': '437.599', 'text': 'peripheral perfeating'}, {'start': '435.400', 'end': '440.240', 'text': 'better? You throw that blood pressure'}, {'start': '437.599', 'end': '441.919', 'text': 'cuff on and you got a systolic above 90.'}, {'start': '440.240', 'end': '445.160', 'text': "Now there's a lot of discussion in the"}, {'start': '441.919', 'end': '449.120', 'text': 'guidelines on this 90'}, {'start': '445.160', 'end': '451.880', 'text': '100 110 millimeters of mercury versus'}, {'start': '449.120', 'end': '454.160', 'text': 'stoic for goals before'}, {'start': '451.880', 'end': '455.680', 'text': "converting. What I would say is is don't"}, {'start': '454.160', 'end': '457.759', 'text': 'get wrapped around the axle on those'}, {'start': '455.680', 'end': '459.759', 'text': 'numbers. This is cutting edge medicine,'}, {'start': '457.759', 'end': '462.160', 'text': "right? On PFC we're in an austere"}, {'start': '459.759', 'end': '463.840', 'text': "environment. Here's why. If you're in a"}, {'start': '462.160', 'end': '466.080', 'text': 'hospital with bright lights and a blood'}, {'start': '463.840', 'end': '467.520', 'text': 'bank, absolutely those numbers apply to'}, {'start': '466.080', 'end': '469.120', 'text': "you. But if you're in a field"}, {'start': '467.520', 'end': '471.520', 'text': 'environment where you have very limited'}, {'start': '469.120', 'end': '473.680', 'text': "blood supply and you're likely going to"}, {'start': '471.520', 'end': '475.280', 'text': 'be triaging that blood between multiple'}, {'start': '473.680', 'end': '477.120', 'text': 'patients, I just need you to get that'}, {'start': '475.280', 'end': '478.560', 'text': "patient to a level where they're fairly"}, {'start': '477.120', 'end': '480.000', 'text': "well resuscitated, where they're"}, {'start': '478.560', 'end': '483.919', 'text': "survivable and we're not going to have"}, {'start': '480.000', 'end': '487.440', 'text': 'further bleeding. So you may not get to'}, {'start': '483.919', 'end': '489.120', 'text': 'a full 90 or millimeters of mercury, but'}, {'start': '487.440', 'end': '491.199', 'text': "you've got hemorrhage control. You've"}, {'start': '489.120', 'end': '493.120', 'text': "got a warm patient who's not"}, {'start': '491.199', 'end': '495.360', 'text': "coagulopathic. They're not continuing to"}, {'start': '493.120', 'end': '498.160', 'text': 'bleed. Those are really what I want you'}, {'start': '495.360', 'end': '500.639', 'text': 'to think when we think of auster damage'}, {'start': '498.160', 'end': '502.080', 'text': 'control resuscitation. I want to give'}, {'start': '500.639', 'end': '503.759', 'text': "blood to the point where I've improved"}, {'start': '502.080', 'end': '504.680', 'text': 'the clinical stability and thus survival'}, {'start': '503.759', 'end': '507.039', 'text': 'of my'}, {'start': '504.680', 'end': '510.000', 'text': "patient. Colonel Shackleford's great"}, {'start': '507.039', 'end': '512.159', 'text': 'publication in JAMA 2016 reminds us all'}, {'start': '510.000', 'end': '514.000', 'text': 'you got 30 minutes to do that to get'}, {'start': '512.159', 'end': '515.839', 'text': 'your blood on board for it to really'}, {'start': '514.000', 'end': '517.519', 'text': 'make a difference in mortality. Now'}, {'start': '515.839', 'end': '519.839', 'text': 'again that was packed cells in that that'}, {'start': '517.519', 'end': '522.000', 'text': 'article but we do know that sooner is'}, {'start': '519.839', 'end': '524.360', 'text': 'better for whole blood as well whether'}, {'start': '522.000', 'end': '527.600', 'text': "that's cold or fresh"}, {'start': '524.360', 'end': '529.360', 'text': 'warm but bottom line get have that 30'}, {'start': '527.600', 'end': '531.600', 'text': 'minutes in mind for your resuscitation'}, {'start': '529.360', 'end': '533.120', 'text': 'goal and then in that next 30 minutes'}, {'start': '531.600', 'end': '534.800', 'text': 'you best be thinking about converting'}, {'start': '533.120', 'end': '537.120', 'text': 'that tourniquet because your patient'}, {'start': '534.800', 'end': '541.240', 'text': 'should be fairly resuscitated at that'}, {'start': '537.120', 'end': '544.000', 'text': 'point. Okay. So the 2hour'}, {'start': '541.240', 'end': '546.680', 'text': 'mark I got to be honest it sounds a'}, {'start': '544.000', 'end': '550.640', 'text': 'little bit arbitrary like exactly 2'}, {'start': '546.680', 'end': '552.320', 'text': 'hours. So what what is happening? I put'}, {'start': '550.640', 'end': '554.720', 'text': 'the tourniquet on the bleeding is'}, {'start': '552.320', 'end': '558.000', 'text': 'stopped you know the essentially the'}, {'start': '554.720', 'end': '561.680', 'text': 'dangerous part is passed right bleeding'}, {'start': '558.000', 'end': '563.920', 'text': 'to death. What is happening you know'}, {'start': '561.680', 'end': '566.000', 'text': 'physiologically why like why do they say'}, {'start': '563.920', 'end': '568.640', 'text': "2 hours? What's what's dangerous is"}, {'start': '566.000', 'end': '570.560', 'text': "building up? Yeah. So, let's talk"}, {'start': '568.640', 'end': '573.760', 'text': 'science on this one, Dennis. Where do we'}, {'start': '570.560', 'end': '575.839', 'text': 'think that two hours came from? Um, so'}, {'start': '573.760', 'end': '577.839', 'text': 'first off, a tilt of the hat to John'}, {'start': '575.839', 'end': '580.560', 'text': "Craig. For those who don't know, this is"}, {'start': '577.839', 'end': '583.360', 'text': 'the father of evidence-based tourniquet'}, {'start': '580.560', 'end': '586.560', 'text': 'medicine. Um, so Dr. Craig, well over'}, {'start': '583.360', 'end': '588.800', 'text': '200 publications on tourniquets and and'}, {'start': '586.560', 'end': '590.560', 'text': 'as a standing and voting member of the'}, {'start': '588.800', 'end': '592.959', 'text': 'committee on tactical combat casualty'}, {'start': '590.560', 'end': '595.040', 'text': 'care, um, John took it on as as a'}, {'start': '592.959', 'end': '596.560', 'text': 'passion to really provide the medic best'}, {'start': '595.040', 'end': '597.839', 'text': "evidence and support for what they're"}, {'start': '596.560', 'end': '600.399', 'text': 'doing.'}, {'start': '597.839', 'end': '601.920', 'text': 'The issue here is that a lot of the a'}, {'start': '600.399', 'end': '603.360', 'text': 'lot of the science on this is is'}, {'start': '601.920', 'end': '606.040', 'text': 'hospital-based science. So, we looked at'}, {'start': '603.360', 'end': '608.240', 'text': 'orthopedics literature. How long do'}, {'start': '606.040', 'end': '610.240', 'text': 'orthopods have the tourniquet up when'}, {'start': '608.240', 'end': '612.560', 'text': "they're doing a joint procedure in the"}, {'start': '610.240', 'end': '614.160', 'text': 'operating room? Well, immediately,'}, {'start': '612.560', 'end': '615.680', 'text': "Dennis, you're thinking, well, gosh,"}, {'start': '614.160', 'end': '617.839', 'text': "that's an operating room. They've got"}, {'start': '615.680', 'end': '619.839', 'text': 'all the blood, all the resuscitation'}, {'start': '617.839', 'end': '621.680', 'text': "fluids they need. I mean, that patient's"}, {'start': '619.839', 'end': '623.920', 'text': "warm. They're controlling everything on"}, {'start': '621.680', 'end': '626.320', 'text': 'that patient, including their breathing.'}, {'start': '623.920', 'end': '629.040', 'text': 'Um, so probably not the best surrogate'}, {'start': '626.320', 'end': '630.720', 'text': 'for us. So when we think about the field'}, {'start': '629.040', 'end': '633.760', 'text': 'environment, what I would rather have'}, {'start': '630.720', 'end': '636.000', 'text': 'folks think about is is tissue debt,'}, {'start': '633.760', 'end': '638.000', 'text': "right? What's the what's the tissue debt"}, {'start': '636.000', 'end': '640.160', 'text': "we're developing? In other words, what's"}, {'start': '638.000', 'end': '642.320', 'text': 'the body not getting on that tournicated'}, {'start': '640.160', 'end': '644.800', 'text': "extremity that it needs that I'm going"}, {'start': '642.320', 'end': '647.760', 'text': 'to pay for later as a medic? Because you'}, {'start': '644.800', 'end': '650.800', 'text': 'will pay for that at some point. So'}, {'start': '647.760', 'end': '652.800', 'text': "don't kick your own butt, right? Get"}, {'start': '650.800', 'end': '656.000', 'text': 'that tourniquet down as soon as you can.'}, {'start': '652.800', 'end': '658.880', 'text': "So you're reducing that metabolic load,"}, {'start': '656.000', 'end': '661.360', 'text': 'the acidosis, the hypercalemia, the'}, {'start': '658.880', 'end': '663.760', 'text': 'electrolyte abnormalities, all those'}, {'start': '661.360', 'end': '666.440', 'text': 'metabolic waste products that occur in'}, {'start': '663.760', 'end': '670.079', 'text': "tissue when it's not getting good blood"}, {'start': '666.440', 'end': '672.079', 'text': "flow. So that's the why. Now the two"}, {'start': '670.079', 'end': '675.200', 'text': 'hours again, we can go back to World War'}, {'start': '672.079', 'end': '677.360', 'text': 'II literature and when when tourniquets'}, {'start': '675.200', 'end': '679.279', 'text': 'were were being used very effectively.'}, {'start': '677.360', 'end': '681.600', 'text': 'Wolf and Atkins is a great Google'}, {'start': '679.279', 'end': '686.000', 'text': 'search. So for the listeners, Google two'}, {'start': '681.600', 'end': '688.560', 'text': 'army surgeons in 1944 or 45 published um'}, {'start': '686.000', 'end': '691.120', 'text': 'a a case series on their patients that'}, {'start': '688.560', 'end': '693.680', 'text': 'arrived at their surgical facility far'}, {'start': '691.120', 'end': '696.640', 'text': 'forward in northern Italy and they found'}, {'start': '693.680', 'end': '699.279', 'text': 'that they were able to save limbs up to'}, {'start': '696.640', 'end': '701.839', 'text': '6 hours of tourniquet time. Important'}, {'start': '699.279', 'end': '703.360', 'text': 'caveat here, those patients h were'}, {'start': '701.839', 'end': '705.519', 'text': "cooler because again you're in the"}, {'start': '703.360', 'end': '707.839', 'text': 'northern Italian Alps. Um, these'}, {'start': '705.519', 'end': '709.360', 'text': 'patients had longer transport times and'}, {'start': '707.839', 'end': '711.279', 'text': 'so oftentimes they would arrive with'}, {'start': '709.360', 'end': '714.839', 'text': 'long tourniquet times but the extremity'}, {'start': '711.279', 'end': '717.279', 'text': 'was cool. Notice I say not frozen but'}, {'start': '714.839', 'end': '719.200', 'text': 'cool. We are not recommending that'}, {'start': '717.279', 'end': '721.920', 'text': 'people intentionally cool limbs to'}, {'start': '719.200', 'end': '724.079', 'text': "prolong tourniquet time. We don't know"}, {'start': '721.920', 'end': '725.839', 'text': 'that study is yet to be done. I think'}, {'start': '724.079', 'end': '728.079', 'text': 'the Institute of Surgical Research was'}, {'start': '725.839', 'end': '730.800', 'text': 'actually looking at that study. Can we'}, {'start': '728.079', 'end': '734.079', 'text': 'cool limbs to prolong tourniquet time?'