Latest / B Shifter / The Cyanokit Conversation: What Firefighters Need to Know

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The Cyanokit Conversation: What Firefighters Need to Know · B Shifter

• 0:07
  SPEAKER_02: Hi there, John Vance here.
• 0:09
  SPEAKER_02: I would like to welcome you to the Beat Shifter Podcast.
• 0:12
  SPEAKER_02: Thanks for listening.
• 0:13
  SPEAKER_02: This is the podcast for Incident Commanders and Fire Service Leaders.
• 0:17
  SPEAKER_02: We are going to be talking about the administration of cyano kits in the field for smoke inhalation victims today.
• 0:24
  SPEAKER_02: It will be an overview, just a high level, especially if your department is not currently using this as part of your protocol or treatment of smoke inhalation victims.
• 0:34
  SPEAKER_02: We're going to give you some good information.
• 0:36
  SPEAKER_02: We'll be joined by Dr.
• 0:37
  SPEAKER_02: Dustin Calhoun from the Cincinnati area today, along with two of our blue card lead instructors, Steve Lester and Scott Williams.
• 0:46
  SPEAKER_02: So stay tuned for that.
• 0:47
  SPEAKER_02: Some good information on the administration of cyano kits for smoke inhalation victims that potentially have altered the level of consciousness and when you should administer, when you shouldn't, and really how to get that program going within your department.
• 1:02
  SPEAKER_02: Before we get to that, a couple of announcements to make.
• 1:04
  SPEAKER_02: We have a blue card train, the trainer coming up at the Alan V.
• 1:07
  SPEAKER_02: Brunicini Command Training Center.
• 1:10
  SPEAKER_02: That happens September 14th through the 18th in Phoenix, Arizona.
• 1:14
  SPEAKER_02: If you've never made your way out to Phoenix, Arizona, to the AVB, CTC before, it is a great experience.
• 1:22
  SPEAKER_02: It's a great learning experience.
• 1:23
  SPEAKER_02: It's a good way to bond with fellow incident commanders.
• 1:26
  SPEAKER_02: And Phoenix starts to be beautiful in September, too.
• 1:29
  SPEAKER_02: So go to uh BShifter.com, go to our calendar to sign up for that.
• 1:34
  SPEAKER_02: And also in Phoenix, we are doing the first big box workshop in a couple of years at least out at the AVB CTC in Phoenix October 19th and 20th.
• 1:44
  SPEAKER_02: Seats available for that one right now for day one.
• 1:48
  SPEAKER_02: Shane Ray is there talking to us about fire protection systems and how we should be handling those as the fire department.
• 1:55
  SPEAKER_02: And then day two, practical application.
• 1:58
  SPEAKER_02: We will do some simulations.
• 2:00
  SPEAKER_02: We'll talk about protocol and some case studies in the implementation of our procedures for big box fires.
• 2:08
  SPEAKER_02: Join us in Phoenix for that.
• 2:10
  SPEAKER_02: For all of that, you can go to bShifter.com.
• 2:14
  SPEAKER_02: Now let's go to our topic for the day administration of cyanokits out in the field.
• 2:21
  SPEAKER_02: And today on the B Shifter Podcast, we have Dr.
• 2:23
  SPEAKER_02: Dustin Calhoun.
• 2:24
  SPEAKER_02: He's from the UC Health in Cincinnati, Associate Professor of Clinical Emergency Medicine at the University of Cincinnati College of Medicine, also the medical director for the City of Springdale Fire Department, as well as the Cincinnati Fire Department.
• 2:37
  SPEAKER_02: You sound like a busy guy, Dustin.
• 2:39
  SPEAKER_02: So thanks for being here with us today.
• 2:41
  SPEAKER_02: We really appreciate it.
• 2:43
  SPEAKER_00: Thanks for having me on.
• 2:44
  SPEAKER_00: This is a great topic.
• 2:45
  SPEAKER_00: I'm excited to talk with everybody.
• 2:47
  SPEAKER_02: We are so excited to learn more.
• 2:48
  SPEAKER_02: And then down in Cobb County coming to us from their training center today, we have uh Steve Lester and Scott Williams.
• 2:55
  SPEAKER_02: Scott Williams, Assistant Chief, Springdale Fire Department.
• 2:57
  SPEAKER_02: Steve Lester, soon to be the retired division chief of training from the Cobb County Fire Department.
• 3:04
  SPEAKER_02: But you've got other missions coming up that we'll we'll talk about soon, too.
• 3:07
  SPEAKER_02: If folks are sticking along with us, they'll they'll know where you are soon.
• 3:11
  SPEAKER_02: So thanks so much for being here on this discussion on cyano kits today.
• 3:16
  SPEAKER_02: And we wanted to start thank you guys.
• 3:20
  SPEAKER_02: We wanted to start off by asking, and we'll just go to uh Dustin on this one from the medical side of things.
• 3:26
  SPEAKER_02: Cyanokits, when we start talking about them in class, because we even have them on our checklist for the incident commander, we're met with about half the time blank looks and people have no idea what we're talking about.
• 3:39
  SPEAKER_02: So if you can give us an overview on what a cyanokit is and really the reason why it exists and what we use it for in the field.
• 3:48
  SPEAKER_00: Sure.
• 3:48
  SPEAKER_00: It's a great talk.
• 3:49
  SPEAKER_00: And there's the there's a good reason that EMS providers don't tend to have a lot of knowledge about them, or at least over the you know, decade or so before now.
• 3:58
  SPEAKER_00: The old kit, the old treatment that we had for cyanide poisoning was what often people refer to as a lily kit because of the manufacturer.
• 4:05
  SPEAKER_00: And those were great for industrial cyanide poisoning, i.e., you're using cyanide to do something and being exposed to it solely.
• 4:14
  SPEAKER_00: When you're using it in the setting with fire, which the majority of the folks that we're going to be treating for cyanide toxicity, that's how they acquired it.
• 4:21
  SPEAKER_00: They're also getting it in the setting of carbon monoxide.
• 4:24
  SPEAKER_00: And the old kit had a real problem when used in the setting of carbon monoxide without being able to closely manage levels.
• 4:31
  SPEAKER_00: Because you do take a patient with that old kit and you actually convert them to a form of like methemoglobinemia, which is a problem when you also have carboxy hemoglobinemia.
• 4:42
  SPEAKER_00: So you get rid of all of that with the cyanic.
• 4:45
  SPEAKER_00: The cyanicit or hydroxycobalamin is essentially B12.
