Understanding the Working Canine and Your Role as a Tactical Medic in Management of Field Injuries

- Tonight we have a very interesting topic on the use of working canines in the tactical medicine environment. So Dr. Bradley, I will turn it over to you.

- Thank you Rick. I'll just give a brief introduction so Dr. Zoran can get to the reason y'all are all here. I had the privilege of meeting Dr. Zoran when I was actually a resident and I did a US&R training course out in Texas A&M. So since then, we've had more interactions and she's a great doctor and vet and she's representing one of the top schools, I will biasedly say in the nation with Texas A&M. And I will unbiasedly say she actually is part of one of the top vet schools in the country, if not the world with Texas A&M. So I'll let her kind of talk about her background and credentials 'cause we can spend all day on that. And I'll turn it over to you, Dr. Zoran, to take it away.

- Thank you so much Keegan and welcome everybody this evening. It's a great pleasure to be here. I enjoy talking about this topic a lot, so it's gonna be fun. I wish I could see faces. I have to admit, speaking on Zoom is a little bit less satisfying than speaking in person 'cause it's kind of fun to see people's faces interact that way, but I certainly understand how that works around the country today. So with that, just a brief background about me. I am, actually Kansas farm girl that grew up and went to Kansas State University and then went into the private practice world for a little bit. Decided that wasn't enough of a thing for me, so went back, specialized in internal medicine and nutrition. Spent 20 years... Moved to Texas A&M and spent 20 years teaching veterinary students, internal medicine and nutrition things, particularly relating to working dogs, GI things. But in my initial five years at Texas A&M University, I had the great good fortune to meet some folks at Texas Task Force One and became the working dog, veterinary consultant for that team back in 1997. So, I've known dogs that went to 9/11 and all of the deployments since that time. So, I've had quite a lot of connections with that phase of working dogs, the search and rescue group. In 2014 when I decided I'd had enough of academic internal medicine, I transferred entirely into the teaching world of disaster preparedness and response. And there is a program here at Texas A&M University that is unique in the United States for training veterinary students and disaster preparedness and response. We have the largest veterinary emergency response team in the United States and I'm bragging, but it's true. And so, since basically 2010, I've been on that deployable team. Since 2014, I've been on Texas Task Force One as the veterinary support for the working canines. We've got 28 on that team. And in 2019, just to close the intro part out 'cause I wanna move on, I became a FEMA IST veterinarian. In other words, at the federal level when large deployments happen, one to three veterinarians are put into theater or oversight the working dogs. And so, that's my background in my relationship with working canines. We fortunately have not had any catastrophic injuries in our field. I tap wood right now as I'm speaking. I've been around the working canine world a long time and know things can happen and go south quickly. So with that, we are going to now view my side of the working canines. And I thought not knowing what everybody knows and doesn't know in this group, that I would start with, What is a working canine dog? Dog lovers are everywhere and there's quite a few on this call right now. This is a unique set of dogs that are exceptionally high drive, exceptionally different in their mindset about behaviors, exceptionally needy of things to do or they become destructive. And I just set that as the background because I have to actually spend quite a lot of time helping my fourth year veterinary students who are about to go out into the world to understand how different it is to work with a working canine. They are just not the same as a regular pet dog in any way. Working canines are actually defined now fairly carefully. And part of that is because a lot of people tried to turn their therapy dogs into working dogs to get free flights and so on, as you may or may not know. So we have three major sections of working canines, the protection canines, the detection canines and service dogs. I'm going to be speaking a lot this evening about detection dogs because those are the ones that I work with the most and that's where I'm most familiar. But I do want to introduce both of those other types of dogs because if the pre-hospital care program is able to expand into all states as we hope and to become a very high level way of protecting these valuable assets, you really need to understand the difference between these. Protection canines are typically part of law enforcement security, profiles such as border patrol and certainly they are part of military working dog land. Protection canines can be dual trained, meaning they can also be detection dogs. But protection dogs are absolutely trained to apprehend. And because of that, you must, anytime you are working with a protection dog, have a very high level of confidence in your handler to help protect you and any other people that are working with that dog because they can be triggered by very small things. And because they're bite trained, they're exceptionally, you just have to be very careful. They are highly trained dogs. They will not bite you just to bite you, but when they're injured or when they're in drive, which would be the likely time they would be shot or injured, are times when they can become quite unpredictable. Detection dogs on the other hand are the scent work dogs that most people are aware of at schools to detect drugs, bombs, contraband, all of those sort of things. The dogs that walk around at the airports and the little beagles, cute little beagles that walk around the airport. Search and rescue dogs are the group that I work with. They are trained either as life find, meaning looking for living people or HR, human remains detection dogs. They are a little bit different than typical calm, walk around the room detection dogs because they have to be athletic to do the work that they do. They have to be high drive to do the work that they do. And so, I'm gonna give you a little bit more background about them in a minute because they are at high risk for injury as well. And then last but not least, service dogs. You guys probably are not gonna get a lot of action with service dogs because they are site hearing, medical detection type dogs that typically are not gonna be in harm's way. All right, so one of the things that I wanted to just start at the front and then I'll say it again at the end 'cause this is a really critical piece. If you are trying to develop a program where your medics, your paramedics, your field medics are all working with dogs and dog handlers, this is an in an incredibly important relationship that has to not only be respected, but also not broken in the midst of danger. That dog and that handler spend enormous amount... Of time together and that enormous amount of time creates a bond that if you attempt to separate, can become dangerous for everybody that's trying to do something.

- [Rick] Hey everybody, make sure that your mics are on mute, please, thank you. Please continue, Dr. Zoran.