}, {'start': '730.800', 'end': '735.680', 'text': 'Until that study happens, 2 hours is'}, {'start': '734.079', 'end': '737.760', 'text': 'absolutely your threshold because at'}, {'start': '735.680', 'end': '739.680', 'text': "that point you're creating metabolic"}, {'start': '737.760', 'end': '742.000', 'text': "disaster that you don't have the tools"}, {'start': '739.680', 'end': '743.680', 'text': 'to deal with in the field. Sure, keep'}, {'start': '742.000', 'end': '745.680', 'text': 'that tourniquet on for three, four, five'}, {'start': '743.680', 'end': '747.279', 'text': 'hours, but be prepared for the'}, {'start': '745.680', 'end': '750.880', 'text': "consequences when you do because they're"}, {'start': '747.279', 'end': '753.800', 'text': 'going to be big. Yep. And what I love'}, {'start': '750.880', 'end': '755.920', 'text': 'telling the students, and they hate'}, {'start': '753.800', 'end': '759.120', 'text': "hearing, you're going to pay for"}, {'start': '755.920', 'end': '761.839', 'text': 'everything you do or fail to do. And so'}, {'start': '759.120', 'end': '763.760', 'text': "what you've done kind of in haste"}, {'start': '761.839', 'end': '765.720', 'text': "initially, you're going to pay for later"}, {'start': '763.760', 'end': '768.800', 'text': 'on. Um,'}, {'start': '765.720', 'end': '770.120', 'text': "so you know, you sold me. I'm going to"}, {'start': '768.800', 'end': '772.560', 'text': 'convert my'}, {'start': '770.120', 'end': '775.200', 'text': 'tourniquet. How actually do I need to'}, {'start': '772.560', 'end': '776.959', 'text': 'get this done?'}, {'start': '775.200', 'end': '779.040', 'text': "Yeah, Dennis, how come you didn't ask me"}, {'start': '776.959', 'end': '782.480', 'text': 'like, do I do a quarter turn on the'}, {'start': '779.040', 'end': '784.399', 'text': 'windless every 5 seconds? You know, how'}, {'start': '782.480', 'end': '786.320', 'text': "come this isn't protocolized? Or I have"}, {'start': '784.399', 'end': '789.440', 'text': 'medics ask all the time, "Well, I heard'}, {'start': '786.320', 'end': '791.120', 'text': 'you need to do a half turn, reassess, do'}, {'start': '789.440', 'end': '793.760', 'text': "another half turn, and then I've had"}, {'start': '791.120', 'end': '795.360', 'text': 'some medics say just windless loose and'}, {'start': '793.760', 'end': '798.760', 'text': 'be prepared and watch the limb and see'}, {'start': '795.360', 'end': '801.760', 'text': 'what happens." What\'s the right answer?'}, {'start': '798.760', 'end': '803.680', 'text': 'Yes. Yes. Is the right answer. Anytime'}, {'start': '801.760', 'end': '805.279', 'text': "we've got that much diversity of opinion"}, {'start': '803.680', 'end': '807.360', 'text': 'in medicine, it tells us that we lack'}, {'start': '805.279', 'end': '810.320', 'text': 'the evidence to really definitively say'}, {'start': '807.360', 'end': '811.839', 'text': 'one way or the other is right. I I am'}, {'start': '810.320', 'end': '813.880', 'text': 'not personally aware of any any'}, {'start': '811.839', 'end': '816.279', 'text': "literature that's that's compared or"}, {'start': '813.880', 'end': '819.040', 'text': 'evaluated either in a prospective'}, {'start': '816.279', 'end': '821.279', 'text': 'fashion or retrospectively tourniquet'}, {'start': '819.040', 'end': '822.800', 'text': 'conversion techniques. In other words,'}, {'start': '821.279', 'end': '825.200', 'text': "what's the best way to take down a"}, {'start': '822.800', 'end': '827.839', 'text': 'tourniquet? Um we have a lot of case'}, {'start': '825.200', 'end': '829.760', 'text': 'reports of how to do that. And so what I'}, {'start': '827.839', 'end': '832.000', 'text': 'would tell folks is be less worried'}, {'start': '829.760', 'end': '834.079', 'text': 'about the how on the widget and be more'}, {'start': '832.000', 'end': '836.320', 'text': 'worried about your patient. So whichever'}, {'start': '834.079', 'end': '840.320', 'text': 'way you choose to reduce that tourniquet'}, {'start': '836.320', 'end': '842.480', 'text': 'or take it down and take it off um one'}, {'start': '840.320', 'end': '844.079', 'text': 'look at your patient be less worried'}, {'start': '842.480', 'end': '845.519', 'text': "about what type of tourniquet how you're"}, {'start': '844.079', 'end': '847.600', 'text': 'doing the tourniquet how many turns on'}, {'start': '845.519', 'end': '849.760', 'text': "the windless look at how your patient's"}, {'start': '847.600', 'end': '852.480', 'text': 'doing. Are they resuscitated? Do you'}, {'start': '849.760', 'end': '854.079', 'text': 'have means for for primary and alternate'}, {'start': '852.480', 'end': '856.560', 'text': 'control of hemorrhage if they start'}, {'start': '854.079', 'end': '858.480', 'text': 'bleeding again on that extremity?'}, {'start': '856.560', 'end': '860.240', 'text': 'Obviously, you can return it if you'}, {'start': '858.480', 'end': '861.839', 'text': 'want, but that sort of defeats the point'}, {'start': '860.240', 'end': '863.279', 'text': "of why you're why you're trying to"}, {'start': '861.839', 'end': '865.959', 'text': "convert and why you're trying to get it"}, {'start': '863.279', 'end': '868.240', 'text': 'off. And then most'}, {'start': '865.959', 'end': '870.160', 'text': 'importantly, as you take that tourniquet'}, {'start': '868.240', 'end': '872.320', 'text': 'off, be prepared for especially if'}, {'start': '870.160', 'end': '875.120', 'text': 'tourniquet time is prolonged, 2 hours or'}, {'start': '872.320', 'end': '877.120', 'text': 'longer, be prepared for that reperusion'}, {'start': '875.120', 'end': '878.399', 'text': 'injury, which is all those metabolic'}, {'start': '877.120', 'end': '881.920', 'text': 'waste products getting back to the'}, {'start': '878.399', 'end': '886.480', 'text': 'patient. Yeah. And I would say just from'}, {'start': '881.920', 'end': '890.079', 'text': 'you know experience um those uh those'}, {'start': '886.480', 'end': '893.199', 'text': 'problems that that will ensue do not'}, {'start': '890.079', 'end': '895.600', 'text': 'happen quickly. Um strangely enough they'}, {'start': '893.199', 'end': '898.560', 'text': 'seem to take long enough that you start'}, {'start': '895.600', 'end': '901.839', 'text': "to feel confident about what you've done"}, {'start': '898.560', 'end': '905.120', 'text': 'and then they start coming in. So being'}, {'start': '901.839', 'end': '907.760', 'text': 'prepared um things like calcium, things'}, {'start': '905.120', 'end': '910.560', 'text': 'like just having more uh hemorrhage'}, {'start': '907.760', 'end': '913.320', 'text': 'control things available. um monitoring'}, {'start': '910.560', 'end': '916.160', 'text': 'that patient constantly.'}, {'start': '913.320', 'end': '919.279', 'text': 'Um I find that if I have done all those'}, {'start': '916.160', 'end': '922.320', 'text': 'things then everything seems to go quick'}, {'start': '919.279', 'end': '923.839', 'text': "go well for me and my patient but it's"}, {'start': '922.320', 'end': '924.680', 'text': "the moment that I don't have those"}, {'start': '923.839', 'end': '926.959', 'text': 'things'}, {'start': '924.680', 'end': '929.199', 'text': "prepared that's when the badness starts"}, {'start': '926.959', 'end': '931.600', 'text': 'happening. Yeah. Well said. Chance'}, {'start': '929.199', 'end': '933.920', 'text': 'favors the prepared mind. Right.'}, {'start': '931.600', 'end': '937.920', 'text': 'The other thing Dennis is is we have a'}, {'start': '933.920', 'end': '940.800', 'text': 'huge uh knowledge canyon or a knowledge'}, {'start': '937.920', 'end': '943.040', 'text': 'divide here in that think about how many'}, {'start': '940.800', 'end': '946.079', 'text': 'people are trained to apply tourniquets'}, {'start': '943.040', 'end': '948.399', 'text': 'right now and how confident right so'}, {'start': '946.079', 'end': '950.240', 'text': "there's a huge confidence gap really if"}, {'start': '948.399', 'end': '952.639', 'text': "we want to use a term it's a confidence"}, {'start': '950.240', 'end': '955.120', 'text': "gap we've got a huge portion of our"}, {'start': '952.639', 'end': '958.240', 'text': 'military population that is confident'}, {'start': '955.120', 'end': '960.240', 'text': 'and even eager to throw a tourniquet on.'}, {'start': '958.240', 'end': '962.480', 'text': 'How many people do we have that share'}, {'start': '960.240', 'end': '964.560', 'text': 'that same level of confidence for'}, {'start': '962.480', 'end': '967.040', 'text': 'reducing or converting that trinket and'}, {'start': '964.560', 'end': '969.839', 'text': 'taking it off? I would say probably far'}, {'start': '967.040', 'end': '972.720', 'text': 'less. Um, so really this puts a lot of'}, {'start': '969.839', 'end': '974.800', 'text': 'pressure on our medics and our corman to'}, {'start': '972.720', 'end': '976.399', 'text': 'look at, okay, have I met the'}, {'start': '974.800', 'end': '978.480', 'text': 'parameters? Can I take this tourniquet'}, {'start': '976.399', 'end': '980.880', 'text': 'down? Was it even appropriately placed?'}, {'start': '978.480', 'end': '982.959', 'text': 'You used a great term earlier, hasty.'}, {'start': '980.880', 'end': '984.959', 'text': 'Right. Great. Throw that hasty'}, {'start': '982.959', 'end': '986.240', 'text': 'tourniquet on. But the implication is'}, {'start': '984.959', 'end': '987.519', 'text': "there at some point we're going to be"}, {'start': '986.240', 'end': '991.040', 'text': "not hasty and we're going to be"}, {'start': '987.519', 'end': '993.040', 'text': 'deliberate about our medicine. Yep.'}, {'start': '991.040', 'end': '995.759', 'text': 'Yeah. Absolutely. And I would even'}, {'start': '993.040', 'end': '998.880', 'text': 'caveat like the providers that are going'}, {'start': '995.759', 'end': '1000.560', 'text': "to be at the aid stations. If you've"}, {'start': '998.880', 'end': '1002.000', 'text': 'trained over 20 years, throw a'}, {'start': '1000.560', 'end': '1004.880', 'text': 'tourniquet on it. Throw a tourniquet.'}, {'start': '1002.000', 'end': '1007.800', 'text': "Throw a tourniquet on it. um that's the"}, {'start': '1004.880', 'end': '1010.880', 'text': "patient that's going to arrive"}, {'start': '1007.800', 'end': '1013.240', 'text': "and you're going to have to start doing"}, {'start': '1010.880', 'end': '1016.320', 'text': 'lots and lots and lots of tourniquet'}, {'start': '1013.240', 'end': '1019.120', 'text': 'conversions which are not easy not easy'}, {'start': '1016.320', 'end': '1021.880', 'text': 'at all and they are all going to require'}, {'start': '1019.120', 'end': '1024.160', 'text': 'uh some kind of resources and time'}, {'start': '1021.880', 'end': '1028.000', 'text': 'management in order to get these things'}, {'start': '1024.160', 'end': '1030.240', 'text': 'done. So I would caution uh providers or'}, {'start': '1028.000', 'end': '1033.240', 'text': 'senior medics or whomever that are doing'}, {'start': '1030.240', 'end': '1033.240', 'text': 'training'}, {'start': '1034.079', 'end': '1038.400', 'text': 'give the training model that is'}, {'start': '1035.919', 'end': '1041.120', 'text': 'appropriate to do this intervention, not'}, {'start': '1038.400', 'end': '1044.720', 'text': 'just kind of the whitewash of just throw'}, {'start': '1041.120', 'end': '1046.160', 'text': "turn on it, it's good. Move on. Great"}, {'start': '1044.720', 'end': '1047.679', 'text': "point. You're going to pay for that."