• 4:49
  SPEAKER_00: Now we got to be real little careful when we use that because it's not just like you know buying a bottle of B12 at GNC or something like that and taking a whole bunch of it.
• 4:57
  SPEAKER_00: But that's essentially what it is.
• 4:59
  SPEAKER_00: So cyanide is uh a fascinating aspect of all of EMS, particularly fire-based EMS, because then you're really talking about your own folks as well as the patients you're taking care of.
• 5:10
  SPEAKER_00: Um but any sort of setting when you're around combustion.
• 5:13
  SPEAKER_00: I mean, this is another sort of common misconception, um, is that idea that we're really talking about either synthetic combustion or something like that.
• 5:20
  SPEAKER_00: And sure, that is the major source.
• 5:22
  SPEAKER_00: One of the big ones are the blown insulation that we see in so many structures now.
• 5:27
  SPEAKER_00: Um, but really other stuff, even natural products like wool and silk, as they as they heat even.
• 5:33
  SPEAKER_00: I guess I I even really misspoke when I said combustion, because that's a misnomer as well.
• 5:37
  SPEAKER_00: Just heating certain objects even before the point of ignition can allow hydrogen cyanide into the air.
• 5:44
  SPEAKER_00: So anytime you're around a structure fire, anytime you're around something that is smoldering, all those sort of things.
• 5:49
  SPEAKER_00: And that includes the the after portion, right?
• 5:52
  SPEAKER_00: Um, when you're doing overhaul at a scene, um, there is still hydrogen cyanide being produced.
• 5:58
  SPEAKER_00: So that's sort of where we're getting this.
• 6:00
  SPEAKER_00: And the we're really talking about an enclosed space typically.
• 6:05
  SPEAKER_00: So if you're talking about a big bonfire out in the middle of a field, the likelihood of someone being exposed to a concerning level of hydrogen cyanide is probably not great.
• 6:13
  SPEAKER_00: Um, but when you're talking about structure fires, um, there's a significant risk there, even for the folks in sort of the near proximity around it.
• 6:21
  SPEAKER_00: We absorb it in a lot of different ways.
• 6:23
  SPEAKER_00: The big ones are breathing it in, and then the big one that's unappreciated by most is the absorption through our skin, which tends to take longer and can lead to some delayed effects.
• 6:32
  SPEAKER_00: And what the what that does is it essentially asphyxiates the patient and asphyxiates their cells.
• 6:38
  SPEAKER_00: Um so, unlike some of the other asphyxiants that just sort of displaced oxygen, this actually prevents the body's ability to use it at the cellular level.
• 6:47
  SPEAKER_00: Um, so rather than putting people into some sort of PTSD from the Krebs cycle that they probably had to memorize somewhere along the way, um, what we're essentially talking about is preventing the cells from doing what they normally do, right?
• 7:00
  SPEAKER_00: They take sugar and oxygen and they make energy and CO2.
• 7:04
  SPEAKER_00: The you can think of the cyanide as stepping in there and blocking that process, preventing your cells from creating energy using oxygen.
• 7:12
  SPEAKER_00: And what the hydroxycobalamin or the cyanokit does is it steps in there and it essentially binds.
• 7:17
  SPEAKER_00: You can think of it as binding the cyanide, even pulling it off of the mitochondria where it is acting and preventing that blockage from occurring.
• 7:27
  SPEAKER_00: You then essentially process that and urinate a lot of that out.
• 7:31
  SPEAKER_00: So it's a pretty impressive medicine or treatment simply because the dosing is very easy.
• 7:38
  SPEAKER_00: There's not a ton of negative side effect to it.
• 7:41
  SPEAKER_00: The biggest trick these days is affording it and having getting a good handle on exactly when to use it.
• 7:46
  SPEAKER_02: We see that it usually calls for rapid administration.
• 7:49
  SPEAKER_02: Why is that important?
• 7:51
  SPEAKER_02: How important is it to get that on board immediately for a smoke inhalation victim?
• 7:56
  SPEAKER_00: That's a great question.
• 7:57
  SPEAKER_00: It it really relates to that ongoing damage.
• 8:00
  SPEAKER_00: Like a lot of medical processes, the longer it goes, the more damage it does, the harder it is to reverse.
• 8:05
  SPEAKER_00: Um, when you're talking about a cardiac arrest victim, which is sort of your most black and white obvious use of this, if you pull a patient out of a structure fire and they're in cardiac arrest, 100%, they need a cyanicit.
• 8:16
  SPEAKER_00: And in a huge portion of those cases, it will be cyanide toxicity as the cause.
• 8:21
  SPEAKER_00: And if that is the cause, you will not get them back without reversing the effect on the mitochondria.
• 8:27
  SPEAKER_00: So that's that's the reason for that to be a good question.
• 8:31
  SPEAKER_02: And Steve and Scott, you both have a lot of experience of field administration.
• 8:37
  SPEAKER_02: How did this start within your departments?
• 8:39
  SPEAKER_02: And what questions can we uh bounce then to uh Dustin as far as that getting this into the protocols for folks who may not be able to offer this at this time?
• 8:52
  SPEAKER_01: Well, for us, it was about late 21, early 22, and we started really seeing the benefits of this.
• 8:59
  SPEAKER_01: We understood it would really improve the outcomes of our patients.
• 9:03
  SPEAKER_01: So we started looking into this in Hamilton County, Ohio.
• 9:06
  SPEAKER_01: We found that the health collaborative had given out four different kits to different departments.
• 9:11
  SPEAKER_01: Nobody really knew where they were.
• 9:13
  SPEAKER_01: Nobody was trained on how to use them, and we didn't know how to get them on our scenes if we needed them.
• 9:18
  SPEAKER_01: So we reached out in March of 22, uh, reached out to BTG Especialty Pharmaceuticals who makes the cyan kit directly, talked with them to see what we need how we could go about getting a kit, and that's when we purchased our first one at Springdale.
• 9:34
  SPEAKER_01: Dr.
• 9:35
  SPEAKER_01: Calhoun came in in April of 22 and did a training for us, made sure all of our personnel knew how to use it.
• 9:41
  SPEAKER_01: And then it's obviously in our Southwest Ohio protocols so that we know when we need to administer it.
• 9:47
  SPEAKER_01: So that's kind of how it began in our department, and we didn't have them prior to that to use on fire scenes.
• 9:55
  SPEAKER_03: Yeah, very similar situation down here in Cobb County.
• 9:57
  SPEAKER_03: You know, we uh we started carrying it, I want to say around 2017, 2018.
• 10:04
  SPEAKER_03: It started out on our uh medical operations unit, and that is a specialized team that we use here in in Cobb County.