- Thank you very much, that's helpful. But this handler canine relationship, probably the best description that you guys will have some sense of this relationship is apparent with a small child or even a baby that has to speak for that small person. It's the same with the handler canine relation. The dog can't tell you what's wrong. The dog can't tell you any number of things. But if that handler's there, there's gonna be a greater level of safety and calmness of that dog, that if separated will... I see this in my world, even with search and rescue canines, which are nowhere near as intense as protection dogs. It's really critical. It's one of the first things that we train all of the handlers is if the handler goes down and the canine is in need of support, a second handler has to become that canine's spokesperson and handler. Regular people cannot do it. They will not accept it. And so, that's a first really important take home to just have that awareness. Understand that handler's gonna have to stay close by. We will also talk about some injury types, work effort types and things along that line. I'm gonna focus most of my stuff that I'm gonna talk about this evening on search and rescue because that's what I know better. But I have worked with protection dogs and I know some of their injuries as well. So if there are questions at the end, we can certainly get into that. All right, so I have the great good fortune to be a member of this group, Texas A&M Task Force One. This is a recent very small group picture of some canine handlers that had just finished a training day. This is the larger group out at Disaster City where they're based here in College Station. However, the handlers don't all live here in College Station. So to give you a little bit of background about that, in case you're unaware. The FEMA US&R teams, there are 28 of them in the United States. So the Texas A&M Task Force is one of 28. These dogs are, I like to tell my vet students, these dogs are like the NFL football of search and rescue. There are search and rescue teams in every city and every community in the United States. Primarily there for search and rescue for missing kids, missing Alzheimer's people, HR canines to search warehouses and houses that burn, looking for deceased people, searching crime scenes. There are search and rescue dogs at all levels of society, local, regional, state and federal. The FEMA US&R teams are the federal teams. And as I said, they are the highest trained group of dogs. So, I'm very, very, very fortunate to be able to work with them, not only as a team member, but as their veterinarian. Just to give you a little bit more background about them, most of the teams in the US have somewhere between 20 and 28 dogs on their team, depending upon where they are on the cycle of training. Those are divided into three teams, six to eight dogs per team to make the deployable months every third month, so around the year. The key about these dogs is they have training requirements of a certain number of hours a month, which basically is a daily exercise in training. This is a very high level of dedication to these dogs. Once the dog is a year of age, no dogs can enter the system until they're at least a year of age and most of them actually don't enter the system until 18 months because the level of intensity of work on their joints and their bodies is so high that we want them to be full grown. And so, once they start an active training to be US&R, it's typically about a year from the start at 18 months. And then from that point, once they certify, that certification is good for three years and that cycle repeats itself, typically two, maybe three times, depending on the dog for their career. So this is a very, very high level commitment job for a very high level canine to be able to search in the most intense disaster experiences. Haiti, the Surfside condo collapse, everybody knows about the earthquakes over in Syria, which we had dogs from the United States go to. And certainly, all of the other disasters that we experience. These dogs typically are one of two types of breeds. Floppies and pointy ears. The floppies are typically Labradors. There are a few goldens, there are a few borders, there are a few other floppy ear type dogs, but they're overwhelmingly Labradors. And primarily, the reason for that is dogs that are willing to do this work have to be, not only high drive, not only very athletic, not only very, very, very focused on reward, their reward is toy, so they're not looking for people to find people. I hate to tell all my dog people in the room this, they are looking to find a person, so they get their paycheck and their paycheck is a toy. And this is true across all the things. There's no dog on the planet that will search for 12 hours a day unless he has high drive, high toy drive and is fearless, basically has no self regard for personal safety, which is how the Labrador get in this. The other group of dogs that are very common in this are Malinois. Malinois are very similar in their high drive, in their toy reward. Their other big deal is their very high prey drive. And so, that creates a much higher intensity of work ethic. In general, on the search and rescue side of things, we see a fair amount of trauma across all types of search and rescue situations, whether it's tornadoes, hurricanes, fires, collapse structures, name it, I have seen all of them. We have actually had a dog in training fall from a two-story training building break their back. Very traumatic to all it. The dog was euthanized very shortly after that because it was a stair step fracture of the lower back and the dog was never gonna walk again. So trauma is a real fear for these things and a really important thing for having situational awareness about. The other thing in the search and rescue world is they're physical and environmental things of very high level. The military working dogs are very familiar with this. And heat stress, particularly in the southern United States with the heat and humidity that we deal with is a huge stressor. On the other side of the United States up in Alaska, there's dogs that work in an incredible cold. That's an equally intense physiologic environment that we have to think about. The other thing that you might not think about, I spend a lot of time thinking about, is when we go into a disaster environment, everybody that goes with us is wearing PPE, is wearing oftentimes respirators, is covered up. Dogs cannot wear respirators, dogs cannot wear PPE of any kind. They go into all of the rubble in all of the searches without even their collars or any type of other type of wearables because it's a great entrapment risk. And so, they are going to breathe in everything that's there. They're going to have mucus membrane exposure to everything that's there. And as anybody that's worked in an environment where there's a lot of disruption, there's going to be the risk for snakes and every other kind of thing in the planet that wants to bite you, sting you or otherwise when you're out in the world. So, this is what we deal with regularly. Just a short background of some of the things that we've dealt with over the past 10 years, Bastrop wildfires. Wildfires are unique in a couple of ways because we have to not only worry about their work, rest cycles in that typically extreme heat, but hot surfaces. And this is the one time that we will actually put foot protection on the dogs. And as you can see, Sarge on the right there, got his front feet booted up, his back feet aren't booted up yet. Dogs have rubber booties and have leather booties for working on concrete pavements in cities. A lot of protection dogs will wear them in the summer to try to protect their feet from the hot pavement. That absolutely doesn't work in a fire environment because as they step down into the ash, those booties fill. And so, you have to create an entirely different type of structure and so this is something that we and others have done over the years to protect their feet and their lower legs when they search in fires. Floods are a big deal, of course in our state, Wimberley, several years ago. The biggest thing about Wimberley that made the search and rescue really challenging was they had to search this type of environment down almost 20 miles of river on each side that looked like this. And the dogs were searching for two families, two fathers, two sets of kids, two set of grandparents from two separate families that went missing, the Chabas and the McCombs family. And they were tracking, we were using GPS devices to try to follow 'em because people couldn't go where they were going and they were going 15 to 20 miles a day. And so, there becomes a great deal of management of that athletic endeavor, energy requirement, heat management requirement, hydration management requirement. And ages ago, we used to talk about that management of hydration in working canines, whether it was military working canines or search and rescue or dogs on the street, we would just drop an IV in 'em and that has become absolutely... We and others have found, Penn Vet Working Dog Center has done some of this work as we have at A&M here, have found that far and away the safest way for