}, {'start': '1046.160', 'end': '1049.039', 'text': "You're going to pay for that. That's"}, {'start': '1047.679', 'end': '1051.840', 'text': "exactly it. You're stuck with the"}, {'start': '1049.039', 'end': '1053.280', 'text': "physiology you've created. Unlike, you"}, {'start': '1051.840', 'end': '1055.520', 'text': 'know, at the peak of the war in the'}, {'start': '1053.280', 'end': '1057.039', 'text': 'global war on terror, I could throw as'}, {'start': '1055.520', 'end': '1058.400', 'text': 'many tourniquets on as I wanted because'}, {'start': '1057.039', 'end': '1061.360', 'text': 'you know whose problem that was going to'}, {'start': '1058.400', 'end': '1062.799', 'text': "be? Somebody in the oper, right? It's"}, {'start': '1061.360', 'end': '1064.240', 'text': "going to be the trauma team's problem."}, {'start': '1062.799', 'end': '1066.799', 'text': "And they've got a whole team. They've"}, {'start': '1064.240', 'end': '1069.200', 'text': 'got bright lights and cold steel to deal'}, {'start': '1066.799', 'end': '1070.799', 'text': 'with those issues. And all of our'}, {'start': '1069.200', 'end': '1072.400', 'text': 'patients were in those operating rooms'}, {'start': '1070.799', 'end': '1074.640', 'text': 'to have those tourniquets taken down in'}, {'start': '1072.400', 'end': '1076.000', 'text': 'a controlled setting. Well, that may not'}, {'start': '1074.640', 'end': '1078.720', 'text': "be the case. And if you're listening to"}, {'start': '1076.000', 'end': '1080.799', 'text': "this podcast, that's you, right? Our"}, {'start': '1078.720', 'end': '1082.480', 'text': "listeners, folks that won't have the"}, {'start': '1080.799', 'end': '1084.480', 'text': 'bright lights and cold steel always'}, {'start': '1082.480', 'end': '1087.720', 'text': 'readily available. So, these are great'}, {'start': '1084.480', 'end': '1090.960', 'text': "points you're making. Yeah."}, {'start': '1087.720', 'end': '1092.520', 'text': 'So, you know, we extended times on'}, {'start': '1090.960', 'end': '1095.280', 'text': "tourniquets. It's going to be"}, {'start': '1092.520', 'end': '1097.440', 'text': "inevitable. We're talking about Ukraine,"}, {'start': '1095.280', 'end': '1100.799', 'text': 'you know, bombardments that are lasting'}, {'start': '1097.440', 'end': '1103.679', 'text': '4 hours, 6 hours until they can get just'}, {'start': '1100.799', 'end': '1107.679', 'text': "get the guy off the ax, that's going to"}, {'start': '1103.679', 'end': '1109.480', 'text': 'happen. Okay. what kind of things now'}, {'start': '1107.679', 'end': '1112.000', 'text': 'that I want to do this tourniquet'}, {'start': '1109.480', 'end': '1113.679', 'text': "conversion whether that because I'm"}, {'start': '1112.000', 'end': '1115.600', 'text': "receiving a patient it's been on there"}, {'start': '1113.679', 'end': '1118.640', 'text': 'for a long time whether that be'}, {'start': '1115.600', 'end': '1120.720', 'text': "operationally it's taken a it's taken a"}, {'start': '1118.640', 'end': '1125.240', 'text': 'long time to get the patient to that'}, {'start': '1120.720', 'end': '1127.760', 'text': 'place um that we can now do this uh'}, {'start': '1125.240', 'end': '1129.840', 'text': 'procedure what do I need to watch out'}, {'start': '1127.760', 'end': '1131.880', 'text': 'for?'}, {'start': '1129.840', 'end': '1135.200', 'text': 'Yeah, great great'}, {'start': '1131.880', 'end': '1137.440', 'text': 'question. So, this is where we have a'}, {'start': '1135.200', 'end': '1140.880', 'text': 'blending of the science and sort of our'}, {'start': '1137.440', 'end': '1143.440', 'text': 'expert opinion. Um, and what I would say'}, {'start': '1140.880', 'end': '1146.400', 'text': 'is, you know, once you get beyond that'}, {'start': '1143.440', 'end': '1148.160', 'text': "that 4hour range, we're really on shaky"}, {'start': '1146.400', 'end': '1149.840', 'text': 'ground when it comes to the literature'}, {'start': '1148.160', 'end': '1152.400', 'text': 'in terms of recommendations and what you'}, {'start': '1149.840', 'end': '1154.840', 'text': 'need and what you have to do. I will say'}, {'start': '1152.400', 'end': '1156.640', 'text': "as a surrogate, we've looked at"}, {'start': '1154.840', 'end': '1158.840', 'text': "rabdtomyolyis. We've looked at other"}, {'start': '1156.640', 'end': '1161.520', 'text': 'forms of acute kidney'}, {'start': '1158.840', 'end': '1163.200', 'text': "injury as it pertains to you're going to"}, {'start': '1161.520', 'end': '1166.000', 'text': "open that tourniquet up and you're going"}, {'start': '1163.200', 'end': '1168.960', 'text': 'to flood the kidneys with some pretty'}, {'start': '1166.000', 'end': '1172.160', 'text': 'bad stuff. Um that includes myoglobin'}, {'start': '1168.960', 'end': '1173.919', 'text': 'from the crushed tissue. Uh so a lot of'}, {'start': '1172.160', 'end': '1175.520', 'text': "people ask, well, isn't crush injury"}, {'start': '1173.919', 'end': '1177.280', 'text': 'just a surrogate for tourniquet'}, {'start': '1175.520', 'end': '1179.520', 'text': 'conversion? And when you get out to'}, {'start': '1177.280', 'end': '1181.600', 'text': 'those four, six hour marks, yeah, it'}, {'start': '1179.520', 'end': '1183.360', 'text': "probably is, Dennis. And that's a you'll"}, {'start': '1181.600', 'end': '1184.960', 'text': 'recall early in the days of prolonged'}, {'start': '1183.360', 'end': '1187.360', 'text': 'field care that was one of the things we'}, {'start': '1184.960', 'end': '1189.919', 'text': 'wanted the joint trauma system and the'}, {'start': '1187.360', 'end': '1191.520', 'text': 'surgical researchers to look at was well'}, {'start': '1189.919', 'end': '1193.679', 'text': "we're looking at crush because yeah"}, {'start': '1191.520', 'end': '1195.679', 'text': 'crush happens in a in our population'}, {'start': '1193.679', 'end': '1197.679', 'text': 'they get pinned under vehicles and so'}, {'start': '1195.679', 'end': '1199.520', 'text': 'forth but we also want to think about it'}, {'start': '1197.679', 'end': '1201.200', 'text': 'just in case what if you do have'}, {'start': '1199.520', 'end': '1203.200', 'text': "prolonged tourniquet time and it's like"}, {'start': '1201.200', 'end': '1204.640', 'text': "that person that's crushed under a"}, {'start': '1203.200', 'end': '1208.480', 'text': 'collapsed building and is stuck there'}, {'start': '1204.640', 'end': '1210.240', 'text': 'for 6 10 12 hours. I I think the big'}, {'start': '1208.480', 'end': '1212.400', 'text': 'thing is you need to think at this point'}, {'start': '1210.240', 'end': '1214.400', 'text': 'number one is the limb even salvageable'}, {'start': '1212.400', 'end': '1216.400', 'text': 'at that point. So you need as the medic'}, {'start': '1214.400', 'end': '1218.640', 'text': 'and then the patient need to be'}, {'start': '1216.400', 'end': '1221.600', 'text': 'medically prepared for the fact and'}, {'start': '1218.640', 'end': '1223.840', 'text': 'mentally prepared that that limb may not'}, {'start': '1221.600', 'end': '1227.039', 'text': 'be salvageable once you get in that 4 6'}, {'start': '1223.840', 'end': '1228.400', 'text': 'hour or longer range. And then of course'}, {'start': '1227.039', 'end': '1230.400', 'text': 'going back to what we were talking about'}, {'start': '1228.400', 'end': '1232.000', 'text': 'reperfusion injury, when you choose to'}, {'start': '1230.400', 'end': '1235.360', 'text': "convert a tourniquet that's been on that"}, {'start': '1232.000', 'end': '1238.320', 'text': "long, you're choosing to say I'm I'm"}, {'start': '1235.360', 'end': '1240.799', 'text': 'ready for the cardiac. In other words, I'}, {'start': '1238.320', 'end': '1243.440', 'text': "don't want to trade a limb problem for a"}, {'start': '1240.799', 'end': '1245.360', 'text': 'life problem because I have the'}, {'start': '1243.440', 'end': '1247.039', 'text': 'potential to cause great harm to this'}, {'start': '1245.360', 'end': '1250.159', 'text': 'patient taking this tourniquet off at'}, {'start': '1247.039', 'end': '1252.960', 'text': 'this point because of all the eskeeia'}, {'start': '1250.159', 'end': '1255.360', 'text': "that's been distal to that device. So,"}, {'start': '1252.960', 'end': '1257.200', 'text': "if my patient's not resuscitated and if"}, {'start': '1255.360', 'end': '1259.120', 'text': "I don't have some some pretty common"}, {'start': '1257.200', 'end': '1260.280', 'text': 'tools available to me, you mentioned a'}, {'start': '1259.120', 'end': '1263.200', 'text': 'couple of them,'}, {'start': '1260.280', 'end': '1265.280', 'text': 'calcium, cardiac monitoring of some sort'}, {'start': '1263.200', 'end': '1266.799', 'text': "and and we've minimum, better, best,"}, {'start': '1265.280', 'end': '1269.200', 'text': 'right? Minimum might just be a finger'}, {'start': '1266.799', 'end': '1271.600', 'text': "pulse ox. Ideally, you've got a cardiac"}, {'start': '1269.200', 'end': '1273.600', 'text': 'monitor where you can see rhythm and you'}, {'start': '1271.600', 'end': '1276.400', 'text': 'can see a 12 lead. So, you can look for'}, {'start': '1273.600', 'end': '1278.760', 'text': 'those EKG changes that indicate the'}, {'start': '1276.400', 'end': '1281.679', 'text': 'heart is not happy with this flood of'}, {'start': '1278.760', 'end': '1283.600', 'text': 'electrolytes that are coming back. And'}, {'start': '1281.679', 'end': '1285.440', 'text': 'then further that ideally you can'}, {'start': '1283.600', 'end': '1287.360', 'text': 'monitor kidney function and performance'}, {'start': '1285.440', 'end': '1289.679', 'text': "to to make sure that you're not really"}, {'start': '1287.360', 'end': '1292.440', 'text': 'causing injury to the kidneys. Last'}, {'start': '1289.679', 'end': '1295.760', 'text': 'thing we want to do is convert a stable'}, {'start': '1292.440', 'end': '1297.919', 'text': 'patient with a catastrophic limb injury'}, {'start': '1295.760', 'end': '1300.720', 'text': "to an unstable patient who's now got"}, {'start': '1297.919', 'end': '1303.520', 'text': 'cardiac and kidney and organ. Does that'}, {'start': '1300.720', 'end': '1307.280', 'text': 'make sense? Yeah. Yeah, it makes 100%'}, {'start': '1303.520', 'end': '1311.760', 'text': 'sense. Um I think two questions come'}, {'start': '1307.280', 'end': '1315.440', 'text': 'come to mind. Um, as as much as I want'}, {'start': '1311.760', 'end': '1317.760', 'text': 'to say, you know, every uh member of the'}, {'start': '1315.440', 'end': '1319.760', 'text': "DoD, everybody that's going to be on the"}, {'start': '1317.760', 'end': '1323.520', 'text': 'good side of the battlefield are'}, {'start': '1319.760', 'end': '1326.159', 'text': "enormous monsters. Um, there's it's kind"}, {'start': '1323.520', 'end': '1329.679', 'text': 'of the scale of badness. Our arms have'}, {'start': '1326.159', 'end': '1332.720', 'text': 'less mass than like our thighs, right?'}, {'start': '1329.679', 'end': '1335.280', 'text': 'So, is there, you know, I have a'}, {'start': '1332.720', 'end': '1337.520', 'text': 'tourniquet on, you know, the the lower'}, {'start': '1335.280', 'end': '1340.880', 'text': 'half of an extremity because his foot'}, {'start': '1337.520', 'end': '1343.280', 'text': 'has been crushed or shot or whatever.'