• 10:11
  SPEAKER_03: They they're basically our special ops paramedics.
• 10:14
  SPEAKER_03: A lot of them are registered nurses on that team.
• 10:16
  SPEAKER_03: I was actually a founding member of that team back in 2004.
• 10:21
  SPEAKER_03: So, yeah, we started carrying that on that particular unit.
• 10:24
  SPEAKER_03: Uh, in about 2018, we rolled out initial education along with our medical director, Dr.
• 10:30
  SPEAKER_03: Eric Nicks, who works out of the Well Star Health System.
• 10:34
  SPEAKER_03: We uh big thing for us was education of our transport providers and our hospital personnel because they were not familiar with the kit.
• 10:41
  SPEAKER_03: So I had to develop a presentation and deliver to them because you know we in Cobb County, we don't transport, uh, we're not a transport provider.
• 10:49
  SPEAKER_03: We depend on a private provider, EMS, to do our transport for us.
• 10:52
  SPEAKER_03: So it was highly very important to us that we educated our our ground partners, our transport providers, on uh on the kit and what to expect when given that patient, when that patient's been administered that kit on the scene and then turned over to them for transport.
• 11:06
  SPEAKER_03: And then also our hospital personnel to make sure that they were educated as well on the medication so that when they received the patient and they saw some of the side effects, some of the benign side effects from the drugs, such as the urethemia or the red skin, the dark red colored urine, things like that, that they wouldn't be alarmed uh by that.
• 11:26
  SPEAKER_03: Also, the the kit does have a tendency to skew some lab values as well.
• 11:30
  SPEAKER_03: So when they're drawing labs and stuff like that in the emergency room or the emergency department, some of those lab values can be skewed.
• 11:36
  SPEAKER_03: So it's very important that they know uh what the drug does and how it affects that.
• 11:41
  SPEAKER_02: So we hear a lot of times with rescues that are being made, they they bring a patient out and the IC calls for the cyanokit to be brought to where the patient is because typically not every unit has it, as Dr.
• 11:54
  SPEAKER_02: Calhoun alluded to.
• 11:55
  SPEAKER_02: The cost of it is one of the things that kind of holds it back so it's not on every unit all the time or not in every med bag.
• 12:02
  SPEAKER_02: So, how does that administration look and and where do we start the ball rolling with that smoke inhalation patient?
• 12:10
  SPEAKER_03: So in our system, I'll just I just go back to previously it was being only carried by our special operations medics.
• 12:17
  SPEAKER_03: At that point in time, there would be an intercept at some point where that special operations team would intercept or come to the scene by via special request to administer that kit.
• 12:28
  SPEAKER_03: We later determined that that was becoming a time problem.
• 12:31
  SPEAKER_03: And as as Dr.
• 12:32
  SPEAKER_03: Calhoun alluded, you know, that time is everything in these types of administrations.
• 12:36
  SPEAKER_03: So that's when we instituted and we put them on all the battalion chief vehicles.
• 12:40
  SPEAKER_03: So every battalion chief uh vehicle had a has a kit, and now we've upgraded that now to where all of our advanced life support rescue units have them as well.
• 12:49
  SPEAKER_03: So we have a lot of kits that are available as a resource just here in Cobb County.
• 12:54
  SPEAKER_01: Yeah, in Hamilton County, same way uh at Springdale, we carry one in our district vehicle as well as on our engine company because we want them on the fire scene for the firefighters and the victims.
• 13:05
  SPEAKER_01: Not always will our medic be on the fire that the fire company's on if they're on a mutual aid fire.
• 13:10
  SPEAKER_01: So that's one of the big components of this is departments that do carry them, just when you place them on a vehicle, making sure that you're thinking through that process to make sure that they are on your fire scenes.
• 13:22
  SPEAKER_01: And throughout Hamilton County, I think that's where most of them are being carried, is on either the district vehicles or the fire companies.
• 13:29
  SPEAKER_00: Yeah, it's the same.
• 13:30
  SPEAKER_00: The Cincinnati Fire Department does the same.
• 13:31
  SPEAKER_00: They uh for about 70,000 runs, they have four in service at any time.
• 13:37
  SPEAKER_00: And those are again on a district vehicle because those were the we we considered uh the we have an ALS supervisor vehicle that's separate.
• 13:44
  SPEAKER_00: We consider putting them on there, but the district chief actually gets to most fire scenes sooner.
• 13:49
  SPEAKER_00: And so that was the reason for choosing that.
• 13:53
  SPEAKER_02: How long does it typically take to prepare and administer this?
• 13:56
  SPEAKER_02: And and what's your goal as far as administration go, Dr.
• 14:00
  SPEAKER_02: Kelvin?
• 14:01
  SPEAKER_00: Oh, it's so it's quick.
• 14:03
  SPEAKER_00: It's a lyophilized product, so it's a powder in a bottle.
• 14:06
  SPEAKER_00: Slightly more complicated than what most the thing that most people are probably most familiar with is solumedrol, right, which is the inner powder, but it comes with its own water, so you're just crushing to combine them.
• 14:17
  SPEAKER_00: Um, this you actually do have to infuse uh the saline into the the bottle that it comes with.
• 14:23
  SPEAKER_00: Again, very simple though, so that adds just a little bit of a step there.
• 14:26
  SPEAKER_00: Um, there's a little bit of a mixing process.
• 14:28
  SPEAKER_00: It comes with all the pieces you need other than the saline.
• 14:32
  SPEAKER_00: So it's a very quick product.
• 14:33
  SPEAKER_00: There is not a whole lot.
• 14:35
  SPEAKER_00: The training really does uh focus heavily on patient selection, who to give this to, and encouraging an understanding of cyanide toxicity, not so much how to give, because it it's any IV that is functioning will work.
• 14:48
  SPEAKER_00: I mean, the the boxes are pretty well labeled as far as if I handed you this with zero training, you would probably mix it up and administer it correctly.
• 14:56
  SPEAKER_02: What what outcomes have you seen when it's given early versus delayed administration?
• 15:02
  SPEAKER_00: You know, the numbers, I always hate to talk too much there because the numbers are so small, it's it's it's hard to say that are they truly statistically significant or not.
• 15:11
  SPEAKER_00: But um anecdotally, we have definitely seen some significant improvements, some cardiac arrests on fire scenes that if I were guessing, I would say probably would not have been salvageable had it not been for that on-scene cyanochid.
• 15:25
  SPEAKER_02: How about going over to uh Scott, what what have you uh seen on the scene and and what kind of success stories have you had out of your department?