dogs to get rehydrated is oral, which makes sense to every human in this room. It's just that you can't make a dog drink. And so, we have developed some unique things, I'll point to in a second. But when your dog is working that sort of rubble for 15 or 20 miles, they've gotta be highly fit beasts or they're not gonna get very far. So muscle fatigue, lower limb injury, snakes are a big deal. The way we deal with hydration is water baiting. Water baiting makes sense if you think about it. Water baiting is very simply, adding protein to their water. Humans will drink more water if you put the flavored stuff in it or if you've got a marathon athlete that's running, they're using the goo or they're using a lot of the other carb based electrolyte solutions. Dogs don't use carbohydrates when they're working beyond sprint. So, a sprinter dog will use carbohydrates. Anything beyond a sprint, so multiple hours of work in a day or endurance work requires protein. They switch entirely into their carnivorous mode and so they have to have protein and yet, they can't eat kibble when they're working. Kibble will go into their stomachs, pull water to it and increase risk of bloat. Tornadoes, all kinds of injuries in tornadoes. I've never been to a tornado that we didn't have some major lacerations from dogs. Most of the time when we're, I'm sorry, I'll back up. Most of the time when we're working on lacerations in these dogs and I'll mention this right now 'cause this is critical for you guys to have some understanding about this. A lot of our dogs, when we patch up a wound in the field, the goal is to get 'em back to work without using any anesthetic drugs other than local if we can get away with it. All of the opioids, most of the sedative drugs and a lot of the drugs that you might be comfortable with using like cat val, have a major impact on their scenting ability. And so, if you use any of those drugs in the field, you've just taken 'em out of business. And so, we have to use unique different ways of managing them or make the decision that they're being pulled from service, which is an important decision and isn't made lightly. Again, hydration, one of the ways that we monitor these dogs is unique because I don't know how many of you have taken your dogs to the vet and had the experience of finding out how little your dog likes to have rectal thermometers used. Working dogs in drive absolutely will have nothing to do with it. And so, the way we monitor temps and our dogs is they all have temperature microchips implanted or at least our Texas dogs do. They're microchip, it has a microchip in it and a thermistor attached to it that can be read with a microchip reader. There's work underway to get telemetry into all of this. Right now, it's not telemetry. The handlers carry their own chip readers, they're small. And they can then monitor these dogs. All of these dogs will work at temperatures of 106, 107 or 108 at periods of time during high heat days. A normal pet dog that gets over 105 is gonna be in the ER in heat stroke. These dogs are acclimated. These dogs are lean. These dogs are muscular and will work at very high core temps compared to regular dogs. Hurricane Ian, big deal in Hurricane Ian was we had dogs falling into pools that were cesspools. Same as in Harvey. Those dogs were coming out of their searches, basically covered in human feces from sewers, covered in petroleum products from all of the things that show up in disaster scenes like this. And so decon becomes another important thing for people that are working field canine work. These dogs will come out of this work, searching these areas covered in things that are quite dangerous to you, including some of the places that we worry about a lot, which are the opioids, covered in some of that powder and dust, which we'll talk more about it in a little bit. So with that background, I wanna now just do some brief overview stuff because you guys are medical folks. These dogs have a lot of similarities to people, but they have some very big differences to people. So, just giving you a little bit of that background gives you some chance to have some situational awareness about this. I'm gonna say this at the end, but one of the most important things that you need to do is know where appropriate veterinary care is around you and know a veterinarian. If you are gonna be assisting medical units in assisting working dogs, you need to have those contacts on speed dial. So, I'm gonna go through this slide really quickly, but one of the first things that kind of confuses the issue for a lot of human medical folks is the fact that our animals, while everything sets in similar locations to some degree, it's on a different plane. And so, there are different issues of how you get to things and how things work. Just to give you some basic anatomy, I'm gonna spend a lot of time talking here in the next few minutes about the respiratory tract and cardiovascular, just so you have some awareness of how to get to find and approach these areas because field stabilization is basically about get them out to higher level care as quickly as possible, but understand where they are. My medics on Task Force One, I would prefer they not spend a long time trying to figure out how to drop a line in a dog if they can just make sure he is breathing and his heart's beating and that we've got him moving. And so, there's a lot of things that if you don't do it frequently and every day, it's gonna be difficult for you and I'll show you here in a second. These are just more pictures of locations of things. If you notice, one of the best ways to find the heart in a dog when he's standing is find the point of his elbow. It's gonna be right above that. It sits behind that humorous, as it sits in there. But when he's laying down on the ground, if he stretches legs forward, you will have a more challenging time finding his heart than if his elbows in the normal position. The other thing and this is probably similarly true to humans, but different in that the stomach and the liver are all sitting up underneath the rib cage. And so, unless it's enlarged for any reason, you're not gonna feel it and you're not gonna understand what its problem is. And so, those are things to have some situational awareness about. Finding pulses on dogs that are in drive are really hard except for one location and that's the femoral. You can find them on pedal. It's really hard when they're moving and excited. You can find them on front legs. It's really hard when they're moving and excited. These are all locations that we use when they're anesthetized, but in a living, breathing, moving dog, heart and femorals are the best places to go. The femorals gonna be found, sitting right in front of the femur, there's a tunnel that sits right there. And that femoral artery sits right in that tunnel. And the easiest way to access it is to feel like this. All of you that have got your dog sitting next to you in the room right now, take your dog and put your hand right up in that flank area and see if you can't find that tunnel and feel that pulse. The normal canine pulse for a non-working dog's probably gonna be around a hundred, maybe even 120 if it's a little dog. Higher, if he's running around acting like a fool. Working dogs pulses are gonna be somewhere around 60 or 70. Mucus membrane color, all of that is very similar to humans. CRTs are less than one. They should be pink, unless they've got pigmented gums and then you're gonna have to deal with not being able to look at that typical vitals, just like you would in a human. Again, pointing to that elbow and finding his heart right above the point of that elbow. That's where you're gonna be able to find it to feel it. Just for point of reference, again, temperatures are gonna be all over the place depending on whether they're indoor and quiet or whether they're outside, running around. Working dogs are easily gonna run 103, 104 if they're outside and they're excited. They just don't sit down low until they're inside laying down. Working dogs tend to be, as I said, around 60, pet dogs tend to be around a 100 or 120. Most working dogs, when they're excited or panting, you're gonna have a hard time getting an actual respiratory rate. And panting is panting. And most of the time, you're not gonna do blood pressures in these dogs unless they're asleep because they won't hold still enough for you to get it on. Pulse Oxs will absolutely work on dogs that have lighter skin. So a tan labrador, you can get it on their ear, you can get it on their prepuce, you can get it on their vulva, you can get it on their tongue or their lip. Same as people, the black colored ones, the black coated dogs. Yeah, that's not gonna work very well. One of the things that we always worry about in our working dogs is this right here. It is the absolute business end of their job. And so, when they come out of the field, if there's anything in their nose, around their nose or on their nose, it needs to be washed off before they have a chance to lick it off or get it off because that's how they get exposed to a lot of stuff. The reason I put this picture up here is a lot of my medics that I work with on Task Force always wanna learn how to intubate