}, {'start': '1340.880', 'end': '1347.760', 'text': "I've had a a long tourniquet time on"}, {'start': '1343.280', 'end': '1351.840', 'text': 'like a foot or a hand versus a thigh or'}, {'start': '1347.760', 'end': '1353.159', 'text': 'a bicep or like does it matter how much'}, {'start': '1351.840', 'end': '1355.760', 'text': 'tissue is'}, {'start': '1353.159', 'end': '1358.080', 'text': 'involved when it comes to the badness'}, {'start': '1355.760', 'end': '1360.080', 'text': "that's on the other side of that? Yeah,"}, {'start': '1358.080', 'end': '1362.080', 'text': 'sure. I mean, think about that watershed'}, {'start': '1360.080', 'end': '1363.520', 'text': 'principle, right? Everything distal that'}, {'start': '1362.080', 'end': '1365.280', 'text': "tourniquet's going to be es schemic. The"}, {'start': '1363.520', 'end': '1367.760', 'text': 'more tissue you have, the more, you'}, {'start': '1365.280', 'end': '1369.760', 'text': 'know, metabolic waste and byproducts'}, {'start': '1367.760', 'end': '1372.600', 'text': "you're going to have. So, you're greater"}, {'start': '1369.760', 'end': '1375.039', 'text': 'risk for a reperusion'}, {'start': '1372.600', 'end': '1378.159', 'text': 'injury. What those numbers are on which'}, {'start': '1375.039', 'end': '1380.720', 'text': 'limbs relative to patient size, I mean,'}, {'start': '1378.159', 'end': '1383.039', 'text': "I I don't know. I don't think we"}, {'start': '1380.720', 'end': '1385.039', 'text': "definitive published data on that. I'm"}, {'start': '1383.039', 'end': '1387.520', 'text': "sure there's some animal study data out"}, {'start': '1385.039', 'end': '1389.360', 'text': 'there from, you know, surgical research,'}, {'start': '1387.520', 'end': '1390.960', 'text': 'but what I would really say on this,'}, {'start': '1389.360', 'end': '1393.919', 'text': "Dennis, the key point that you're"}, {'start': '1390.960', 'end': '1396.159', 'text': 'driving at is, you know, are you'}, {'start': '1393.919', 'end': '1399.039', 'text': 'prepared to deal with that? And then the'}, {'start': '1396.159', 'end': '1400.799', 'text': 'flip side is what would happen to our'}, {'start': '1399.039', 'end': '1402.320', 'text': 'patient population, you know, our'}, {'start': '1400.799', 'end': '1404.480', 'text': 'soldiers and sailors and all our folks'}, {'start': '1402.320', 'end': '1406.080', 'text': 'that are in fighting if they knew'}, {'start': '1404.480', 'end': '1407.679', 'text': 'anytime a tourniquet was applied, they'}, {'start': '1406.080', 'end': '1411.000', 'text': 'were going to lose the limb, right?'}, {'start': '1407.679', 'end': '1415.200', 'text': "Yeah. That's that's not good for morale."}, {'start': '1411.000', 'end': '1418.400', 'text': 'So my bias my bias is always going to be'}, {'start': '1415.200', 'end': '1420.640', 'text': 'towards try and get that tourniquet off.'}, {'start': '1418.400', 'end': '1423.520', 'text': "Let's try and salvage the limb. Let's do"}, {'start': '1420.640', 'end': '1425.679', 'text': 'the absolute best we can to get distal'}, {'start': '1423.520', 'end': '1428.320', 'text': 'hemorrhage control and get that'}, {'start': '1425.679', 'end': '1430.000', 'text': 'tourniquet off and and salvage the limb.'}, {'start': '1428.320', 'end': '1433.080', 'text': "Let's give that limb the best chance we"}, {'start': '1430.000', 'end': '1435.679', 'text': "can while not risking the patient's"}, {'start': '1433.080', 'end': '1437.919', 'text': "life. That's about right. That's the art"}, {'start': '1435.679', 'end': '1439.600', 'text': "of medicine. Um so and that's why I keep"}, {'start': '1437.919', 'end': '1441.360', 'text': 'going back to assess your patient. How'}, {'start': '1439.600', 'end': '1443.440', 'text': 'is your patient doing? Are they going to'}, {'start': '1441.360', 'end': '1445.440', 'text': 'be able to absorb? For example, if'}, {'start': '1443.440', 'end': '1446.720', 'text': "they're pretty touch and go, you barely"}, {'start': '1445.440', 'end': '1448.159', 'text': "got that systolic up, they're not"}, {'start': '1446.720', 'end': '1450.480', 'text': "mentating well, they've got a lot of"}, {'start': '1448.159', 'end': '1454.039', 'text': "other multi-system trauma and you've got"}, {'start': '1450.480', 'end': '1456.159', 'text': 'too high and tights on bilateral'}, {'start': '1454.039', 'end': '1458.159', 'text': "thighs, I'm going to proceed with some"}, {'start': '1456.159', 'end': '1459.440', 'text': "trepidation on that, right? I'm going to"}, {'start': '1458.159', 'end': '1460.960', 'text': "make sure I'm certainly not going to"}, {'start': '1459.440', 'end': '1462.720', 'text': "convert that patient if I haven't"}, {'start': '1460.960', 'end': '1464.480', 'text': "resuscitated them. They're warm and"}, {'start': '1462.720', 'end': '1465.960', 'text': "they're non-coagulopathic. In other"}, {'start': '1464.480', 'end': '1468.400', 'text': "words, they're not oozing from other"}, {'start': '1465.960', 'end': '1470.640', 'text': "injuries. um if they're doing well"}, {'start': '1468.400', 'end': '1472.720', 'text': "otherwise and I've got a cardiac monitor"}, {'start': '1470.640', 'end': '1473.919', 'text': "or I've got the ability to to mitigate"}, {'start': '1472.720', 'end': '1475.840', 'text': 'some of those effects. In other words,'}, {'start': '1473.919', 'end': '1477.360', 'text': "I've maybe got some by carb, I've got"}, {'start': '1475.840', 'end': '1478.960', 'text': 'calcium,'}, {'start': '1477.360', 'end': '1480.880', 'text': "um then I'm going to give it a try"}, {'start': '1478.960', 'end': '1482.799', 'text': 'because for the better of our force, we'}, {'start': '1480.880', 'end': '1484.760', 'text': "we don't want to kill morale and say,"}, {'start': '1482.799', 'end': '1489.919', 'text': '"Well, hey, anytime you got a tourniquet'}, {'start': '1484.760', 'end': '1492.159', 'text': 'on to the limb." Yeah. Um also kind of a'}, {'start': '1489.919', 'end': '1496.159', 'text': 'question in my mind, you talked about'}, {'start': '1492.159', 'end': '1498.240', 'text': 'salvageable limbs. Um, at no point in'}, {'start': '1496.159', 'end': '1501.679', 'text': 'time has anybody ever told me what is'}, {'start': '1498.240', 'end': '1505.080', 'text': 'salv salvageable and not salvageable.'}, {'start': '1501.679', 'end': '1508.240', 'text': "Um, I've seen some pretty messed up uh"}, {'start': '1505.080', 'end': '1510.000', 'text': 'extremities that are able to be put, you'}, {'start': '1508.240', 'end': '1512.720', 'text': 'know, kind of pieced together by, you'}, {'start': '1510.000', 'end': '1515.679', 'text': 'know, a skilled surgeon.'}, {'start': '1512.720', 'end': '1518.880', 'text': 'Likew, you know, likewise, you know, I'}, {'start': '1515.679', 'end': '1522.000', 'text': "don't want to be the the the decider in"}, {'start': '1518.880', 'end': '1524.240', 'text': 'an imperfect situation and have somebody'}, {'start': '1522.000', 'end': '1527.120', 'text': 'who does have the skill, does have the'}, {'start': '1524.240', 'end': '1529.120', 'text': 'equipment, does have the time. Um, to'}, {'start': '1527.120', 'end': '1530.960', 'text': 'turn around and tell me like, well, you'}, {'start': '1529.120', 'end': '1532.240', 'text': 'screwed that guy. You should have taken'}, {'start': '1530.960', 'end': '1536.240', 'text': 'it, you know, you should have done all'}, {'start': '1532.240', 'end': '1537.919', 'text': "these other things. Um, even though I'm"}, {'start': '1536.240', 'end': '1542.200', 'text': "in a trench, I'm in the mud. I'm"}, {'start': '1537.919', 'end': '1545.200', 'text': "wherever I am. And I've had imperfect"}, {'start': '1542.200', 'end': '1547.120', 'text': 'uh information, imperfect patient,'}, {'start': '1545.200', 'end': '1549.360', 'text': "imperfect situation, and I've had to"}, {'start': '1547.120', 'end': '1550.960', 'text': 'make life completely lifealtering'}, {'start': '1549.360', 'end': '1555.039', 'text': 'decisions'}, {'start': '1550.960', 'end': '1557.039', 'text': 'uh with what I have. So, and and maybe'}, {'start': '1555.039', 'end': '1559.200', 'text': "you're not the guy for that that"}, {'start': '1557.039', 'end': '1562.559', 'text': 'in-depth of a question, but would you'}, {'start': '1559.200', 'end': '1564.720', 'text': 'have like just any advice as far as what'}, {'start': '1562.559', 'end': '1567.200', 'text': 'is salvageable and what is not'}, {'start': '1564.720', 'end': '1569.440', 'text': "salvageable? Yeah, Dennis, that's a"}, {'start': '1567.200', 'end': '1571.440', 'text': "great great point. I'm sure, you know,"}, {'start': '1569.440', 'end': '1574.559', 'text': "I'm thinking back to 20 years of"}, {'start': '1571.440', 'end': '1576.320', 'text': "Afghanistan, Iraq, and Syria, and I'm"}, {'start': '1574.559', 'end': '1581.039', 'text': "thinking of how many patients we've had"}, {'start': '1576.320', 'end': '1583.840', 'text': "with heroic. I'm talking 120 plus units"}, {'start': '1581.039', 'end': '1587.919', 'text': 'of blood products or or just blood, you'}, {'start': '1583.840', 'end': '1591.200', 'text': 'know, units of blood um to save a limb.'}, {'start': '1587.919', 'end': '1592.960', 'text': 'Um, heroic levels of support that we'}, {'start': '1591.200', 'end': '1594.559', 'text': 'were able to provide just because that'}, {'start': '1592.960', 'end': '1597.679', 'text': 'was the only patient or maybe one of'}, {'start': '1594.559', 'end': '1600.640', 'text': 'three patients. Um, so I would say if'}, {'start': '1597.679', 'end': '1604.159', 'text': 'you have those resources, by all means,'}, {'start': '1600.640', 'end': '1606.559', 'text': 'yes, try and save those limbs, convert,'}, {'start': '1604.159', 'end': '1608.320', 'text': "give the blood, maybe you'll have to"}, {'start': '1606.559', 'end': '1610.400', 'text': 'replace the trinket four more times'}, {'start': '1608.320', 'end': '1613.240', 'text': 'until you get them fully resuscitated'}, {'start': '1610.400', 'end': '1615.039', 'text': "and they're not bleeding, they're"}, {'start': '1613.240', 'end': '1617.440', 'text': "non-coagulopathic, but that's a problem"}, {'start': '1615.039', 'end': '1619.200', 'text': 'of those who have a lot of resources,'}, {'start': '1617.440', 'end': '1621.440', 'text': 'right? For those of us that have limited'}, {'start': '1619.200', 'end': '1623.520', 'text': 'resources, we may only have four units'}, {'start': '1621.440', 'end': '1626.000', 'text': 'or six units of cold chain stored whole'}, {'start': '1623.520', 'end': '1629.039', 'text': "blood. I've already depleted my walking"}, {'start': '1626.000', 'end': '1632.080', 'text': "blood bank. I can't get six more units"}, {'start': '1629.039', 'end': '1635.200', 'text': 'of warm blood into this patient. At that'}, {'start': '1632.080', 'end': '1638.640', 'text': "point, it's a typical medic triage"}, {'start': '1635.200', 'end': '1640.640', 'text': 'decision, and it is a terrible one. Do'}, {'start': '1638.640', 'end': '1642.720', 'text': 'can I continue to give blood products'}, {'start': '1640.640', 'end': '1646.559', 'text': 'and offer some profusion to this limb'}, {'start': '1642.720', 'end': '1648.640', 'text': 'that may or may not survive? Um, and'}, {'start': '1646.559', 'end': '1650.799', 'text': 'have I got an ability to get hemorrhage'}, {'start': '1648.640', 'end': '1652.159', 'text': 'control definitively? In other words, to'}, {'start': '1650.799', 'end': '1655.000', 'text': 'stop the bleeding either through'}, {'start': '1652.159', 'end': '1657.360', 'text': 'surgical means or or'}, {'start': '1655.000', 'end': '1659.279', 'text': "otherwise. That's a tough one, right?"}, {'start': '1657.360', 'end': '1660.960', 'text': 'So, my answer would be in an ideal'}, {'start': '1659.279', 'end': '1663.039', 'text': "world, you've got enough blood where you"}, {'start': '1660.960', 'end': '1665.039', 'text': 'can take that tourniquet down, you can'}, {'start': '1663.039', 'end': '1666.640', 'text': 'see where the bleeding is, the damage to'}, {'start': '1665.039', 'end': '1668.240', 'text': 'the vascule, and you can determine'}, {'start': '1666.640', 'end': '1670.720', 'text': "whether they're going to have distal"}, {'start': '1668.240', 'end': '1673.240', 'text': 'arterial flow. And this is just me'}, {'start': '1670.720', 'end': '1675.440', 'text': 'thinking of this from a non-surggeon'}, {'start': '1673.240', 'end': '1678.240', 'text': "perspective, then that's potentially a"}, {'start': '1675.440', 'end': '1680.559', 'text': 'stop. But if I boom, all of that'}, {'start': '1678.240', 'end': '1683.320', 'text': 'plumbing is disrupted. They got no pipes'}, {'start': '1680.559', 'end': '1686.000', 'text': 'left down to the ankle or the foot.'