• 15:34
  SPEAKER_01: So we back in September of 22, we put these in service again in March, April of 22.
• 15:40
  SPEAKER_01: We used our first kit in September.
• 15:42
  SPEAKER_01: We went to a mutual aid apartment building on fire.
• 15:45
  SPEAKER_01: When the origin first crews got inside, they found four children, nine years and under, back in a bedroom, all unconscious, brought them out to the front.
• 15:55
  SPEAKER_01: Uh, we were the only department that had a kit on that scene.
• 15:59
  SPEAKER_01: So the patient that our engine company was treating got the kit.
• 16:03
  SPEAKER_01: The other three did not.
• 16:04
  SPEAKER_01: And two of the four of those kids uh sadly died from that fire.
• 16:10
  SPEAKER_01: Back in May last month in our county, we used two of these.
• 16:14
  SPEAKER_01: Uh one was on a nine-year-old boy from another apartment fire.
• 16:18
  SPEAKER_01: Our district car was the only vehicle dispatched from our department.
• 16:21
  SPEAKER_01: When he arrived on the scene, the first crews had just pulled this child out.
• 16:26
  SPEAKER_01: Uh, the medical was doing CPR in the front yard.
• 16:29
  SPEAKER_01: He took his kit over, gave it to them.
• 16:31
  SPEAKER_01: They administered that kit to that child.
• 16:34
  SPEAKER_01: In this last month, he has been taken off the ventilator.
• 16:38
  SPEAKER_01: He is progressing, still in the hospital, but making progress.
• 16:42
  SPEAKER_01: So we have seen significant saves with these.
• 16:45
  SPEAKER_01: And it and like Dr.
• 16:47
  SPEAKER_01: Cathoon said, had we not had them, especially that child last month in cardiac arrest, chances are he would not have survived.
• 16:55
  SPEAKER_03: Yeah, same here, Cobb County.
• 16:57
  SPEAKER_03: We we had a an incident probably about two years ago now where we pulled four people from a structure fire, all living in the same structure.
• 17:06
  SPEAKER_03: Four people were pulled and four kits were administered.
• 17:09
  SPEAKER_03: Luckily, we had we had the resources on scene to be able to deliver every victim, they got their own kit.
• 17:14
  SPEAKER_03: Unfortunately, the burns were so significant in those victims that no one survived, but they did all receive the kit.
• 17:21
  SPEAKER_03: Uh, we have seen a couple of cardiac arrests that have been reversed, secondary to the cyano kid administration.
• 17:27
  SPEAKER_03: I think it's an important point to to uh to take in here as well that you know cyano kid is safe to administer via the interosseous route, too.
• 17:35
  SPEAKER_03: We see this a lot where we've we pull these victims from from structure fires and they're they may they may have significant burns on their extremities, you may have difficulty getting IV access.
• 17:46
  SPEAKER_03: Also, they're gonna be suffering some severe cardiovascular collapse.
• 17:49
  SPEAKER_03: That's one of the one of the side effects of uh severe cyanide toxicity.
• 17:52
  SPEAKER_03: These patients are gonna be very, very shocky if if if they even have a pulse detectable at all.
• 17:59
  SPEAKER_03: So uh being able to give this medication via the interosseous or the IO route is very significant.
• 18:05
  SPEAKER_03: And you can just use a three-way stopcock and you know, draw off a syringe, give it one syringe at a time until you've administered the entire product and uh it goes directly into the into the circulatory system and can reverse.
• 18:16
  SPEAKER_03: So that's that's a key.
• 18:18
  SPEAKER_03: That's a big thing there is being able to use that via the interosseo route.
• 18:21
  SPEAKER_03: The key there is that you have to flush it.
• 18:24
  SPEAKER_03: You have to flush it very good when you're when you've uh completed the administration.
• 18:28
  SPEAKER_03: You have to put a lot of fluid behind that and get that, get those lines completely flushed through with all that, get all that drug on board before you start to give like your epinephrine or any other cardiac or your ACLS drug.
• 18:40
  SPEAKER_00: Yeah, that push-pull method that you mentioned there using the syringe is really important.
• 18:43
  SPEAKER_00: A lot of people don't think about that because it is in a glass vial.
• 18:47
  SPEAKER_00: So you're not gonna get the you there's no way to do pressure like squeezing it like you would with an IV.
• 18:53
  SPEAKER_00: And a lot of IOs won't run well without pressure.
• 18:56
  SPEAKER_00: So that push-pull method using a three-way stockcock or some other method that we're more familiar with, with like pediatric fluid boluses, is something that people don't think about.
• 19:05
  SPEAKER_00: Peeds are not an uncommon use of this.
• 19:08
  SPEAKER_00: As Chief Williams mentioned, that's where some of the most common uses around here have been.
• 19:12
  SPEAKER_00: And it it people always worry, we had one of those first uh incidents that happened around here, there were more kids than there were cyanokids.
• 19:21
  SPEAKER_00: Um, so the question sort of comes up two questions.
• 19:23
  SPEAKER_00: One is what's the dosing?
• 19:25
  SPEAKER_00: Because unless that's changed, the last time I checked, there wasn't actually a manufacturer-endorsed official dose for pediatrics.
• 19:32
  SPEAKER_00: Um, there is a fairly well accepted dose.
• 19:34
  SPEAKER_00: It's just not in all the literature that comes with the device.
• 19:37
  SPEAKER_00: So making sure that you are comfortable with what your dose is and your protocol, that you know, your your toxicologist or your whoever it is that's going to be overseeing that patient after you get them knows what it is.
• 19:47
  SPEAKER_00: And then having sort of processing in place where if you need to, you can split that kit.
• 19:53
  SPEAKER_00: So it comes in the one vial with one set of administration.
• 19:56
  SPEAKER_00: How do you give, how do you dose that and give the vial to three kids as opposed to one adult?
• 20:03
  SPEAKER_00: Because there's plenty of medicine there, depending on the size, and we hate to waste it.
• 20:06
  SPEAKER_00: Um, and oftentimes there may not be enough kits for multiple pediatric patients.
• 20:10
  SPEAKER_02: Switching gears a little bit to the incident commander and their role in this, what role does the IC play in identifying potential victims and getting that kit to where it needs to be?
• 20:22
  SPEAKER_02: And we'll start with Scott on that.
• 20:25
  SPEAKER_01: Yeah, I think it starts with the company officer as he locates that victim, just giving that information out.
• 20:31
  SPEAKER_01: If you can think of those things when you give that priority traffic, hey, I've got an adult or a pediatric patient, they're conscious or unconscious, and then where we're bringing them out, and then them starting, hey, I need a sino kit as part of my needs report.