a dog. And that's a fun thing to do. And a lot of times, you can do it without any instruments at all if you've got a sleep dog or a totally passed out dog. But you will never intubate a dog that isn't anesthetized, otherwise because it literally lives... So if you look at this picture here on the left, the larynx, the laryngeal opening is literally over this bump in the tongue. And so when you open the dog's mouth up, you're gonna see the bump in this tongue. And the only way that you get this visualization is as you grab the tongue and you pull it forward. Well there's no awake dog on the planet that's gonna let you do that without biting you or getting away from you. This dog picture on the left is, you can see his tongue being pulled forward by the person holding it and this is your laryngoscope, the laryngoscopes you guys use. We use eight, it's an eight inch tongue on that laryngoscope to be able to see all the way back there. It's way the heck back there. So, without a sleep dog, you're not gonna get this done. So it's another reason why I tell my medics, don't screw around trying to intubate a dog unless he's dead. And if he's dead, then you have to be worried about why did he get dead? What did he get exposed to that got him dead that you might get exposed to trying to intubate him? This is just the other view that we used. The the first view I showed you is your favorite upside down view. This is a view I used. So, here's a really important one for all of us, particularly police dogs, but also all of our search and rescue dogs. One of my nightmare scenarios. Dogs that are searching in destroyed houses or searching for people out in wilderness areas are gonna come across meth houses, crack houses, all of the houses with all of the things. Excuse me, let me take a quick drink. And opioid exposure in a dog is gonna be very straightforward because the panting, the open mouth, the licking the nose, the nose is gonna be down on the ground. They are more resistant than humans to these. It takes a little bit more to get 'em in deep trouble. But once it's on them and they start to have any of the signs of this and you start to handle 'em or you start to look at 'em or you start to be around in their face, you're gonna get exposed. And so, while there's been a lot of conversation about trying to use intranasal Narcan and my opinion is you get it in where you can get it in, but I teach all of my handlers. Every one of my handlers carries Narcan and every one of 'em gonna stick it in the epaxal muscles, which is here. Those are the epaxal muscles. Every one of 'em is gonna stick it in the epaxal muscles 'cause I don't want 'em anywhere near the face. I don't want them getting exposed, while this is all going down. So, an oxygen mask is the best way to try to get oxygen to them, but don't attempt to intubate 'em unless you are fully, fully covered up yourself. Safety and behavior. Every working dog that gets injured is gonna be an idiot, an absolute idiot. They are scared, they're painful. And those canines guys will ruin your career forever. A hand bite, an arm bite, those canines are an inch long and the root that goes up into the nose is an inch and a half long. The bite force on just a Labrador is enough to absolutely tear you to pieces. And it's not because they're mean, it's because they're scared because they don't want you messing with them because you hurt 'em inadvertently, whatever. So the first thing is, the handler always stays with them. And the second thing, they always get muzzled because it's the only way you can work on them without potentially compromising your own safety. All working canines can be triggered to bite. The protection canines are gonna be a lot more prone to it. They are pointy ear dogs, generally. All pointy ear dogs have a space bubble and I mean that sincerely. They don't want strange people in their space bubble. And even a simple gesture of reaching out can be a trigger. So, you need to do a lot of work training and working with handlers and working with medics before you turn people loose on this job. If the handler's not carrying a muzzle and they all oughta be, but if they're not, muzzle can be fashioned using gauze. I don't like to use this approach in an injured canine 'cause they typically need to pant, especially if you've had to give them something. And so, it's a final thing. I'm starting to get down to the last few slides 'cause I want to give us some time to ask questions and go across the things. The bottom line is, I tell my medics all the time. I'm gonna show you some places to put catheters in if you're out in the field and they can't be evacuated. But the truth of the matter is, don't waste time trying to place a catheter if you can evacuate 'em. If you can evacuate 'em, evacuate 'em. Because if you're not used to finding a vein in a hairy beast, it ain't gonna go as easy as you think. The same thing is about bandaging. Those legs are curvy and it's hard. It's better just to try to stabilize them with something solid and wrap it down, rather then trying to create a true bandage. Use all of the stop bleeding methods that you have at your disposal. There's lots of examples of police working dogs that have been shot, that people have put quick stop in or people have put other stop bleeding human trauma kits into them and have saved their life doing that. Absolutely do that and evacuate 'em. Just to give you an example of cephalics. That's the main vein we like to use, except it's close to the mouth. If you don't have good muzzle control, if you don't have a good face control with it, then this is a scary place to be in a working dog. This is the easiest vein to hit and you can see it very nicely when it's shaved. You're not gonna be carrying a razor or a clipper and that's gonna make it a little bit tougher. The other place you can go is the outside of the back leg. Again, if you've got good muzzle control, this is a safer place for somebody to try to set a line. You can see that vein right there. I guarantee you, it ain't gonna stand up like that if this dog is shocking. And so, trying to set a catheter and then wrap it in and this location is not gonna be easy. Trying to tape a catheter in to hair on a dog is a non-starter, that's why we shave him. And so again, if there's time to put a catheter in and probably doesn't need it and probably the best thing to do is get 'em out, unless you can't. Using something that's firm, whether it's one of you guys's splints that you carry, the better ideas wrap the whole dang thing, not to do this. There are many, many, many, many dogs that have been brought to the veterinary world that no longer have feeling or circulation in their toes because of wraps like that. Last but not least, this is probably the most important slide that I have in here. It is incredibly important for us to develop this relationship with people in the medic world because there are so many times that working dogs are injured during, particularly in police work, but out in search and rescue world, in very difficult situations where the only person that might be there is the paramedic. It's incredibly important to start to develop this pre-hospital care stuff. But one of the things that has to happen is the medics have to get training in what their role is with a dog and understanding what they can and can't do. The medics docs that are running behind them, there are docs that are out there that are gonna be their support system have to understand that you're not a veterinarian and giving drugs to a dog in a whole lot of states in this country right now is practicing without a license. It is also important to recognize that a lot of the drug doses that we use in dogs are not the same in people. A lot of the drugs that you use are not the same as in people. For example, all of my medics want to drop some ketamine into a dog without putting anything else with it. And if you ever do that and drop ketamine into a dog without pairing it with torb or dazolam, you will hate your life forever. You will turn that thing into an absolute scary beast. So there are just some things that you need veterinarians around to help you with. So, developing a contact list of ER veterinarians, veterinarians that are high level specialty care that work in 24 hour hospitals that can be contacts for you, that can give you that advice in the field, that's gonna be exceptionally important. And then, this next thing is just getting training. Having classes, go to the pre-hospital care classes for medics and then find a veterinarian that will let you come in and just spend some hands on time. As you know, you wouldn't want me coming into your hospital touching a bunch of folks when it's not my day job to do that. These dogs are exceptionally valuable to the working world and to their handlers. And so, we wanna make sure that we are absolutely partnering in this project going forward to make this the best for all concerned. So, develop that relationship, develop training opportunities, develop a list of clinics. They're 24 hour trauma centers in veterinary side are everywhere now in urban areas, everywhere. You just need to know where they are. And with that, I'm gonna be quiet and let you guys ask me some questions.