}, {'start': '1683.320', 'end': '1687.600', 'text': 'Well, you know, and blood goes in and'}, {'start': '1686.000', 'end': '1688.960', 'text': 'blood just immediately pours out'}, {'start': '1687.600', 'end': '1692.080', 'text': 'through, you know, all the severed'}, {'start': '1688.960', 'end': '1694.240', 'text': 'arteries. At that point, you know, even'}, {'start': '1692.080', 'end': '1695.600', 'text': 'a more junior and less experienced'}, {'start': '1694.240', 'end': '1698.000', 'text': 'provider is going to say, "That\'s'}, {'start': '1695.600', 'end': '1699.600', 'text': 'probably not a salvageable limb." The'}, {'start': '1698.000', 'end': '1702.320', 'text': 'problem with what I just said, Dennis,'}, {'start': '1699.600', 'end': '1705.080', 'text': "is what? That implies you've got blood"}, {'start': '1702.320', 'end': '1707.919', 'text': 'available to to really test this thing'}, {'start': '1705.080', 'end': '1709.840', 'text': 'out. This is an unenviable position.'}, {'start': '1707.919', 'end': '1712.240', 'text': "It's a tough position for our medics to"}, {'start': '1709.840', 'end': '1713.679', 'text': "be in because really that's why I go"}, {'start': '1712.240', 'end': '1715.919', 'text': 'back to what we said at the beginning.'}, {'start': '1713.679', 'end': '1718.840', 'text': "You're re your main job is resuscitate"}, {'start': '1715.919', 'end': '1721.919', 'text': 'the patient. Get them warm and'}, {'start': '1718.840', 'end': '1724.640', 'text': 'non-coiliopathic. If we can do that, the'}, {'start': '1721.919', 'end': '1727.520', 'text': 'limb may or may not survive. But either'}, {'start': '1724.640', 'end': '1729.600', 'text': 'way, not having an extremity is a'}, {'start': '1727.520', 'end': '1731.679', 'text': 'problem of the living. to quote Andre'}, {'start': '1729.600', 'end': '1733.360', 'text': 'Cap when asked about blood transfusions'}, {'start': '1731.679', 'end': '1735.440', 'text': 'and getting infectious diseases from'}, {'start': '1733.360', 'end': '1736.559', 'text': 'blood transfusions. Dr. Cap has a great'}, {'start': '1735.440', 'end': '1738.640', 'text': 'quote. He goes, "Well, you know what?'}, {'start': '1736.559', 'end': '1741.120', 'text': "That's a problem of the living because"}, {'start': '1738.640', 'end': '1743.760', 'text': "they're alive to deal with their their"}, {'start': '1741.120', 'end': '1745.520', 'text': 'transfusion related illness." Um, same'}, {'start': '1743.760', 'end': '1748.080', 'text': "thing here. You know, yeah, you're an"}, {'start': '1745.520', 'end': '1749.679', 'text': "ampute, but you're alive. I don't mean"}, {'start': '1748.080', 'end': '1752.320', 'text': 'to be insensitive because I know that'}, {'start': '1749.679', 'end': '1754.559', 'text': 'that has massive impacts on the quality'}, {'start': '1752.320', 'end': '1756.640', 'text': 'of life for for our folks that are'}, {'start': '1754.559', 'end': '1759.200', 'text': 'amputes and have have suffered through'}, {'start': '1756.640', 'end': '1760.679', 'text': "this. Um, but the flip side is I don't"}, {'start': '1759.200', 'end': '1763.840', 'text': 'want the medics to walk'}, {'start': '1760.679', 'end': '1765.880', 'text': 'away doing neither thing well, neither'}, {'start': '1763.840', 'end': '1768.080', 'text': 'resuscitating nor converting the'}, {'start': '1765.880', 'end': '1769.520', 'text': 'tourniquet. Uh, we want always want to'}, {'start': '1768.080', 'end': '1771.279', 'text': 'make a good faith effort for that, but'}, {'start': '1769.520', 'end': '1772.399', 'text': "at a certain point, you can't you got to"}, {'start': '1771.279', 'end': '1773.600', 'text': 'be able to lay your head down on the'}, {'start': '1772.399', 'end': '1775.760', 'text': 'pillow at night and say you did'}, {'start': '1773.600', 'end': '1778.559', 'text': 'everything you could for that patient.'}, {'start': '1775.760', 'end': '1780.919', 'text': "Yeah, absolutely. And I've seen uh"}, {'start': '1778.559', 'end': '1785.520', 'text': 'medics'}, {'start': '1780.919', 'end': '1788.720', 'text': 'um with a very difficult decision and'}, {'start': '1785.520', 'end': '1790.559', 'text': 'have that moment of hesitancy of like I'}, {'start': '1788.720', 'end': '1793.360', 'text': "don't actually know what the right thing"}, {'start': '1790.559', 'end': '1796.559', 'text': 'is to do you know and then when you walk'}, {'start': '1793.360', 'end': '1800.720', 'text': 'through well these are the goals do have'}, {'start': '1796.559', 'end': '1802.640', 'text': 'we bought enough room that if we'}, {'start': '1800.720', 'end': '1805.039', 'text': 'converted that tourniquet and he did'}, {'start': '1802.640', 'end': '1807.120', 'text': "bleed you'd be able to stop it before"}, {'start': '1805.039', 'end': '1810.720', 'text': 'something catastrophic happens.'}, {'start': '1807.120', 'end': '1812.480', 'text': 'Yes. Okay. What possibly could happen?'}, {'start': '1810.720', 'end': '1814.799', 'text': 'Well, this and this and this and this.'}, {'start': '1812.480', 'end': '1816.240', 'text': 'Like, okay. What are your answers for'}, {'start': '1814.799', 'end': '1818.000', 'text': 'those things if they were to happen'}, {'start': '1816.240', 'end': '1819.520', 'text': 'right now? Well, I would do this and I'}, {'start': '1818.000', 'end': '1822.320', 'text': 'would do this and I would do this.'}, {'start': '1819.520', 'end': '1823.919', 'text': "Great. Let's get those things in order."}, {'start': '1822.320', 'end': '1825.240', 'text': "Let's get our monitoring on. Let's"}, {'start': '1823.919', 'end': '1827.279', 'text': 'assess the'}, {'start': '1825.240', 'end': '1832.039', 'text': "situation. If we've bought ourselves"}, {'start': '1827.279', 'end': '1835.440', 'text': 'some room, is it worth saving that limb?'}, {'start': '1832.039', 'end': '1838.640', 'text': "Yes. Okay. Let's get oursel prepared and"}, {'start': '1835.440', 'end': '1840.559', 'text': "let's try it. And unfortunately, that's"}, {'start': '1838.640', 'end': '1842.720', 'text': "what it's going to I think what it's"}, {'start': '1840.559', 'end': '1845.520', 'text': 'going to take is buying yourself enough'}, {'start': '1842.720', 'end': '1848.520', 'text': 'room that if you are wrong, you can'}, {'start': '1845.520', 'end': '1850.960', 'text': 'salvage, you can save the'}, {'start': '1848.520', 'end': '1853.919', 'text': "life, making sure that you're prepared"}, {'start': '1850.960', 'end': '1857.840', 'text': 'for the bad things to happen, assuming'}, {'start': '1853.919', 'end': '1860.640', 'text': 'that they are going to happen, and then'}, {'start': '1857.840', 'end': '1862.440', 'text': 'taking on uh taking on the challenges as'}, {'start': '1860.640', 'end': '1866.320', 'text': 'they as they arrive.'}, {'start': '1862.440', 'end': '1869.880', 'text': 'Yeah, perfectly said, Dennis.'}, {'start': '1866.320', 'end': '1873.760', 'text': 'Finally, I got one. Um,'}, {'start': '1869.880', 'end': '1875.600', 'text': "so crush syndrome. Okay, we've got CPGs"}, {'start': '1873.760', 'end': '1877.960', 'text': 'on it. We go over it and over it and'}, {'start': '1875.600', 'end': '1882.159', 'text': 'over it again in other in other'}, {'start': '1877.960', 'end': '1884.919', 'text': 'podcasts, in other uh kind of forums.'}, {'start': '1882.159', 'end': '1888.240', 'text': 'Are there any other things? So like'}, {'start': '1884.919', 'end': '1893.840', 'text': 'rebuleed can that can that uh onslaught'}, {'start': '1888.240', 'end': '1895.679', 'text': 'of acidosis and uh um other essentially'}, {'start': '1893.840', 'end': '1898.880', 'text': 'garbage going through the vascular'}, {'start': '1895.679', 'end': '1902.240', 'text': 'system. Can that cause me other problems'}, {'start': '1898.880', 'end': '1903.919', 'text': 'with my uh lethal triad or diamond or'}, {'start': '1902.240', 'end': '1905.919', 'text': "pentagon or whatever we're calling it"}, {'start': '1903.919', 'end': '1909.320', 'text': 'now?'}, {'start': '1905.919', 'end': '1912.159', 'text': "Yeah. So, so let's talk about the most"}, {'start': '1909.320', 'end': '1913.919', 'text': 'common issues related with reperusion'}, {'start': '1912.159', 'end': '1915.279', 'text': 'injury and those are I want to focus on'}, {'start': '1913.919', 'end': '1917.679', 'text': 'those because those are the things that'}, {'start': '1915.279', 'end': '1919.360', 'text': 'the medics have tools to deal with,'}, {'start': '1917.679', 'end': '1920.880', 'text': "right? So, that's in your in the"}, {'start': '1919.360', 'end': '1922.880', 'text': 'tactical protocols, the medical'}, {'start': '1920.880', 'end': '1925.440', 'text': "protocols and that's things like your"}, {'start': '1922.880', 'end': '1927.519', 'text': 'calcium gluconate or your or calcium'}, {'start': '1925.440', 'end': '1930.080', 'text': "chloride, right? Chloride's nice because"}, {'start': '1927.519', 'end': '1933.080', 'text': "it's smaller volume, 10 mls instead of"}, {'start': '1930.080', 'end': '1937.200', 'text': '30, same amount, you know, of elemental'}, {'start': '1933.080', 'end': '1939.600', 'text': 'calcium. Um but but these are tools that'}, {'start': '1937.200', 'end': '1941.279', 'text': 'you have that you can deal with. One of'}, {'start': '1939.600', 'end': '1943.360', 'text': 'the main problems that main problem'}, {'start': '1941.279', 'end': '1945.960', 'text': "that'll kill you right there is"}, {'start': '1943.360', 'end': '1948.159', 'text': 'arrhythmias associated with'}, {'start': '1945.960', 'end': '1951.519', 'text': "hypercalemia. Um so that's elevated"}, {'start': '1948.159', 'end': '1953.840', 'text': 'serum potassium. The calcium just helps'}, {'start': '1951.519', 'end': '1957.039', 'text': 'stabilize that myioardium to prevent'}, {'start': '1953.840', 'end': '1959.200', 'text': 'those effects from that high potassium.'}, {'start': '1957.039', 'end': '1961.600', 'text': "Obviously, we all know if the heart's"}, {'start': '1959.200', 'end': '1963.519', 'text': "not beaten right and and we're adding"}, {'start': '1961.600', 'end': '1964.880', 'text': "more insult to injury there that that's"}, {'start': '1963.519', 'end': '1965.919', 'text': "going to be a lethal, then then you're"}, {'start': '1964.880', 'end': '1968.480', 'text': 'going to proceed down a different'}, {'start': '1965.919', 'end': '1970.399', 'text': 'algorithm which is going to be ACLS and'}, {'start': '1968.480', 'end': '1972.399', 'text': "you're going to be coding your patient."}, {'start': '1970.399', 'end': '1974.080', 'text': "So, that's a dead right there problem."}, {'start': '1972.399', 'end': '1975.200', 'text': "Now, what I would say is if you're if"}, {'start': '1974.080', 'end': '1976.559', 'text': "you're dealing with those tools and"}, {'start': '1975.200', 'end': '1978.399', 'text': "you're prepared, you're equipped, great."}, {'start': '1976.559', 'end': '1979.760', 'text': 'You got that piece of reperusion injury.'