• 20:45
  SPEAKER_01: But once the IC gets that information, if the sino kit's not requested, he needs to at least get that from the vehicle to the medic crew so they can evaluate whether or not to get that.
• 20:56
  SPEAKER_01: So there is a huge component there.
• 20:58
  SPEAKER_01: That's why we have it on the command worksheet too, just as that memory jog, if you will, so that we can remember to give uh get that kit started for them.
• 21:07
  SPEAKER_03: Yeah, and I'll just I'll just take that a step further.
• 21:09
  SPEAKER_03: You know, it's uh with with the taken from the from the point of view of the strategic instant commander or IC2, you know, it's important.
• 21:17
  SPEAKER_03: As that as you get that life safety profile and you realize that, hey, the likelihood of having victims in this structure is pretty high, you need to go ahead and start have the you need to have the forethought to go ahead and get get those resources to the scene as quickly as possible.
• 21:31
  SPEAKER_03: Like as those searches are underway, go ahead and assign that that group to medical and have them come forward, you know, they're in that worm zone with that medical equipment and ready to provide care as soon as that victim's located.
• 21:43
  SPEAKER_03: You know, we're doing a trainer down here today.
• 21:45
  SPEAKER_03: I j I literally just finished a portion of the lecture where we talked about life safety and profiling life safety.
• 21:51
  SPEAKER_03: And you know, you can make the the coolest, sexiest grab in the world, but if you can't treat them once they get to the front yard, everything you've done is for nothing.
• 21:59
  unknown: So
• 22:00
  SPEAKER_03: It's very important that we have those EMS resources standing by, ready to go to work as soon as that victim hits the front yard.
• 22:05
  SPEAKER_02: And Dr.
• 22:05
  SPEAKER_02: Calhoun, what information from the fire ground helps the hospital with the treatment of that patient?
• 22:11
  SPEAKER_02: Aside from the information obviously the transport crew is going to have, but what what things can we pass on as both incident commanders and personnel in the fire ground?
• 22:21
  SPEAKER_00: Sure.
• 22:22
  SPEAKER_00: A big thing would be trying to get a little bit of a handle on what that patient actually experienced.
• 22:28
  SPEAKER_00: Is this, you know, if it's a cardiac arrest, if it, or even if it's it's just a sick medical patient, what was their exposure?
• 22:36
  SPEAKER_00: Were they in a uh you know smoke-filled compartment for a lengthy period of time?
• 22:41
  SPEAKER_00: Was this more of a burn without really there, you know, there are certainly cases where you get burns without significant smoke exposure beforehand.
• 22:48
  SPEAKER_00: So trying to differentiate because that that single dose of a cyanicit may or may not be adequate.
• 22:54
  SPEAKER_00: And sometimes we wind up redosing at times.
• 22:57
  SPEAKER_00: So having a feel for the likelihood of that exposure, because unfortunately, this is one of those situations where the emergence department really isn't at any advantage over the field.
• 23:07
  SPEAKER_00: We don't have a test for this either.
• 23:09
  SPEAKER_00: There is no useful test in the emergency department that just tells me a cyanide level.
• 23:13
  SPEAKER_00: Those are send-offs, tox labs that we don't usually have.
• 23:16
  SPEAKER_00: So being able to make some estimates, and we have a lactate level and a few other things that we can try and estimate off of, but really understanding what that patient experienced before the firefighters encountered them and then what they've gotten.
• 23:30
  SPEAKER_00: Did they get the full cyanic?
• 23:31
  SPEAKER_00: How long after it was, um, what sort of rhythms we're seeing, you know, the other typical medical things are all going to play into decision making in the hospital.
• 23:40
  SPEAKER_03: I think it's important to also mention here that, you know, I think the doc brought up a great point there where they don't have us, there's no specific test for cyanide, right?
• 23:48
  SPEAKER_03: But we know, you know, through the air coalition and other things that are out there, NFPA, some of the UL studies and stuff, we know the toxic twins, right?
• 23:58
  SPEAKER_03: Carbon monoxide, hydrogen cyanide, they just they're together, right?
• 24:02
  SPEAKER_03: You you typically don't have one without the other.
• 24:05
  SPEAKER_03: And in today's modern construction, I mean, we can say the majority of residential homes out there these days, where we find victims, because the number of the life safety profiles are directly related to the number of beds in the building, right?
• 24:17
  SPEAKER_03: So we know these people are they're living there, they're sleeping at night.
• 24:20
  SPEAKER_03: Those are our victims that we're concerned about.
• 24:23
  SPEAKER_03: We know that as they're if they're being exposed to any type of smoke, they're getting both carbon monoxide and hydrogen cyanide.
• 24:30
  SPEAKER_03: So we, you know, we don't we talk about assumptions, but you know, when you've been exposed to one, you've been exposed to the other.
• 24:37
  SPEAKER_03: So it's important that we treat for both.
• 24:40
  SPEAKER_03: There is no, we can't just go out there and prick their finger like glucose and say, oh yeah, they have cyanide.
• 24:46
  SPEAKER_03: That doesn't exist.
• 24:47
  SPEAKER_03: Yeah.
• 24:47
  SPEAKER_03: We have to treat based on their symptoms.
• 24:50
  SPEAKER_00: That's a great reminder, though, that we do most of us these days have monitors that have the carboxy cooxymetry on them.
• 24:57
  SPEAKER_00: So when you do get that alarm, that should at least register in your mind, could this also be cyanide?
• 25:03
  SPEAKER_00: Doesn't mean you have to necessarily treat it, right?
• 25:05
  SPEAKER_00: There are plenty of patients who have had mild to moderate cyanide exposure that I wouldn't necessarily expect a fire department to burn a cyanokid on.
• 25:13
  SPEAKER_00: Those could potentially be treated in the hospital when there's some more confirmatory, but it should trigger something.
• 25:18
  SPEAKER_00: But then recognizing that it's it's certainly not a failsafe.
• 25:21
  SPEAKER_00: You can have a much higher level of cyanide exposure than a carbon monoxide level.
• 25:25
  SPEAKER_00: And then you can also have the patients who, for you know, tone of their skin, things like that, we know that the monitors don't work as well on them.
• 25:31
  SPEAKER_00: Um so we certainly wouldn't want to rely on that.
• 25:34
  SPEAKER_00: A zero CO level doesn't necessarily mean either a zero CO level or a zero cyanide level.
• 25:40
  SPEAKER_03: As part of our signs and symptoms, you know, the big, the big key for us to be able to give a cyanide kit is you had to be you had to have exposure inside a compartment fire with altered mental level of consciousness.