- All right, we have a couple questions in the chat. Let's see, why don't we, quite a few questions. So we have a question. What care can we still provide in the field in states that don't allow non-vet to provide first aid?

- So, the typical first aid type of things, no drugs, right? So no drugs, that's the key thing. Drugs are where the veterinary community needs... To be involved to give advice. Your medics could give a drug if a veterinarian's telling them to do it. If a non veterinarian's telling 'em to do it, they're practicing without a license. So first aid things, wrapping things, very, very basic things, giving oxygen by mask. Very, very basic things.

- [Dominique] Okay, thank you. We have two questions about Ios, using IOs in the field.

- So, same situation that you're gonna find on the human side, we, we absolutely use them. I have actually never set an IO in the field. And the reason for that is I've always been able to get an an IV line in. You are going to find that putting an IO in a dog is a lot harder than it looks. Their bone marrow is different than humans and getting it set either into that humerus or up at the wing of the ilium in the hip in a non sleepy dog, unless he is really down and out, I mean, he's collapsed and completely out, you're gonna have a hard time getting it done. But you can use them.

- [Dominique] All right, let's see, we have a couple of questions about tourniquets. Can you use tourniquet on canines and well, that's basically a repeat question. So tourniquet use in dogs.

- So tourniquet for setting a catheter or tourniquet for stopping bleeding? So tourniquet for setting catheter, yes. If you only have your own self and your handler and it's easier for you to get that vein to stand up and you're trying to set a catheter, a little tourniquet on there doesn't hurt anything for a short term. Absolutely not for bleeding for a couple of reasons. One, in order to get it tight enough on any of the main bleeders that you're gonna run into, you are going to absolutely destroy the rest of that limb. In a back leg, you can't get it tight enough by the way the limb is shaped, you just can't get it done. So yeah, it's all about sticking stuff in the hole. It's what it's about. Sticking stuff in the hole or putting pressure on it.

- [Dominique] Great, we have a question about what specific type of muzzle would you recommend.

- So, I actually asked my handlers to carry two kinds of muzzles. The protection canines should all be carrying basket muzzles at all times. That is not universally the case. Basket muzzles are great because they allow 'em to pant and that's helpful for their anxiety. They still bite the hell out of you with a basket muzzle. And so, I use two kinds of muzzles, a basket muzzle together with a cloth one, puts two layers on. And if I got a really injured animal, sometimes that's necessary. But basket is probably your best bet.

- [Dominique] Terrific, okay, let's see. We have a question here about hypothermia. Ice rescues, ski patrol, cold weather search and rescue.

- Yeah, so I am probably not anywhere near an authority on this subject. Probably the best person to talk to you about that would be Lori Gordon. She's one of my fellow IST veterinarians on the FEMA side. She spends the entire month of March, in fact, she's up there right now in Alaska with the sled dogs, working in that, in exceptionally cold environment. They do have to wear feet protection big time and they do have to very much pay attention to exceptional amounts of energy intake to keep those dogs body temperatures in a good place when they're working in those environments. My one experience with hypothermia in our dogs actually happened in Oso, Washington when the landslide happened. Up in Oso, there was a bunch of homes that were destroyed and we had to send dogs looking for the people that got buried. And it was about 35 to 40 degrees and raining. And so the dogs were working in mud in 35 to 40 and we literally were feeding them 10 to 15 times their caloric intake and pulling them into a heated tent and warm watering them every two hours to keep them warm and to keep 'em from losing weight from shivering. It was an exceptional experience in what hypothermia can do in a working dog, so it's a real problem.

- [Dominique] All right, there is a question about EMS protocols for working dogs. Are there standard EMS protocols?

- So, that's one of the things that Rick Merkel and Lee Palmer and the entire group is working on. I don't know, Rick, if you wanna pipe in at this moment and talk about any of that. I know you guys are talking about the legislative piece as well, but those protocols are being developed.

- Yeah, thanks Dr. Zoran. I appreciate it. Yeah, so there's a wide assortment of protocols that are currently going through several different states. Namely most recently the states of Maine and Massachusetts. Massachusetts with the recent passage of Niro's Law, several EMS states are starting to develop statewide standardized treatment guidelines for their EMS providers that goes with their recently passed legislation. Best practices guidelines for EMS agencies to produce their own clinical guidelines. It's best to gather that information from the veterinary committee on trauma, guidelines that best practice recommendations for dogs and cats, the military working dog, joint clinical practice guidelines and things of those natures and the canine TECC guidelines and things of that nature along with recover. So really it's kind of an ad hoc for some states into what guidelines wanna be developed. Much like we are here in South Texas, as a delegated practice state for EMS, we usually just coordinate with the veterinary medical director in corelation with EMS medical director to come up with those guidelines. Doc, if you're okay, I'll kind of let Dr. Kate Zimmerman from Maine, she's on this call as well, kind of chime in real quick with some of her recent experience in Maine with their statewide op kine protocols that they just put in place.

- Yep, absolutely.

- Hi, so I'm Kate Zimmerman, I'm an emergency medicine and EMS doc for humans and the associate state medical director. And we have worked closely with Lee Palmer and emergency and critical care veterinarians in the southern part of the state where our emergency veterinary care centers are decreed statewide protocols, based on the resources that Rick talked about, K9 TECC and so I wrote those in conjunction with Lee Palmer, who's reviewed them in our local veterinarians. And those are open source. If you go to maine.gov/ems, you can look at our state protocols and they're added on as an annex. You do need to make sure you're working closely with your Board of Veterinary Medicine again and know that your Veterinary Practices Act. We've actually run into a little bit of a hitch recently as some change in AGs and interpretation. So we're working through that right now. On the K9 TECC website, there's also examples of different legislation from the various states that provide some immunity. But again, you need to make sure you're not practicing veterinary medicine without a license because the immunity covers you kind of from a civil standpoint, but if you're practicing, my understanding, I'm not a lawyer, but my understanding is if you're like practicing veterinary medicine without a license and you start working in the criminal side of things, so you have to have your ducks in a row. But we're working hard. I'm working with the National Association of Veterinary EMS and our goal is to, and Rick, you can chime in, but create some standardized, pre-hospital education defined scopes, et cetera, similar to what some of our human counterparts or associations do, as well as this pre-hospital veterinary movement takes, I don't know, takes effect or gets moving. So, it's an exciting time. But you guys are the experts, the veterinarians and I feel like we're here to help in any way that we can.

- I totally agree, Kate, thank you so much. It's partnerships, we've got to build those partnerships and those of you in the room that are very interested in this entire program need to be reaching out to your veterinary ER docs to create those partnerships.

- And I kinda can't stress it enough and I think Dr. Zimmerman, you probably shared this. Where we are with pre-hospital operational canine care is where we were at with EMS back in late sixties and early seventies. It literally was take the casualty, put 'em in the vehicle and drive as fast as you can to the facility and hope that everything worked out for you. And we learned over the past 40 years that that wasn't the best thing for human patients. And we're now learning that lesson with prehospital canines as well.

- Yes.