}, {'start': '1978.399', 'end': '1981.519', 'text': "You're alluding to some other stuff"}, {'start': '1979.760', 'end': '1984.159', 'text': 'though, Dennis. You know, how is this'}, {'start': '1981.519', 'end': '1986.640', 'text': 'going to affect my coagulability? Well,'}, {'start': '1984.159', 'end': '1988.320', 'text': "again, let's think about that. So"}, {'start': '1986.640', 'end': '1991.039', 'text': 'potentially you still have viable red'}, {'start': '1988.320', 'end': '1993.679', 'text': 'blood cells and platelets there um that'}, {'start': '1991.039', 'end': '1995.760', 'text': 'that now have shifted their hemoglobin'}, {'start': '1993.679', 'end': '1998.000', 'text': 'dissociation curve, right? That oxygen'}, {'start': '1995.760', 'end': '2000.320', 'text': "dissociation curve. And I realize I'm"}, {'start': '1998.000', 'end': '2002.559', 'text': 'giving people bad memories as they think'}, {'start': '2000.320', 'end': '2005.200', 'text': 'about myiochem and jam and all that'}, {'start': '2002.559', 'end': '2007.519', 'text': 'stuff in their head for their exams. But'}, {'start': '2005.200', 'end': '2009.440', 'text': "we don't know is the bottom line. We"}, {'start': '2007.519', 'end': '2011.480', 'text': "don't know, especially depending on the"}, {'start': '2009.440', 'end': '2013.760', 'text': "watershed. So what's the area of tissue"}, {'start': '2011.480', 'end': '2015.120', 'text': "that's how that's going to impact that"}, {'start': '2013.760', 'end': '2018.039', 'text': 'patient once you release that'}, {'start': '2015.120', 'end': '2020.840', 'text': 'tourniquet. What I would say is'}, {'start': '2018.039', 'end': '2022.720', 'text': "plan that's why you want to warm"}, {'start': '2020.840', 'end': '2025.440', 'text': "non-coagulopathic. So they shouldn't be"}, {'start': '2022.720', 'end': '2028.159', 'text': 'oozing from any non-turnicated injuries'}, {'start': '2025.440', 'end': '2029.600', 'text': "before you're converting. Um if you you"}, {'start': '2028.159', 'end': '2030.880', 'text': 'still choose you can still choose'}, {'start': '2029.600', 'end': '2032.240', 'text': 'convert, right? So you can still take'}, {'start': '2030.880', 'end': '2034.480', 'text': "that tourniquet down even if they're"}, {'start': '2032.240', 'end': '2036.480', 'text': 'oozing elsewhere. But be prepared,'}, {'start': '2034.480', 'end': '2039.200', 'text': 'right? you better have a mechanical'}, {'start': '2036.480', 'end': '2040.799', 'text': 'means for for control um other than that'}, {'start': '2039.200', 'end': '2043.679', 'text': 'tourniquet for example are you going to'}, {'start': '2040.799', 'end': '2046.880', 'text': 'use forceps to liate a vessel that type'}, {'start': '2043.679', 'end': '2048.399', 'text': 'of a that type of radical thinking'}, {'start': '2046.880', 'end': '2050.639', 'text': "because you're you're not going to make"}, {'start': '2048.399', 'end': '2054.399', 'text': 'their coagulopathy any better by'}, {'start': '2050.639', 'end': '2055.839', 'text': 'reducing that direct right I again I'}, {'start': '2054.399', 'end': '2057.520', 'text': "don't know I don't know that we have a"}, {'start': '2055.839', 'end': '2059.520', 'text': 'timeline or a specific standard or'}, {'start': '2057.520', 'end': '2063.000', 'text': "there's evidence to show you know you"}, {'start': '2059.520', 'end': '2066.359', 'text': 'can expect a 30% reduction in clot'}, {'start': '2063.000', 'end': '2069.280', 'text': 'stability if But'}, {'start': '2066.359', 'end': '2070.800', 'text': "isated. We don't have that data. If we"}, {'start': '2069.280', 'end': '2073.359', 'text': 'do, and again, that would be a great'}, {'start': '2070.800', 'end': '2074.639', 'text': 'study to look at at some point, I think'}, {'start': '2073.359', 'end': '2076.879', 'text': "we'd find that there's pretty"}, {'start': '2074.639', 'end': '2080.599', 'text': 'significant impairment in u the'}, {'start': '2076.879', 'end': '2083.520', 'text': 'coagulation taxade. Yeah, absolutely.'}, {'start': '2080.599', 'end': '2085.839', 'text': 'And as much as I would love to have the'}, {'start': '2083.520', 'end': '2088.079', 'text': 'data, I have no actual way to measure'}, {'start': '2085.839', 'end': '2090.000', 'text': "it. So, you're going to have to you're"}, {'start': '2088.079', 'end': '2092.879', 'text': 'going to have to take it as it comes and'}, {'start': '2090.000', 'end': '2095.280', 'text': 'understand these things could happen.'}, {'start': '2092.879', 'end': '2098.560', 'text': 'one, do you have more blood available?'}, {'start': '2095.280', 'end': '2100.160', 'text': "Can you get it? Um, you know, they're"}, {'start': '2098.560', 'end': '2101.760', 'text': 'going to have to deal with that. The'}, {'start': '2100.160', 'end': '2102.440', 'text': 'their body is going to have to deal with'}, {'start': '2101.760', 'end': '2106.680', 'text': 'that'}, {'start': '2102.440', 'end': '2109.599', 'text': 'acidosis. Can you help them? Mhm. And,'}, {'start': '2106.680', 'end': '2112.400', 'text': 'um, essentially constantly monitor,'}, {'start': '2109.599', 'end': '2115.359', 'text': 'constantly assess and kind of limp this'}, {'start': '2112.400', 'end': '2118.000', 'text': 'patient along until their body can take'}, {'start': '2115.359', 'end': '2120.720', 'text': 'over. Yeah, great point, Dennis. and and'}, {'start': '2118.000', 'end': '2122.960', 'text': 'you get into a a fantastic point right'}, {'start': '2120.720', 'end': '2124.400', 'text': 'there with the acidosis, right? So, I'}, {'start': '2122.960', 'end': '2127.280', 'text': 'may not be able to do much about the'}, {'start': '2124.400', 'end': '2130.079', 'text': 'coagulation cascades outside of giving'}, {'start': '2127.280', 'end': '2132.720', 'text': 'blood, right? Blood is the answer. Um,'}, {'start': '2130.079', 'end': '2134.320', 'text': 'but what what can I do about acidosis?'}, {'start': '2132.720', 'end': '2136.079', 'text': 'So, that is something that the medic has'}, {'start': '2134.320', 'end': '2137.440', 'text': 'other tools in their toolkit and I think'}, {'start': '2136.079', 'end': '2139.599', 'text': "you're alluding to this. That's, you"}, {'start': '2137.440', 'end': '2141.119', 'text': 'know, our sodium by cararb 50 mil'}, {'start': '2139.599', 'end': '2143.599', 'text': "equivalents that's available in those"}, {'start': '2141.119', 'end': '2145.440', 'text': 'standard sodium by cararb ampules. you'}, {'start': '2143.599', 'end': '2147.760', 'text': 'know, three of those suckers mixed in'}, {'start': '2145.440', 'end': '2150.079', 'text': 'your standard bag of saline gives you a'}, {'start': '2147.760', 'end': '2154.240', 'text': 'little bit of a hyperosmolar solution.'}, {'start': '2150.079', 'end': '2156.240', 'text': 'Um, and we believe if they are having'}, {'start': '2154.240', 'end': '2158.079', 'text': "because here's the surrogate issue like"}, {'start': '2156.240', 'end': '2160.440', 'text': "I don't have a study showing that for"}, {'start': '2158.079', 'end': '2163.359', 'text': 'tourniquet reduction that protects the'}, {'start': '2160.440', 'end': '2165.280', 'text': "kidneys. We haven't done that study but"}, {'start': '2163.359', 'end': '2167.359', 'text': "we've done it with a lot of other"}, {'start': '2165.280', 'end': '2169.119', 'text': 'nephrotoxic in other words bad for your'}, {'start': '2167.359', 'end': '2171.920', 'text': 'kidneys types of things that can be'}, {'start': '2169.119', 'end': '2174.960', 'text': "dapty. There's an old 2006 publication"}, {'start': '2171.920', 'end': '2178.200', 'text': 'that showed the effect of protection on'}, {'start': '2174.960', 'end': '2180.880', 'text': 'the kidneys from from alkal'}, {'start': '2178.200', 'end': '2183.359', 'text': 'alkalinization sorry hard word to say'}, {'start': '2180.880', 'end': '2187.119', 'text': 'reversing the acidosis with bicarb from'}, {'start': '2183.359', 'end': '2190.240', 'text': 'the renal insult of a bad toxic drug for'}, {'start': '2187.119', 'end': '2193.440', 'text': "kidneys dapty there's other studies most"}, {'start': '2190.240', 'end': '2197.040', 'text': 'recently 2018 Lancet published the B'}, {'start': '2193.440', 'end': '2200.000', 'text': 'byar ICU study so the bycar ICU study'}, {'start': '2197.040', 'end': '2203.200', 'text': 'looked at in patients with'}, {'start': '2200.000', 'end': '2205.920', 'text': 'acute renal injury that are very sick.'}, {'start': '2203.200', 'end': '2207.680', 'text': 'Most of them on ventilators who had a'}, {'start': '2205.920', 'end': '2210.440', 'text': "metabolic component. So this isn't"}, {'start': '2207.680', 'end': '2214.079', 'text': "respiratory acidosis, it's metabolic"}, {'start': '2210.440', 'end': '2217.280', 'text': 'acidosis, sepsis most often. Was there a'}, {'start': '2214.079', 'end': '2219.760', 'text': 'benefit in mortality or a reduction in'}, {'start': '2217.280', 'end': '2222.800', 'text': 'end organ injury in those patients when'}, {'start': '2219.760', 'end': '2224.680', 'text': 'they received sodium by carb? That study'}, {'start': '2222.800', 'end': '2228.720', 'text': 'showed no benefit in'}, {'start': '2224.680', 'end': '2231.119', 'text': "mortality. Okay? Didn't change liy. Now"}, {'start': '2228.720', 'end': '2234.119', 'text': 'keep in mind these are sick patients.'}, {'start': '2231.119', 'end': '2237.760', 'text': 'What it did show was a benefit'}, {'start': '2234.119', 'end': '2240.560', 'text': 'in end impact on the kidneys for those'}, {'start': '2237.760', 'end': '2242.640', 'text': 'patients that had acute kidney injury.'}, {'start': '2240.560', 'end': '2244.079', 'text': 'So when we think about our shock patient'}, {'start': '2242.640', 'end': '2245.760', 'text': "on the battlefield who's had a"}, {'start': '2244.079', 'end': '2248.240', 'text': "tourniquet applied and we're going to"}, {'start': '2245.760', 'end': '2250.079', 'text': 'take that tourniquet down and jam them'}, {'start': '2248.240', 'end': '2252.960', 'text': 'with a bunch of myoglobin broken down'}, {'start': '2250.079', 'end': '2255.760', 'text': 'muscle tissue and and cells. That'}, {'start': '2252.960', 'end': '2259.520', 'text': 'myoglobin component is the renal toxic'}, {'start': '2255.760', 'end': '2261.680', 'text': 'component. I think we can imply again'}, {'start': '2259.520', 'end': '2264.560', 'text': "there's no definitive data to say this"}, {'start': '2261.680', 'end': '2266.640', 'text': 'but the bycar ICU trial gives us sound'}, {'start': '2264.560', 'end': '2268.560', 'text': 'footing as a medic to stand on to say'}, {'start': '2266.640', 'end': '2270.320', 'text': "man if I've had a long tourniquet time"}, {'start': '2268.560', 'end': '2272.560', 'text': "on a thigh an area where there's going"}, {'start': '2270.320', 'end': '2274.800', 'text': "to be a ton of myoglobin or they've"}, {'start': '2272.560', 'end': '2278.000', 'text': "already got CocaCola urine they're"}, {'start': '2274.800', 'end': '2280.480', 'text': 'peeing that dark brown pigmented urine'}, {'start': '2278.000', 'end': '2284.480', 'text': "you're probably on safe scientific"}, {'start': '2280.480', 'end': '2288.160', 'text': 'footing giving them by carb to alkalize'}, {'start': '2284.480', 'end': '2291.599', 'text': "yep it makes sense And I mean I've heard"}, {'start': '2288.160', 'end': '2294.800', 'text': 'by carb as far as um mentioned being'}, {'start': '2291.599', 'end': '2297.280', 'text': 'used a lot.'}, {'start': '2294.800', 'end': '2299.640', 'text': 'What is the downside?'