• 25:51
  SPEAKER_03: That altered mental status piece is that's that's huge when it comes to whether the patient should receive a cyano kit or not.
• 25:57
  SPEAKER_00: Yeah, your brain does not like hypoxia.
• 25:59
  SPEAKER_00: It does not like not being able to use sugar and oxygen.
• 26:02
  SPEAKER_00: It's one of the first things that's going to start to disobey.
• 26:05
  SPEAKER_00: So when it starts to disobey, you've got to figure out why.
• 26:09
  SPEAKER_02: You guys have hit on some of this, but what else?
• 26:11
  SPEAKER_02: And we'll start with Dr.
• 26:12
  SPEAKER_02: Calhoun, should every firefighter know before their next shift about cyanide exposure and smoke inhalation that we haven't covered yet today.
• 26:21
  SPEAKER_00: Sure.
• 26:22
  SPEAKER_00: I think that a big one, because we've really concentrated on the patient, which is absolutely always our big priority.
• 26:29
  SPEAKER_00: Our other big priority is our own safety, and our own folks become that patient.
• 26:33
  SPEAKER_00: And that is one of the ways that places are funding these cyanic kids is through a firefighter safety concept and just pushing that forward.
• 26:41
  SPEAKER_00: So recognizing that it can be our own people and recognizing, as we mentioned earlier on, that it doesn't require flames.
• 26:48
  SPEAKER_00: So you can be being exposed to high levels of hydrogen cyanide from heat, and that heat continues during a lot of the overhaul process.
• 26:57
  SPEAKER_00: So, you know, we all push to be having appropriate PPE during overhaul processes.
• 27:04
  SPEAKER_00: This is one more reason for that.
• 27:06
  SPEAKER_00: So I think recognizing that, recognizing the skin exposure, there is decent evidence that we all think about the post-incident cardiac arrest that happens among firefighters being related to coronary artery disease or other chronic exposures.
• 27:21
  SPEAKER_00: That may be the case, but in at least some of those cases, it is probably dermal exposure to cyanide that takes a little while longer to absorb and then leads to cardiac arrest later in the bunkhouse.
• 27:33
  SPEAKER_00: So we've got to keep those things in mind as we sort of educate our own teams on this.
• 27:39
  SPEAKER_01: Yeah, and we look at the command worksheet, right?
• 27:41
  SPEAKER_01: We have the post-air monitoring box on there, and cyanide is one of the things we're looking for.
• 27:47
  SPEAKER_01: So our meters at Springdale will pick that up, and we want our crews to make sure that they're checking the levels inside the home before we have crews take their air packs off.
• 27:57
  SPEAKER_01: And certainly for the fire investigators, when they go in, we need to make sure that the air is good before we send them in to start digging through things to find out that cause and origin of the fire.
• 28:07
  SPEAKER_01: So I think those are other components.
• 28:08
  SPEAKER_01: Uh, understanding where your meters will read, what those levels are that we're looking for, and then just understanding where the kits are carried on the vehicles so that we can get them quickly if they're needed.
• 28:21
  SPEAKER_02: If there's one piece of advice we can give fire chiefs, because we know we get those blank looks when we're doing classes, because not everybody is administering this or has even heard of it before, what piece of advice would you give to fire chiefs about deploying cyano kits for the first time, getting it into the medical protocol, getting the training, everything else?
• 28:40
  SPEAKER_02: And we'll start with Dr.
• 28:41
  SPEAKER_02: Calhoun.
• 28:43
  SPEAKER_00: I think that's a great question.
• 28:46
  SPEAKER_00: I think I would say it is very important, but it's also something that we should use balance, I guess is the right word.
• 28:55
  SPEAKER_00: I can't come up with the right word, but we we should be balanced with how we do it, right?
• 28:58
  SPEAKER_00: This isn't necessarily you should go out and spend, I think they're what,$1,500,$2,000 a piece.
• 29:03
  SPEAKER_00: I certainly wouldn't necessarily think that it's in most departments' best interest to put one on every single vehicle they have.
• 29:10
  SPEAKER_00: You know, that if you have those kind of resources, fantastic.
• 29:12
  SPEAKER_00: But I wouldn't want to see this cutting into other important safety initiatives, other important training and things like that.
• 29:18
  SPEAKER_00: Um, so really analyzing how do we how do we appropriately implement this, how do we get this to every fire that we have as early as possible, but we don't necessarily need two dozen in every fire we have as early as possible.
• 29:32
  SPEAKER_03: Yeah, and I think you know, a lot of our fire chiefs out there and a lot of our customers that we see on the road teaching blue card, you know, a lot of those departments aren't advanced life support.
• 29:42
  SPEAKER_03: You know, they don't have paramedics on duty.
• 29:44
  SPEAKER_03: They depend on either EMTs, maybe basic EMTs, or even first responders.
• 29:48
  SPEAKER_03: So I would the advice I would give for fire for chiefs in those types of departments, your paid combination type departments, is typically they have a county EMS service or a local EMS service that services that community.
• 30:00
  SPEAKER_03: Build those relationships with those EMS services and your and also your emergency department personnel.
• 30:06
  SPEAKER_03: And if you can't, if it's not a it's not something that you can provide as a fire department, maybe at least those those local EMS services could provide it.
• 30:14
  SPEAKER_03: And maybe you could come together and collaborate together and work to get that that medication put on those ambulances because it is very important and it needs to be given in the pre-hospital environment as quickly as possible.
• 30:25
  SPEAKER_03: So I think it's important for those chiefs and in those systems that only provide basic or first responder is to build those relationships with their uh with their transport partners and their hospital personnel.
• 30:36
  SPEAKER_01: Yeah, and they are expensive.
• 30:38
  SPEAKER_01: We just replaced the one we used over the last month.
• 30:40
  SPEAKER_01: I was able to get it for$1,300.
• 30:42
  SPEAKER_01: So they range depending on the you know the medical supplier you're using, how much they're gonna cost.
• 30:48
  SPEAKER_01: But we were able to get it for$1,300 to get it restocked on our unit.
• 30:51
  SPEAKER_01: So things to think about there.
• 30:53
  SPEAKER_01: And then just, you know, when we look at the firefighter rescue survey, we know that on a residential setting, there's about 1.6 victims.
• 31:00
  SPEAKER_01: When one's found, there's generally a second victim found.
• 31:03
  SPEAKER_01: So just using that data to help us, making sure we have two kits on the scene, making sure we have two medic units dispatch that initial alarm.