- In the NAEMSP op section, we are working on a... So the National Association of EMS physicians, we're working on a physician statement and a joint physician statement with and we're in the process of talking to the folks from Vet Cot to see if we can have their buy-in as well. So vet caused the veterinary committee on trauma, similar to our American College of Surgeons. So, we're waiting for those final discussions to happen and hopefully we can create a statement that supports this movement, moving forward.

- [Dominique] All right, great. So for everyone, the link that they're talking about, the K9tcc.org is in the chat. I think Dr. Merkel has it in his and I can add that again. So, we've had a couple questions about CPR. What are your thoughts on CPR for dogs?

- Excuse me, so there's a really good program out on the canine side. Rick mentioned it, it's called Recover. It's the way we do CPR in dogs. I will tell you... I guess bluntly since I'm talking to physicians, the success rate in CPR in canines is not great because dogs don't typically have heart attacks and have arrhythmias that cause heart stoppage. If their heart stops beating for whatever reason, it's another reason. It's blood loss, it's trauma, it's whatever. And so, pulling out the paddles and pulling out the typical things that we do on the human side to get a person back, that's number one. Number two, in canine CPR it is very breed specific and that you learn and recover, if you're gonna involve yourself in any of this type of activity, I would encourage any of the EMTP that are gonna be involved in that to get recover training because the patient has to be positioned in a specific way to get any kind of blood flow when you're doing the compressions. And big dogs versus medium sized dogs versus barrel chested dogs, they're all different. It's not like a human where you're putting that sternum, you're putting 'em on their back and that sternums pushing the heart against the back and you've got all of the compression space there. In the canine chest, it's too compliant. And so, it's an entirely different ball of wax. It's incredibly difficult to do in a great big dog. It's incredibly difficult to do. And that's a lot of years of doing it.

- [Dominique] Okay, back to the tourniquet question.

- Yes.

- [Dominique] What about the SWAT-T tourniquet, the wide rubber sort of... Okay, you're aware of that, the wide-

- Aware, what I would just tell you is and I'll go back and ask my ER docs if they've got more or better information for me specifically about that in dogs. But I have not seen... Very good, thanks Dominique. I have not seen studies showing that that's effective safe in dogs. Working dogs in the field. Unless you have some data somewhere that I haven't seen, which is possible.

- [Dominique] So, yep, there it is.

- Yep, there it is.

- [Dominique] I don't know if anyone in the-

- But Rick, the data, where's the paper? Point 'em to the paper if there is one. That's what I haven't seen. I have not seen that. I mean, I know what it is and I know you can use it, but what I don't know is what the data tell us. I don't know that. I don't have anything to give you from that perspective.

- Yeah, it's a lot of anecdote unfortunately right now.

- That's what it is, yep.

- [Dominique] Okay and then how about, its use as a pressure dressing? Rather than a tourniquet.

- Okay, yep, valuable tool in the toolkit. If the animal's gonna die and you don't have anything else with you for the love of God, put it on. But on the other hand, what I can't tell you is that we've got data that says it's the right answer.

- [Dominique] Do we have any more questions from the group to put in the chat here? So, kind of building on what your last comment was, do you see some areas for future research that need to be done?

- Well, starting right there. So the working dog world gleans as much as it can from military working dogs. But that world, as most of the folks in this room probably know, doesn't share readily or until things have just gotten totally public. And so, they know a lot of things that we need to know is what it comes down to.

- [Dominique] All right, we do have another question. Can a vet legally delegate certain privileges to a paramedic or human physician for basic care in states that still make practice of veterinary medicine illegal?

- Technically, no, unless they're there. If they were there in the area of vicinity and that EMTP was functioning as a technician with the oversight of that veterinarian, that would fall under the same role as the veterinarian in his practice tell or her practice telling that technician to give X drug or place Y catheter or to do Z thing. But technically, they have to be in the room, so to speak. That's the part about getting pre-hospital care where they can do it over the phone. That's really important.

- [Dominique] Okay, I think we have hit all the questions in the chat. Yeah, I think we've hit all the questions in the chat.

- Great.

- [Dominique] All right, well Keegan, you wanna wanna turn that back over to you then?

- Yeah, thank you. Dr. Zoran, that was great. We really appreciate you coming in and talking about this. This is a big topic that I think there's a lot to gain ground on. It sounds like there's a lot of people in the country who are already doing great work with this. I know EMS and pre-hospital is a big place for this. I know I get the privilege to work with you with our US&R team, so I kind of get that luxury. I know most people don't get that, unfortunately. But I think moving forward, there's gonna be a lot of things that a lot of people, not only this group, but other sections can start to really push for 'cause I think there's a lot we can do for our K9 teammates that we can't yet do.

- Totally agree with that. Totally agree with that.

- If you're okay with it and if anyone had any other questions later on, we can provide 'em your contact.

- Yes, share my email, that's quite fine.

- Yeah 'cause I know I'll be reaching out to you with our team out here in north Dallas, so.

- Yep, nope, happy to do it. That's something that we just gotta keep getting the word out.

- Yep.

- Thank you so much everybody for your time this evening.

- Yeah.

- Perfect, thank you.

- [John] Yeah, thank you so much.

- All right, well Keegan, I will see you at the next training probably, I guess maybe, huh?

- Yes, ma'am, I'll be there all with a pen and a notepad. Ready to Keep going.

- All right, sounds good. Well, whenever you're ready, just gimme a holler.

- All right, thank you, take care.

- You as well.

- All right, Dr- Oh, did she just sign out? Dang it, just gonna go and give her an extra thanks there for that presentation. That was really spectacular there.

- It was a lot of good information. That was great information, yep.

- Yeah, I wish we could do more. That was probably the most, not depressing, but kind of frustrating part, that whole limitation on abilities, understandably.

- It sound like things are changing. It's nice that there's efforts to designate what's appropriate, who's the people to do it, what are your limitations or is there any laws you need to be observant over. And I'd like to see some more information from the field that says basically, what's the best way to transport an injured dog? You're on a swat call out, shots fired. All of a sudden, a dog comes running out to you and he is shot in a belly. What's the best way to transport that dog to the 24-hour vet? When you gonna do that? You gonna do it in an ambulance? You're gonna do it in the back of a patrol rig? You're gonna use what vehicle you're gonna use. But again, there's some experts that can probably put that together, figure that out better.

- Transport it with the jaws away from me.

- Yes, keep working in on the other side.

- And I know Dr. Zaron kind of jumped off, but as she briefly kinda introduced me to talk about some legislation, I think Kate's still on here as well, but myself and Dr. Kate Zimmerman are on the board of directors for the National Association of Veterinary EMS. I'm actually the pre-hospital EMS representative for the board, so if you guys have any other specific questions that are EMS or medical director focused, feel free to to shoot me an email or shoot me a text. If it's veterinary specific, more clinically board, obviously Dr. Zoran's the subject matter expert on that behalf. But if there's anything, I'll stay on for a few minutes if there's any questions, since she's not on anymore and answer if you guys got anything.