}, {'start': '2297.280', 'end': '2304.720', 'text': 'I give them some by carb'}, {'start': '2299.640', 'end': '2306.400', 'text': 'and nothing happens. Yeah. So remember'}, {'start': '2304.720', 'end': '2308.240', 'text': "first do no harm. So anytime we're"}, {'start': '2306.400', 'end': '2310.720', 'text': 'throwing a drug, we we got to know what'}, {'start': '2308.240', 'end': '2313.599', 'text': 'the potential adverse events are. There'}, {'start': '2310.720', 'end': '2314.800', 'text': 'are and and I challenge all of our to'}, {'start': '2313.599', 'end': '2318.079', 'text': "look at that if you're a little"}, {'start': '2314.800', 'end': '2319.359', 'text': 'overzealous uh with your by carb or'}, {'start': '2318.079', 'end': '2321.119', 'text': "again you're not monitoring that"}, {'start': '2319.359', 'end': '2323.680', 'text': 'infusion rate. Remember what I just said'}, {'start': '2321.119', 'end': '2325.680', 'text': "that's a hyper osmolar concentration"}, {'start': '2323.680', 'end': '2327.599', 'text': "you're you're pushing into the patient."}, {'start': '2325.680', 'end': '2329.720', 'text': "So that's going to take volume from"}, {'start': '2327.599', 'end': '2331.680', 'text': 'cells and put it into the intravascular'}, {'start': '2329.720', 'end': '2333.280', 'text': "volume. You're probably going to get a"}, {'start': '2331.680', 'end': '2334.800', 'text': 'transient rise in blood pressure which'}, {'start': '2333.280', 'end': '2336.280', 'text': "again if you don't have your hemorrhage"}, {'start': '2334.800', 'end': '2339.119', 'text': "controlled and your patient's not"}, {'start': '2336.280', 'end': '2341.040', 'text': "resuscitated that's a problem right"}, {'start': '2339.119', 'end': '2343.200', 'text': "because you're potentially going to I"}, {'start': '2341.040', 'end': '2345.359', 'text': 'hate using that term pop the clots kind'}, {'start': '2343.200', 'end': '2347.280', 'text': 'of thing but there there is in theory a'}, {'start': '2345.359', 'end': '2350.160', 'text': 'potential for that there are also some'}, {'start': '2347.280', 'end': '2353.520', 'text': 'well-known side effects from um'}, {'start': '2350.160', 'end': '2355.359', 'text': 'overzealous use of of by carb and'}, {'start': '2353.520', 'end': '2357.520', 'text': "finally what I'd say is a lot of our"}, {'start': '2355.359', 'end': '2359.599', 'text': 'young healthy battlefield casualties are'}, {'start': '2357.520', 'end': '2362.079', 'text': 'going to be compensating on their own'}, {'start': '2359.599', 'end': '2365.839', 'text': 'via respiratory means right so their'}, {'start': '2362.079', 'end': '2368.480', 'text': 'body is already adjusting their pH'}, {'start': '2365.839', 'end': '2370.960', 'text': 'for a metabolic acidosis by using their'}, {'start': '2368.480', 'end': '2372.359', 'text': 'own breathing to off gas that CO2 and'}, {'start': '2370.960', 'end': '2375.200', 'text': 'reduce their own'}, {'start': '2372.359', 'end': '2376.880', 'text': "acidmia. So in theory there's a chance"}, {'start': '2375.200', 'end': '2379.200', 'text': 'depending upon when you administer the'}, {'start': '2376.880', 'end': '2381.200', 'text': 'by carb of interfering with their own'}, {'start': '2379.200', 'end': '2383.920', 'text': 'natural homeostasis to try and restore'}, {'start': '2381.200', 'end': '2385.680', 'text': "their acid base balance. Um but it's a"}, {'start': '2383.920', 'end': '2387.280', 'text': "great question. I'd love to delve more"}, {'start': '2385.680', 'end': '2389.119', 'text': 'into that and and just really look at'}, {'start': '2387.280', 'end': '2391.200', 'text': 'what are the harms with by carb. But'}, {'start': '2389.119', 'end': '2392.880', 'text': 'again, nothing nothing for free. You'}, {'start': '2391.200', 'end': '2394.400', 'text': "don't get any anything for free. There"}, {'start': '2392.880', 'end': '2396.320', 'text': "is you're going to have a definitive"}, {'start': '2394.400', 'end': '2399.359', 'text': 'impact on their physiology. You just'}, {'start': '2396.320', 'end': '2401.760', 'text': 'need to be mindful of that. Um, I had'}, {'start': '2399.359', 'end': '2405.839', 'text': 'one other question more relating to the'}, {'start': '2401.760', 'end': '2408.200', 'text': 'crush CPG, but since this is tying in'}, {'start': '2405.839', 'end': '2412.040', 'text': 'and out of that as well,'}, {'start': '2408.200', 'end': '2415.400', 'text': 'um, it mentions using 1 g of'}, {'start': '2412.040', 'end': '2420.560', 'text': "calcium and then it doesn't really delve"}, {'start': '2415.400', 'end': '2424.079', 'text': 'into that 10 mls of calcium chloride or'}, {'start': '2420.560', 'end': '2426.800', 'text': 'is that, you know, the 30 mls of calcium'}, {'start': '2424.079', 'end': '2431.720', 'text': 'gluconate, which if you read the labels,'}, {'start': '2426.800', 'end': '2434.800', 'text': "that's actually three grams of calcium."}, {'start': '2431.720', 'end': '2436.480', 'text': "Um, which one do you want? I'll do any"}, {'start': '2434.800', 'end': '2439.839', 'text': 'of them. Just tell me which one you'}, {'start': '2436.480', 'end': '2442.160', 'text': 'want. Which one we want? Yeah. Well, I I'}, {'start': '2439.839', 'end': '2444.000', 'text': 'think from a practical perspective, um,'}, {'start': '2442.160', 'end': '2447.440', 'text': 'a lot of the concerns with calcium'}, {'start': '2444.000', 'end': '2450.480', 'text': 'chloride were where the uh, irritability'}, {'start': '2447.440', 'end': '2452.079', 'text': 'of the infusion site. Right. So, again,'}, {'start': '2450.480', 'end': '2454.800', 'text': "we're thinking about we're not infusing"}, {'start': '2452.079', 'end': '2457.200', 'text': 'this through a tiny little vein, you'}, {'start': '2454.800', 'end': '2458.880', 'text': 'know, with a 25 gauge.'}, {'start': '2457.200', 'end': '2460.480', 'text': "leaking it in and it's and it's just"}, {'start': '2458.880', 'end': '2461.760', 'text': 'sitting there in the vein. These are'}, {'start': '2460.480', 'end': '2464.160', 'text': 'going to be trauma patients. These are'}, {'start': '2461.760', 'end': '2467.760', 'text': 'patients with fairly large uh volume'}, {'start': '2464.160', 'end': '2469.440', 'text': "catheter infusions going. Um so I let's"}, {'start': '2467.760', 'end': '2471.520', 'text': 'take that theoretic risk of the'}, {'start': '2469.440', 'end': '2473.280', 'text': 'irritability and vessel damage off the'}, {'start': '2471.520', 'end': '2475.599', 'text': 'table with chloride. Those are real'}, {'start': '2473.280', 'end': '2476.960', 'text': 'concerns with calcium chloride. Um but'}, {'start': '2475.599', 'end': '2479.359', 'text': "in our setting where we're really"}, {'start': '2476.960', 'end': '2481.119', 'text': 'looking at big infusion in a trauma'}, {'start': '2479.359', 'end': '2483.520', 'text': 'patient, I think those concerns are'}, {'start': '2481.119', 'end': '2485.599', 'text': "overstated and that's been put to bed."}, {'start': '2483.520', 'end': '2488.880', 'text': 'So, for bang for your buck for elemental'}, {'start': '2485.599', 'end': '2491.440', 'text': 'calcium, 10 mls versus 30. Right now,'}, {'start': '2488.880', 'end': '2494.200', 'text': 'the T-P says, right, the old version of'}, {'start': '2491.440', 'end': '2498.720', 'text': 'the T-f says do 10'}, {'start': '2494.200', 'end': '2500.640', 'text': 'mls of calcium gluconate, not not'}, {'start': '2498.720', 'end': '2503.359', 'text': 'chloride. Chloride, we got it. One gram'}, {'start': '2500.640', 'end': '2505.760', 'text': 'is 10 mls of calcium chloride. Now,'}, {'start': '2503.359', 'end': '2509.280', 'text': "let's switch to calcium gluconate. So,"}, {'start': '2505.760', 'end': '2512.560', 'text': "that's that comes in a 30 ml dosing vial"}, {'start': '2509.280', 'end': '2515.040', 'text': 'like you said, Dennis. Um, and then the'}, {'start': '2512.560', 'end': '2517.040', 'text': 'the T-MAPs tells us just do 10 ml'}, {'start': '2515.040', 'end': '2518.319', 'text': 'infusion of that. So the implied task is'}, {'start': '2517.040', 'end': '2520.680', 'text': 'exactly like you said that gives you the'}, {'start': '2518.319', 'end': '2523.359', 'text': 'equivalent of one gram.'}, {'start': '2520.680', 'end': '2524.880', 'text': "Um, this point I don't know. I'd need to"}, {'start': '2523.359', 'end': '2527.359', 'text': 'go look at those labels and and say'}, {'start': '2524.880', 'end': '2528.880', 'text': "definitively for sure. I've always been"}, {'start': '2527.359', 'end': '2530.400', 'text': 'translating it in my head and you might'}, {'start': '2528.880', 'end': '2532.560', 'text': 'have just caught me. You could be wrong.'}, {'start': '2530.400', 'end': '2534.240', 'text': "I've been thinking 30 mls is the 1 g"}, {'start': '2532.560', 'end': '2535.680', 'text': "equivalent. Um, but let's check the"}, {'start': '2534.240', 'end': '2536.880', 'text': 'labels on that one and post that in the'}, {'start': '2535.680', 'end': '2540.640', 'text': 'show notes.'}, {'start': '2536.880', 'end': '2545.200', 'text': 'Um, so I know labelwise just what I have'}, {'start': '2540.640', 'end': '2548.880', 'text': 'available to me. 10 10 mls of calcium'}, {'start': '2545.200', 'end': '2552.480', 'text': 'chloride, 1 g. Um, I also get 10 ml'}, {'start': '2548.880', 'end': '2556.599', 'text': 'vials of calcium gluconate which say 1 g'}, {'start': '2552.480', 'end': '2559.280', 'text': 'or you can get 30 ml vials of calcium'}, {'start': '2556.599', 'end': '2563.920', 'text': 'gluconate which will give you actually 3'}, {'start': '2559.280', 'end': '2568.160', 'text': "g. You know what I mean? And um it's"}, {'start': '2563.920', 'end': '2569.760', 'text': 'confusing and confusing. Yep. So great'}, {'start': '2568.160', 'end': '2573.119', 'text': 'principle here, Dennis. Always read the'}, {'start': '2569.760', 'end': '2574.640', 'text': 'label, right? So we write and sometimes'}, {'start': '2573.119', 'end': '2576.560', 'text': "the protocols don't catch up with"}, {'start': '2574.640', 'end': '2578.560', 'text': 'manufacturer packaging or what the'}, {'start': '2576.560', 'end': '2580.560', 'text': 'latest bile is. Gosh, remember in the'}, {'start': '2578.560', 'end': '2582.560', 'text': 'early days of TXA, remember it came in'}, {'start': '2580.560', 'end': '2584.079', 'text': 'that ampule. So you in theory you had to'}, {'start': '2582.560', 'end': '2586.480', 'text': 'have a filtered needle, right, to draw'}, {'start': '2584.079', 'end': '2587.920', 'text': "that because it's ampule. Well, gosh, it"}, {'start': '2586.480', 'end': '2589.520', 'text': "wasn't until four or five years after"}, {'start': '2587.920', 'end': '2590.960', 'text': 'everybody was using TXA that we started'}, {'start': '2589.520', 'end': '2594.400', 'text': 'putting in a plastic B where you could'}, {'start': '2590.960', 'end': '2596.800', 'text': 'just draw it normal. Remember that? Yes.'}, {'start': '2594.400', 'end': '2598.079', 'text': "Sadly, I do. Yep. So, there's a great"}, {'start': '2596.800', 'end': '2600.240', 'text': 'example of how the packaging is'}, {'start': '2598.079', 'end': '2602.079', 'text': 'changing. So, this is again implied'}, {'start': '2600.240', 'end': '2605.280', 'text': 'task. Get to know your friendly medical'}, {'start': '2602.079', 'end': '2606.960', 'text': 'logistics folks or your supply and uh'}, {'start': '2605.280', 'end': '2608.880', 'text': 'take a look at your labels and then run'}, {'start': '2606.960', 'end': '2610.720', 'text': 'that by your medical director. As with'}, {'start': '2608.880', 'end': '2612.319', 'text': 'all things on our podcast, Dennis, all'}, {'start': '2610.720', 'end': '2614.160', 'text': 'of this is subject to your medical'}, {'start': '2612.319', 'end': '2615.520', 'text': 'direction and your chain of command.'