• 31:12
  SPEAKER_01: All those things are going to matter to help better outcomes for our patients.
• 31:16
  SPEAKER_02: Dr.
• 31:16
  SPEAKER_02: Calhoun, where where's this going in the next five or 10 years?
• 31:19
  SPEAKER_02: Do you think?
• 31:19
  SPEAKER_02: Uh is there anything else on the horizon for treatment of smoke inhalation victims in the pre-hospital setting?
• 31:27
  SPEAKER_00: I I don't know the direct answer.
• 31:29
  SPEAKER_00: What I would love to see is the cost of the kits to come down.
• 31:33
  SPEAKER_00: And I would also love to see us exploring sort of can, because I do still see departments unfortunately or fortunately, depending on how you look at it, throwing away expired kits.
• 31:41
  SPEAKER_00: I mean, that's fortunate and you haven't had to use them.
• 31:44
  SPEAKER_00: It's unfortunate in that that was$1,300 insurance policy, which is great that you didn't have to use.
• 31:49
  SPEAKER_00: So I'd love to see those shelf lives extended.
• 31:51
  SPEAKER_00: We are learning more and more every day about that.
• 31:54
  SPEAKER_00: The majority of our shelf lives are probably shorter than they necessarily have to be.
• 31:58
  SPEAKER_00: So that would be a nice advancement.
• 32:00
  SPEAKER_00: Um, I don't necessarily see a new treatment coming down the road because this does work very, very well, but making it more cost effective would certainly have some benefit.
• 32:09
  SPEAKER_03: Doc, you want to talk about how you said it does call kids kidney failure and you might not want to give it to any patient or what we talked about for.
• 32:19
  SPEAKER_00: So certainly I always want to be careful when pointing out any drawback to uh a life-saving intervention.
• 32:25
  SPEAKER_00: We don't want people to be hesitant.
• 32:26
  SPEAKER_00: We don't want people because they're not familiar with it or the cost of it to hesitate to use it when it's necessary.
• 32:32
  SPEAKER_00: We can overcome that with education about the appropriate use, and we can overcome that just by recognizing that it's the cost of doing business for some things.
• 32:40
  SPEAKER_00: Um, there are certainly other things we do that are more expensive, but we also don't want to waste resources, and there are there are some risks.
• 32:46
  SPEAKER_00: A lot of times you'll hear folks say, just B12, it's no big deal.
• 32:50
  SPEAKER_00: If you give it, they didn't need it, they just pee it out.
• 32:52
  SPEAKER_00: And that is to some degree true and for the most part true.
• 32:56
  SPEAKER_00: It is a very large dose.
• 32:58
  SPEAKER_00: If you look at you know your pharmaceutical store wherever you buy vitamins and look at what kind of vitamin dosage people use to just if they're you know B12 deficient, we're talking massive amounts more B12 than a supplement would be.
• 33:13
  SPEAKER_00: That kind of B12 is not your kidney's favorite friend because it does have to do some filtering there.
• 33:18
  SPEAKER_00: It can cause acute kidney injury.
• 33:21
  SPEAKER_00: Very rarely would that be super detrimental, but it can be a problem.
• 33:24
  SPEAKER_00: Um, the chief mentioned that it can mess with your labs a little bit.
• 33:27
  SPEAKER_00: Nothing we can't overcome, but if the patient doesn't need it, why have to overcome it?
• 33:32
  SPEAKER_00: So we also don't want to be giving these willy-nilly.
• 33:35
  SPEAKER_00: So you don't you don't need to give a tyana kit to every single patient who comes out of a smoke-filled structure.
• 33:40
  SPEAKER_00: You got to examine them.
• 33:41
  SPEAKER_00: I think the chief's policy there and ours in South East, Ohio involve mental status assessment.
• 33:46
  SPEAKER_00: Um, using that as your cut point is a very, very good place.
• 33:49
  SPEAKER_00: That's always subjective.
• 33:51
  SPEAKER_00: You have to sort of figure out what is mental status.
• 33:53
  SPEAKER_00: You know, you can be a little bit altered from just having been in a fire, all the stress, uh, the little bit of hypoxia.
• 33:59
  SPEAKER_00: So good training as to who to use it on, um, because in addition to the cost and the small, very, very small risk to that patient, there's also the risk to the next patient, right?
• 34:09
  SPEAKER_00: If we give it to this patient, and inevitably you're gonna have a limited number on scene, and they really didn't need it, but that next patient really did, and now you don't have it.
• 34:18
  SPEAKER_00: Um, so we just want to be efficient with how we use our resources and sort of recognize all the different aspects of it.
• 34:25
  SPEAKER_00: That's a great point, Chief.
• 34:26
  SPEAKER_00: Thank you for reminding me.
• 34:27
  SPEAKER_02: You guys have any other questions for Dr.
• 34:29
  SPEAKER_02: Calhoun?
• 34:31
  SPEAKER_01: I appreciate you, Doc.
• 34:32
  SPEAKER_01: Thank you.
• 34:32
  SPEAKER_02: That's right.
• 34:34
  SPEAKER_02: Thank you guys for letting me join.
• 34:35
  SPEAKER_02: Hey, Dr.
• 34:35
  SPEAKER_02: Calhoun, thanks so much for being here with us today.
• 34:38
  SPEAKER_02: We really appreciate the information.
• 34:39
  SPEAKER_02: And uh, we look to have you on again soon if we get when we get more information about this and we hear more blue card departments implementing the use of cyano kits.
• 34:48
  SPEAKER_02: Thanks for being here today.
• 34:49
  SPEAKER_00: Thanks very much.
• 34:51
  SPEAKER_02: So as as as we close the conversation about cyono kits, how do you train on it?
• 34:56
  SPEAKER_02: And and we're gonna go to Chief Williams.
• 34:58
  SPEAKER_02: What did your county do to implement this and get them into the field?
• 35:02
  SPEAKER_01: Well, as far as training goes, if you contact CyanoKit directly, they will send you a trainer kit out, but that's everything in the kit, obviously without the medication.
• 35:11
  SPEAKER_01: And then when we first got these kits, we asked for a trainer kit, they sent it to me, and then I've just sent that around the county for departments to use to train their personnel.
• 35:20
  SPEAKER_01: Inside the pelican case, we keep it in, we keep the dosing instructions there, all in the top flap when you open it up, so no matter which medic crew would get it, they can look at it quickly and understand what they need to give.
• 35:35
  SPEAKER_01: And then something we've done as Hamlet County Fire Chiefs back in March of twenty-five.