- I mean, not so much even specific questions, just really more commentary that it's really good to know that you are all working on this. In discussion of care for working dogs tends to come up in discussions of TEMS and some TEMS training classes will go ahead and do a brief block on it or you'll see at different conferences, stuff about care. But hearing about some of the, not only nuances, but really about, which I really was unaware until very recently about essentially medical legal aspect as far as going and caring for a working dog. I mean, it's really educational and to know that you're all kind of working on this and looking at the bigger picture here is heartening. At the same time as we from the tactical medical section are expanding things conceptually to make this essentially not just TEMS, but tactical and law enforcement medicine and we sort of expand our scope. There's definitely crossover here in terms of with, again, care for a canine working dog. And so, we definitely hope to continue to work and collaborate with you on this.

- Hey Rick, if you're the liaison for EMS for dogies, why don't you put your email in here too, in the chat section?

- Of course and actually I think I see Dr. Winkler, Kevin Winkler creep around here. Dr. Winkler read a bunch of papers of it. He's a veterinary surgeon, I believe outta Georgia, I think. I don't know if Dr. Winkler wants to say anything as well, but I'll put my information in here as well.

- [Kevin] I like you described that I'm creeping around.

- I saw a glimpses of your face on your camera, then you turned it off again. I was like, wait a second. I know that guy.

- [Kevin] Yeah, we're beginning work in Georgia, trying to start the same thing with changing the law. And as Rick said at the EMS level, they're trying to do it on a national basis. Reality is, there's enough states that have changed individually that I don't know we'll ever get any time in the near future. The folks here in Georgia, I'm a little concerned. They just got an opinion from their legal people at their hospital, saying that they can basically go rolling on in and treat it under good SAM level. And I hate to disagree with 'em, but I think they're gonna be wrong. That remains to be seen. The boards of veterinary medicine tend to be very protective of their power and veterinary medicine as a whole is still very locally controlled. There's not a lot of national standards across anywhere and I think it's really depends, state to state, what you run into as to what your board will allow you to do. Texas is sort of notorious for... They can do pretty much anything they wanna do and other states are gonna be a little bit more guarded on what they let the folks on EMS be able to get away with.

- Well, thanks for being on with us, doc. Appreciate all y'all being on and thank y'all for taking an interest in this. It's really great to see this, to see EMS and veterinary medicine start to make that collision course now in the post 2020 Covid world that we live in now as we have our own distinct challenges in our states. You know, like I said, I stand by my quote I said earlier. I was like, EMS and operational canine veterinary medicine is the same like it was back in 68 in the seventies, right? It's just don't know what we're allowed to do. We gotta call the doctor for permission to do stuff, put 'em in the car. Hot lights and cold steel and diesel bolus is all that we can do for them. And I'm glad that that's finally changing across the board.

- You know, there's an element of this that in Oregon here, we have two level one trauma centers in the whole state. They're within a rifle shot of each other. And then we have a lot of rural ERs. And same thing that I'm aware of, I like teaching to rural police departments and they're getting dogs and things are... Someone gets hurt in port landers, the medics, everything's really close by, but if you're in one of the rural parts of Oregon and your dog gets hurt, it's gonna be even more crucial that they get stabilized. And I think knowing how to do that is gonna be important too. But I've not even thought of this whole subject until today.

- I know that you actually bring up a really good point about talking about having level one trauma centers and really critical access hospitals. It's very similar on the veterinary side. I wish Deb was still on to kind of talk about it, but you'd actually be surprised. It's kind of, sometimes the polar opposite from what we think about an EMS medicine, right? Because we're so used to level one trauma center, that's all your surgical specialists are, all your specialties and things of that nature and our critical access hospitals, our standalone facilities, they don't have a lot of capability. But what you'd find is kind of the paradigm in veterinary medicines. Sometimes the more rural the facility, the more comfortable they are, handling some of these procedures. Veterinary surgeons aren't the most common thing out there, but you'd be surprised to see some small animal emergency and critical care specialists who do surgery on a routine basis just because they're it. And in human medicine, we wouldn't see an ER doc doing surgery in the standalone facility. But that's not how it works in veterinary medicine. So, like Dr. Zoran kind of said is reaching out to your local facilities and find out what they can and can't do, whether or not they have blood products or they don't, if they don't have blood products, do they have a transfusion capable canine? Sometimes they'll do a transfusion right there in the clinic to stabilize and get these dogs out. So, starting that conversation with your local facilities, not just discounting and right 'em off that they were small facilities. Sometimes they surprise you with some of the things they have, including anti-venom and things of that nature.

- I was just gonna add-

- [Kevin] Sorry, go ahead.

- Yeah, actually just quickly here and just... So federal agencies, I know like they're medics sometimes, they'll have an expanded scope of practice, sort of depending on their sort of higher ups. Do we know as far as for tactical medics on the federal side and where any particular agencies are giving the go ahead for their tactical medics to go ahead and do care on animals?

- It's not uncommon that this is really kind of where... In my experience, I've seen this where EMS assets assigned to law enforcement agencies are doing canine care. It's really kind of where this startes in this pre-hospital, veterinary conversation several years ago. That was the most common ones that you saw, where medics assigned a SWAT team's taking care of the dog that was assigned to the tactical team and things of that nature. And then a corollary as well. But you saw, like Dan Blitz saying here in the chat box. A lot of the US&R courses build in a K9 first aid class. Actually for FEMA regulations, for a FEMA medical professional that's assigned to a task force actually have to have eight hours of K9 care as a minimum entry. They have to have a K9 first aid class in order to get on the team as a medical specialist. So, that was written into the FEMA guidelines for that position several, several years ago. But it's pretty commonplace in that regard.

- Awesome, thanks Dr. Winkler, you had had some comments too. I apologize, didn't mean to cut you off there.

- [Kevin] Just gonna say two things. One, and Rick caught it before I could say it was, the common thought is to think, hey, what capability this clinic have from a surgical standpoint for the dog, blood transfusion, but don't forget about snake anti-venom, particularly if you're anywhere or if you're in a distance from any kind of major city, you should know before you go into the field, who in the area has anti-venom if you're in an area that that's an endemic problem. And then Brian, to your question about how do you transport 'em, I'd back up with Dr. Zoran said. Whatever you can do to get 'em back the fastest. We don't have 'em in Atlanta transported yet because of the law and where it stands. I've had 'em transported in police vehicles. In one case, by a helicopter that dropped into the street nearby our hospital. So it's however they can get 'em there, the fastest way they can get 'em there. Reality is, most of them, if somebody can work with direct pressure in transit, most of 'em, if you're not too far away, you're gonna be okay getting 'em there. And to your question about shot in the belly. The reality is in the ones I deal with, most of 'em are shot through the front or the back end because they're in between the perpetrator and the police. When the gun start firing, the vests don't do a lot because they're hit from the back end from the police or the front end from the suspect in most cases is what I deal with.