}, {'start': '2614.160', 'end': '2618.079', 'text': "make sure you're running all this by"}, {'start': '2615.520', 'end': '2619.760', 'text': 'them. Um, our hope on this podcast is to'}, {'start': '2618.079', 'end': '2622.319', 'text': 'continue the conversation, get people to'}, {'start': '2619.760', 'end': '2624.079', 'text': 'think about alternative uh, methods, but'}, {'start': '2622.319', 'end': '2626.800', 'text': 'at the end of the day, this still falls'}, {'start': '2624.079', 'end': '2631.200', 'text': 'under your licensed prescribers to to'}, {'start': '2626.800', 'end': '2633.000', 'text': 'dictate. Yeah. Um, one last question'}, {'start': '2631.200', 'end': '2635.920', 'text': 'about calcium.'}, {'start': '2633.000', 'end': '2637.720', 'text': "Um, let's say I have just the 10 ml"}, {'start': '2635.920', 'end': '2641.920', 'text': 'vials of calcium'}, {'start': '2637.720', 'end': '2645.839', 'text': 'gluconate. Okay. Mhm.'}, {'start': '2641.920', 'end': '2648.599', 'text': 'Um, I give said vial uh to my patient.'}, {'start': '2645.839', 'end': '2650.960', 'text': "I'm monitoring him. I h I have my"}, {'start': '2648.599', 'end': '2653.520', 'text': "little, you know, cardiac monitor. It's"}, {'start': '2650.960', 'end': '2655.800', 'text': "a one lead. I'm trying to do all the"}, {'start': '2653.520', 'end': '2658.720', 'text': 'things to the best of my'}, {'start': '2655.800', 'end': '2660.880', 'text': "ability. It doesn't necessarily work or"}, {'start': '2658.720', 'end': '2663.200', 'text': "I'm not seeing it change from what it"}, {'start': '2660.880', 'end': '2667.680', 'text': 'was before I converted the tourniquet to'}, {'start': '2663.200', 'end': '2670.839', 'text': "back to what I'm sorry. I was watching"}, {'start': '2667.680', 'end': '2674.240', 'text': "it. It was normal. I converted. It's now"}, {'start': '2670.839', 'end': '2676.359', 'text': 'abnormal. That one that 110 ml vial did'}, {'start': '2674.240', 'end': '2680.560', 'text': 'not push it back to'}, {'start': '2676.359', 'end': '2682.440', 'text': 'normal. How fast do I need to respond to'}, {'start': '2680.560', 'end': '2685.280', 'text': 'send more'}, {'start': '2682.440', 'end': '2688.480', 'text': 'calcium? Yeah. So, this also a great'}, {'start': '2685.280', 'end': '2690.960', 'text': 'area evolving in in the studies and the'}, {'start': '2688.480', 'end': '2692.480', 'text': 'trauma literature, right, Dennis? I'}, {'start': '2690.960', 'end': '2694.000', 'text': 'think you know the answer to this'}, {'start': '2692.480', 'end': '2696.079', 'text': 'question would have been different 5'}, {'start': '2694.000', 'end': '2698.720', 'text': "years ago but now that we're like you"}, {'start': '2696.079', 'end': '2701.040', 'text': 'were talking about um you know the'}, {'start': '2698.720', 'end': '2703.920', 'text': 'lethal pentad or the lethal diamond and'}, {'start': '2701.040', 'end': '2705.280', 'text': 'and including a hypocalcemia in that'}, {'start': '2703.920', 'end': '2707.440', 'text': 'this was actually discussed at a'}, {'start': '2705.280', 'end': '2710.160', 'text': 'tactical combat casualty care meeting'}, {'start': '2707.440', 'end': '2713.040', 'text': 'you know is there really harm in giving'}, {'start': '2710.160', 'end': '2715.599', 'text': 'calcium to the hemorrhagic shock trauma'}, {'start': '2713.040', 'end': '2718.640', 'text': 'patient and the and the answer generally'}, {'start': '2715.599', 'end': '2721.280', 'text': 'was no because we know these patients'}, {'start': '2718.640', 'end': '2723.760', 'text': 'are typically hypocalcemic upon point of'}, {'start': '2721.280', 'end': '2725.200', 'text': 'entry to the health care system um just'}, {'start': '2723.760', 'end': '2727.760', 'text': 'due to blood loss and all the'}, {'start': '2725.200', 'end': '2729.760', 'text': "coagulation stuff that's going on. So my"}, {'start': '2727.760', 'end': '2732.000', 'text': "answer to that would be I think you'd be"}, {'start': '2729.760', 'end': '2733.920', 'text': 'on safe ground as a medic to to pretty'}, {'start': '2732.000', 'end': '2737.040', 'text': 'quickly follow that with a second dose'}, {'start': '2733.920', 'end': '2739.680', 'text': 'of calcium. Again, depending on your'}, {'start': '2737.040', 'end': '2741.839', 'text': "patient's condition, what do you think"}, {'start': '2739.680', 'end': '2745.040', 'text': 'their total blood loss was? Is this a'}, {'start': '2741.839', 'end': '2747.599', 'text': 'class three hemorrhagic shock patient'}, {'start': '2745.040', 'end': '2749.680', 'text': 'who has massive vitals abnormalities'}, {'start': '2747.599', 'end': '2751.599', 'text': 'before you started your profusion?'}, {'start': '2749.680', 'end': '2754.000', 'text': "Absolutely. That's a patient I would be"}, {'start': '2751.599', 'end': '2756.400', 'text': 'thinking about giving two or three grams'}, {'start': '2754.000', 'end': '2758.000', 'text': 'of calcium right up front because you'}, {'start': '2756.400', 'end': '2759.760', 'text': "know you're going there with your with"}, {'start': '2758.000', 'end': '2761.200', 'text': "your blood replacement. You know you're"}, {'start': '2759.760', 'end': '2763.040', 'text': "going to give that blood and you've"}, {'start': '2761.200', 'end': '2764.800', 'text': 'already got good protocols saying hey'}, {'start': '2763.040', 'end': '2766.720', 'text': 'after that first unit of blood or with'}, {'start': '2764.800', 'end': '2769.040', 'text': 'the first unit of blood get that calcium'}, {'start': '2766.720', 'end': '2771.440', 'text': "going. Um so you know you're going to be"}, {'start': '2769.040', 'end': '2773.119', 'text': "re resuscitating these patients they're"}, {'start': '2771.440', 'end': '2776.680', 'text': "getting blood so you're on safe ground"}, {'start': '2773.119', 'end': '2779.240', 'text': 'for multiple serial doses of calcium.'}, {'start': '2776.680', 'end': '2783.440', 'text': 'Y perfect. Perfect.'}, {'start': '2779.240', 'end': '2786.800', 'text': 'Um, if you had to give any advice to a'}, {'start': '2783.440', 'end': '2789.680', 'text': "young medic going into harm's way when"}, {'start': '2786.800', 'end': '2791.560', 'text': 'it comes to con tourniquet conversion,'}, {'start': '2789.680', 'end': '2793.960', 'text': 'what advice would you give'}, {'start': '2791.560', 'end': '2798.240', 'text': 'him or'}, {'start': '2793.960', 'end': '2800.720', 'text': "her? Convert. Right. If you're in a"}, {'start': '2798.240', 'end': '2802.800', 'text': 'setting tactically'}, {'start': '2800.720', 'end': '2805.240', 'text': "uh where you're no longer under fire,"}, {'start': '2802.800', 'end': '2809.200', 'text': "you're doing tactical field"}, {'start': '2805.240', 'end': '2811.040', 'text': 'care, resuscitate and convert. I think'}, {'start': '2809.200', 'end': '2813.599', 'text': "Dennis, we've hit that today why that's"}, {'start': '2811.040', 'end': '2816.040', 'text': 'so important both for morale'}, {'start': '2813.599', 'end': '2818.800', 'text': 'um for the patients long-term'}, {'start': '2816.040', 'end': '2820.880', 'text': 'morbidity. There are so many reasons to'}, {'start': '2818.800', 'end': '2823.359', 'text': "try and convert and that's why this"}, {'start': '2820.880', 'end': '2825.680', 'text': 'podcast is so important.'}, {'start': '2823.359', 'end': '2827.760', 'text': "It's that experience and confidence gap"}, {'start': '2825.680', 'end': '2830.160', 'text': "we've got right now. Everybody's good at"}, {'start': '2827.760', 'end': '2832.720', 'text': 'throwing these things on. Not a lot of'}, {'start': '2830.160', 'end': '2834.960', 'text': 'people are good or confident at least at'}, {'start': '2832.720', 'end': '2838.000', 'text': 'taking them off, taking the tourniquet'}, {'start': '2834.960', 'end': '2840.040', 'text': 'off. So, my challenge and my and my'}, {'start': '2838.000', 'end': '2841.800', 'text': 'recommendation to the medics would'}, {'start': '2840.040', 'end': '2845.119', 'text': 'be'}, {'start': '2841.800', 'end': '2847.560', 'text': 'prepared. Get your equipment, get your'}, {'start': '2845.119', 'end': '2851.040', 'text': 'hemorrhage control measures, everything'}, {'start': '2847.560', 'end': '2852.560', 'text': 'ready and try and convert. Can you'}, {'start': '2851.040', 'end': '2854.800', 'text': 'imagine a world where every single'}, {'start': '2852.560', 'end': '2856.880', 'text': 'tourniquet we put on resulted in a lost'}, {'start': '2854.800', 'end': '2858.880', 'text': 'limb?'}, {'start': '2856.880', 'end': '2863.680', 'text': "That's a bad statement. That's a that's"}, {'start': '2858.880', 'end': '2865.440', 'text': 'a bad statement, right? So So my thought'}, {'start': '2863.680', 'end': '2866.800', 'text': 'I know this is a hard part of the'}, {'start': '2865.440', 'end': '2868.440', 'text': "medic's job, right? Because they're"}, {'start': '2866.800', 'end': '2872.400', 'text': 'making a'}, {'start': '2868.440', 'end': '2874.880', 'text': 'lifelim decision. Um but my challenge to'}, {'start': '2872.400', 'end': '2877.680', 'text': 'you is be bold because you want to be'}, {'start': '2874.880', 'end': '2879.119', 'text': 'able to sleep with yourself after and'}, {'start': '2877.680', 'end': '2881.200', 'text': "rest, right? knowing you've done"}, {'start': '2879.119', 'end': '2883.680', 'text': 'everything you can for that patient. You'}, {'start': '2881.200', 'end': '2885.200', 'text': 'lose very little other than a little bit'}, {'start': '2883.680', 'end': '2887.920', 'text': "of blood if you're if you're mining your"}, {'start': '2885.200', 'end': '2889.960', 'text': "P's and Q's and you're on your game. You"}, {'start': '2887.920', 'end': '2893.280', 'text': 'lose very little from attempting to'}, {'start': '2889.960', 'end': '2896.160', 'text': 'convert. You lose a limb at a minimum if'}, {'start': '2893.280', 'end': '2899.680', 'text': "you don't and potentially a life if you"}, {'start': '2896.160', 'end': '2902.720', 'text': 'convert too late.'}, {'start': '2899.680', 'end': '2904.400', 'text': 'Cool. Thank you very much, Jamie. I love'}, {'start': '2902.720', 'end': '2906.000', 'text': 'being able to chat with you whenever I'}, {'start': '2904.400', 'end': '2907.839', 'text': 'can.'}, {'start': '2906.000', 'end': '2910.960', 'text': 'Thanks, Dennis. Great, great job on the'}, {'start': '2907.839', 'end': '2912.880', 'text': 'podcast. Keep it up.'}, {'start': '2910.960', 'end': '2916.240', 'text': "That's it for today's podcast. Make sure"}, {'start': '2912.880', 'end': '2916.240', 'text': 'to go to our website,'}, {'start': '2916.359', 'end': '2919.920', 'text': 'www.prolongfieldcare.org. Check out our'}, {'start': '2918.000', 'end': '2922.400', 'text': 'free downloads and a ton of other'}, {'start': '2919.920', 'end': '2925.040', 'text': 'helpful information. Grab a bag of our'}, {'start': '2922.400', 'end': '2927.200', 'text': 'fresh roasted PFC coffee. Links in the'}, {'start': '2925.040', 'end': '2929.200', 'text': 'description below. And stay on the'}, {'start': '2927.200', 'end': '2931.720', 'text': 'bleeding edge of combat and austere'}, {'start': '2929.200', 'end': '2935.720', 'text': 'medicine. This is Dennis for the PFC'}, {'start': '2931.720', 'end': '2935.720', 'text': 'podcast. Out.'}]