• 35:40
  SPEAKER_01: We voted in that anytime we use a kit on a patient or a firefighter, that the Hamlet County Fire Chiefs Association will replace the kit.
• 35:49
  SPEAKER_01: So if it expires, it's on the fire department to replace it.
• 35:52
  SPEAKER_01: But if we use it on a patient or firefighter, they're gonna pay that cost of it.
• 35:57
  SPEAKER_01: So we used two within the last month and both were we just ordered them, send the invoice directly to our treasurer, and he made those payments and we're able to get the kits back in service in a few days.
• 36:09
  SPEAKER_02: Steve, how about with you guys?
• 36:11
  SPEAKER_02: What what happens in Cobb County as far as implementation and training and making sure this stays front and center with your folks?
• 36:17
  SPEAKER_03: Yeah, so like I said, originally we sent out a presentation to, you know, we trained all our medics first and foremost.
• 36:24
  SPEAKER_03: That was that was done face to face, going around from station to station, shift to shift, and showing each uh each paramedic in the fire department the the kit, demonstrated how to set it up, how to reconstitute it, how to administer it, pretty much everything that we've talked about here today.
• 36:41
  SPEAKER_03: And then we uh we prepared that presentation and sent that out to our our transport providers and our hospital staff for them to view uh so that they would be familiar with the kit as well.
• 36:50
  SPEAKER_03: You know, I think the big thing to mention here when we talk about use and training is uh is that it's it is very difficult to reconstitute.
• 37:00
  SPEAKER_03: It's not like the doc was talking about earlier, like uh with solumedrol, you can't just you can't just push the fluid in there and shake it up.
• 37:07
  SPEAKER_03: It has it it's very easy to foam, and if it foams, it doesn't administer properly.
• 37:11
  SPEAKER_03: So when you put that saline into that vial and you begin to reconstitute that medication, you have to slowly roll it back and forth and so that it's it's not allowed to foam up before you administer it.
• 37:22
  SPEAKER_03: That way you make sure you get the full dosage of the medication.
• 37:25
  SPEAKER_03: Another thing that's important is we you have to be sure to use the administration set that comes with the kit.
• 37:31
  SPEAKER_03: You can't just pull an IV drip set out of your cabinet of your ambulance and expect that to work.
• 37:37
  SPEAKER_03: As as paramedics and EMS personnel, we're not used to administering bottles or bot or glass vials of uh of medication.
• 37:44
  SPEAKER_03: Most of our stuff comes in bags, and so the drip sets are different.
• 37:49
  SPEAKER_03: We have to have a vented drip set that allows that bottle to breathe air so that it can drain down through there.
• 37:54
  SPEAKER_03: And the typical IV sets that we carry on the ambulance don't do that.
• 37:57
  SPEAKER_03: So uh use the pieces of the kit and don't let the medication foam up.
• 38:02
  SPEAKER_01: I think it's as important that if we're going to give proper care to the patients, and it's really gonna be about those patients, right?
• 38:09
  SPEAKER_01: It's all about the victims and getting in, getting searches done quickly.
• 38:13
  SPEAKER_01: Uh that we need to make sure that we have those resources dispatched to the scene, whether it be ambulances and the kits.
• 38:19
  SPEAKER_01: When we find those victims, we need to make sure that we're properly we're able to properly treat them, care for them, and have the equipment resources to give them the best outcomes.
• 38:29
  SPEAKER_03: I'll also add to that is there's no there's no supplement for good BLS care, right?
• 38:34
  SPEAKER_03: We have we still have to do airway, we still have to provide ventilations, and we still have to do compressions if needed.
• 38:40
  SPEAKER_03: ABC is is still there, right?
• 38:42
  SPEAKER_03: So uh make sure we have that good basic life support care.
• 38:45
  SPEAKER_03: Uh, don't forget the basics when when it comes to giving this medication because that's what's most important.
• 38:50
  SPEAKER_02: Before we go, let's do a timeless tactical truth.
• 38:59
  SPEAKER_02: Timeless tactical truth from Alan Brunicini and his book.
• 39:03
  SPEAKER_02: And this one says, added value occurs right after we do our core business.
• 39:09
  SPEAKER_02: Added value occurs right after we do our core business.
• 39:13
  SPEAKER_02: I chose this one today because it is great added value to take good care of that patient and do everything that we can for them for their full recovery.
• 39:23
  SPEAKER_02: But in order to administer that cyano kit, we've got to be doing a lot of things right before that is even administered in the front yard.
• 39:32
  SPEAKER_02: Your thoughts on that one, guys.
• 39:34
  SPEAKER_03: Yeah, I think that's great, JV.
• 39:36
  SPEAKER_03: You know, first and foremost, got to get water on the fire right, got to make things better for everybody.
• 39:41
  SPEAKER_03: Let's get water on the fire or at least put water in between the fire and the victims so that we can make that rescue.
• 39:47
  SPEAKER_03: We talked about this earlier in the training that we're doing down here today.
• 39:51
  SPEAKER_03: You know, NFPA 1700 came out just talking about the standard being window-initiated search.
• 39:57
  SPEAKER_03: You know, this is a with the close before you dose campaign, we're telling we're telling the public to close their doors at night and that we'll come get them.
• 40:04
  SPEAKER_03: And so we have to hold up our end of the bargain when it comes to that.
• 40:08
  SPEAKER_03: And a lot of times that's window-initiated search, bringing those patients out those bedroom windows, those victims out those bedroom windows, not taking them back through the products of combustion, getting them out to the front yard and treating them treating them accordingly.
• 40:21
  SPEAKER_03: Yeah, I mean, that's that's what it's all about, right?
• 40:23
  SPEAKER_03: That's what we that's what we're all here to do.
• 40:26
  SPEAKER_03: Those are uh career fires for everybody.
• 40:28
  SPEAKER_01: Yeah, and the mom and dad of that nine-year-old that we just had a month ago that we were able to save.
• 40:33
  SPEAKER_01: And without that kid on the scene and out without the training and the resources there, that child probably would not have survived.
• 40:40
  SPEAKER_01: And even though it's thirteen hundred dollars, can't put a price on a life.
• 40:44
  SPEAKER_01: And then that family is so grateful to have their nine-year-old alive.
• 40:47
  SPEAKER_01: I'm sure it's a long road still ahead of them, but they're gonna take that journey together.
• 40:53
  SPEAKER_02: And thank you for listening to us today on the Bee Shifter Podcast.
• 40:57
  SPEAKER_02: Remember, tell your friends and subscribe.
• 41:00
  SPEAKER_02: We'll talk to you next week on Beat Shifter.