- We actually had some, Dr. Palmer actually will speak about it too, there's actually some case reports of the body armor having some limitations as well with these police canines of a lot of facial injuries and coming up in abdominal chest trauma. Most also from the ricochet of the round coming up off the ground or the concrete and things of that nature too. So, it doesn't always have to be a direct hit. The vests are great, but they also contribute to thermal stress on the canines in some instances as well if the dog's not conditioned to wear it. And Dr. Zoran talked about it at the Penn Vet Working Dog Center, checking them out on the internet's actually pretty worthwhile. They do a lot of heat related studies and things of that nature too.

- [Dominique] Would you say that the majority of what you do ends up being injuries? Or would you say that a lot of it ends up being more environmental, like heat related or?

- Number one cause of working canine death in the United States is heat injuries every single year. It has been literally the leading cause of death for working canines, especially police canines in the United States for almost a decade. Second, third and fourth place on that list depends on the evidence and the research and the statistics that you look at, which it's pretty hard to find that data 'cause there's not a trauma repository, like we have with like the nemsis reporting and things of that nature to pull this data. But it's heat injuries, dogs being overworked, dogs being left in patrol vehicles, being is like the number one leading cause of death for canines in the United States. Secondary by blunt and penetrating trauma and toxic and accidental ingestions. But it's those kind of three that jockey for second and third place with each other, but it's always been heat.

- [Dominique] So even without all the intricacies of practicing veterinary medicine, we can at least work preventatively for the canines and just some awareness about the heat intolerance.

- Yeah, no, I can't stress that enough. And the courses that I teach, I teach a pre-hospital canine course for handlers and medics and I spend an entire hour just on heated emergencies specifically for that reason. Announce prevention is worth a pound of cure in that realm. And I can't stress that enough that it's just tends to be the leading thing that we see. Everybody wants to do all the cool stuff, think about tourniquets and intubating and things like that and it's not really that. It's really the heat, the snake bites and being left in vehicles and toxic ingestions. We think about all the street drugs that are out there nowadays, right? We're just not talking about fentanyl anymore. Now we're looking at xylazine being the next thing and xylazine overdosing canine as xylazine is Narcan resistant. So these drug dogs that are out there in the world getting into this stuff and we don't have antidotes for 'em and it is what it is. So it's prevention and having the handlers recognize it. I think Dr. Sparkman just talked a little bit about, he was just sent an article about Texas police canine dies in snake bite. That was Baytown. That was Baytown. Just last week, the handler didn't recognize the snake bite. I know the veterinarian that treated that canine. She had texted me a couple days ago about it and unfortunately, the handler didn't recognize the signs and symptoms initially of shock. Was unable to assess the dog to locate the bite wound and by the time that they got to the clinic, it was a little too late because the bite went unrecognized.

- Rick, what's your thoughts on the best way to field expediently cool down a dog?

- The answer for that for cooling one, is not transporting them right away. If we can cool the dog in place, cooling in in place is the best thing. We know that we start transporting these dogs, their temperature doesn't drop and because due of the nature of transport. So one, staying in place if you can effectively do it, but active cooling, ice packs to the groin. Ice packs to the groin, the axilla, providing oxygen 'cause that cold oxygen, they thermoregulate predominantly through panting as a mechanism. IV fluid hydration, providing IV fluids. There's some anecdote from the days of spraying alcohol on their pads. It's kind of mixed whether or not that really provides a benefit or not from a objective scientific standpoint. Actually interesting one that goes back and forth and I wish doc was still on to kind of talk about it is the ice baths. As we're trying to get into ice baths for humans for hyperthermia, canines don't usually do too well with the ice baths, with the cold water immersion therapy, at least not from the ice type immersion therapy. Cool water immersion is definitely shown to have some benefit, but not the ice bath that we're now trying to switch to on the human side. So, there's been some back and forth on that for several years on whether or not it's very effective or not. But that's a summary of that evidence that's out there.

- [David] Great, thank you.

- I think that's it. Thank y'all for being on, thanks for listening to me. I know I'm just the little guy in the big pond right now, so I appreciate y'all being on tonight and listening. I'm real passionate about this as well. So thank y'all for taking the time to listen and being on. It's the change that we needed in our profession.

- Yeah, rick, thank you very much. Actually, you had kinda came on the tail end and gave again that sort of more unique EMS perspective that is particularly relevant for this audience, so thank you.

- [John] Yeah, Brian, I totally agree with you there and Rick, thank you very much and thank you so much for the other docs who have contributed too. Really good information and it's great that there's actually a pretty good amount of information out there. Just a matter of getting it out. It's like there's some really good efforts to doing that. So we applaud your efforts, thank you very much. A real quick story on wrap things up too. A good friend from Lawrence High School just passed away this past year. True story, he was working the ER down at Palm Springs and the lady came in and Palm Springs got a whole bunch of little old ladies, little old men who retired and they got millions and millions of dollars down, a lot of money. He came in, had a heart attack, ended up doing okay. Then after about, she's there for three hours, she said, oh my gosh, I left my little dog out in my car. I forgot all about it. And they go, oh, gimme your keys, I'll go check on it. They went out there and Palm Springs, 115 degrees, her poor dog was laying in her front seat, unconscious. Little Yorkie Terrier, basically near death. Heart rate was 180, thing was unconscious, heat exhaustion. So she let the air conditioner run in her car, but the car ran out of gas. So what'd they do? Brought the dog into the ER, revived it, started IV, cooled it down, IV fluids and literally within an hour, the dog was up it, back in the owner's lap, basically back to normal, pretty much. The lady came back three days later, wrote out a check, 2 million dollars to the hospital. The hospital administrator came down with the big grin on his face and said, Dr. High School, you go ahead and treat any dog you went to in this ER. Thank you very much what you did. So, that's one of those hypothermia and hypothermia type of things where it'll pay off for the doc and also the hospital, so good stuff. Anyway, so thought you guys might enjoy that story, but thank you very much again for all the excellent education tonight, we appreciate it.

- Certainly a superstar and I certainly miss him dearly.

- [John] Yeah, me too, you bet.

- [Dominique] I hope we can work together more in the future too.

- [John] Amen.

- All right, well it looks like y'all have a fantastic easy. Thank y'all so much for being on, like I said and thank you for everything that y'all do. This is a pretty interesting multidisciplinary group of people out here tonight, so it's fantastic to see everybody come together.