A Stormy Eagles XXV - My Notes from the 2024 Eagles Meeting

I will state that this was probably the most interesting travel I have had to an Eagles meeting.
Storms in Southern Florida wreaked havoc with getting flights into Ft. Lauderdale. After many hours of sitting in Atlanta we made it to Ft. Lauderdale at sunset... and promptly landed in about eight inches of water (which was interesting to say the least).

 

I won’t delay the real reason you came here... the notes. So, the disclaimer: These are raw snapshots from each rapid-fire presentation. I have checked spelling within the limits of the software, but the product will not be without error. There will be typos and I will fix in the blog as I find or am made aware of them. It happens. Pretty sure i missed taking notes on one lecture at the end of day one.

 

So here you go... the notes from Eagles XXV from the Hard Rock Seminole conference center.

 

Day One

 

Opening -Pepe – Eagles Moderator – Several presenters unable to arrive due to the severe storms and flooding the last few days.

 

Chief Russo – Welcomed all to Florida for the 25^th Gathering of Eagles meeting.

 

The Pentagon Papers: The Five Most Important Papers of the Past Year – Slovis – Nashville – 1) Single dose Epi – Is one and done the answer? The more Epi you give, the more likely you are to get ROSC but NOT better favorable outcome. No improvement in neurological outcome. In shockable rhythms, Epi did not matter. If there is bystander CPR, single dose Epi has better neuro outcomes.  2) Switch AL Pads? A lot out there on DSD. Maybe we just need to change location of defib pads. Vector change needs to happen after two to three shocks. In recurrent VF, no statistical difference in pad placement outcomes. DSD is vastly better in refractory VF. Better than just vector change or staying with AL placement. At least do AP placement or DSD.   3) Epi, When in VF? Never give Epi prior to second VF. Published in Circulation. New article says after third shock. No antiarrhythmic until after third shock as well. 4) Adenosine with Modified Valsalva. Everyone should be using modified Valsalva at this point as it is the treatment of choice. What about adding Adenosine with the modified Valsalva? Gave during initial part of Valsalva. When done, almost doubles conversion rate. 5) Can age alone be predictive of neuro injury? Just do it. 5) One in six of patients that had neuro injury were from asymptomatic head impact. Assume badness in elderly head trauma.

 

Cinco De Trauma - Five Most Important Trauma Publications of the Year – Colwell – San Francisco – 1) Prehospital Vital Signs Matter. Prehospital Shock Index predicts 24-hour mortality in trauma patients with normal shock index upon ED arrival. Abnormal Prehospital shock index means higher 24-hour mortality. Vitals must be obtained to be able to matter. EMS still doing a bd job of getting a BP in kids. IV Fluids in Trauma. Data from the two largest European trauma registries. Variability still exists in fluid being given. Trending towards reduced use of fluid and less mortality. Perhaps leaning toward elimination of fluids in trauma and lean toward blood products only. We should tolerate low BP if not concerned about major head trauma. #) Blood in the Field. Study looked at penetrating trauma. 11% mortality increase for each minute in delay to blood administration. Wonderful alternative to fluids. 4) TXA. One study with lower dose TX had no difference (did not use 2gm). 5) Geriatric falls. Integrating fall prevention strategies with EMS visits resulted in 37% decrease in repeat calls. Done through follow up visit for prevention assessment and finding cause of fall. 6) Ketamine. Found not to be inferior to Morphine for pain control. Study supported Ketamine for pain control. He stated that he added a sixth point.

 

Advocacy: Let My People go! – Terry – ACEP – EMS and Hospital System Overload is still an issue. ER Boarding is still a problem. This is a systems problem. Why? Access to care is exactly what we do. “Wall time” is the same as “boarding time.” Hospital-wide efficiencies are a must. We must insist that the hospitals work with EMS to fix this decades old issue. There are stories of patients being admitted to the ICU from the waiting room. Case study of a female patient who stayed on the ambulance cot for 90 minutes that had an intracranial hemorrhage. She had to be transferred and ended up being a fatality. “When Minutes Count for EMS Patients Act” is being supported by ACEP. ACEP has also drafted a response to the new healthcare safety OSHA regulations. Also supporting payment for on scene treatment, care, and support. ACEP is also supporting the “Our First Responders Act.” Much of this would make what started with ET3 a reality. Drug shortages are still a problem. There is a legislative call for action o policies and advocacy for correcting the drug shortages affecting EMS.

 

What About Keeping Medical Practice as Medical Practice? What are Key Challenges EMS Specialists, Emergency Physicians, and Doctors as a Whole are Facing Today? – Kupas – NAEMSP – The things threatening EMS practice of medicine is threatening medicine as well. A lot of time being spent in EMS advocacy, but we don’t always do a good job in advocating for the EMS Physician. Things like local and state ordinances banning the use of Ketamine limits the practice of medicine and doing what is best for the patient. EMS has never stopped making house calls. EMS Medical oversite is a practice of medicine. “We support the right of the EMS Medical Director to decide what is best for their community and not be hindered by the decisions of others.” Supporting medical director payment by Medicare. A physician can bill for a house call, but a medical director cannot go to an arrest scene and bill for services (differing taxonomy).

 

What Does Equity Mean in EMS and Why Does it Matter? Weston – Milwaukee – What do we know about equity in EMS? What can we do about it? Why should we care? Do we treat all our patients the same? Data says we do not treat our patients the same. Care can be inequitable by race, gender, age, financial status, medical issues, and other areas. Equity is not a niche issue. It actually represents a majority of patients. Define equity, require demographics, modify training, leverage the data in your system, and ultimately change policies. In doing so, you will improve health.

 

New Mexico’s Unique EMS Corps – Pruett – Albuquerque – A ready workforce exists. Young Adults 18-25. Bring them in and give housing support, monthly earned stipends, mentorship, counseling/wellness, and job placement. They have graduated 67 people. One third are native American. 99% have confirmed employment with 90% working in EMS. 400 hours of EMT content for 18-20 students at a time. Concentration on hands-on training. https://emscorps.org

 

Respect Thy Elders! With Escalating, Longer-Living, Anti-Coag’ed, and Boomer Populations, What Does EMS Need to Know? – Colwell – San Francisco – We are not as good as we need to be with this population. How can we be better? We respect peds but lump geriatrics in with adults. As we get older, we hide injuries and pathology. “Older than 65,” nothing magic about that and an argument could be made for age 35. No literature clearly defines geriatric. “Young old” is 65-80. “Old old” is over 80. More severe response to injury and pathology. Geriatrics have pre-existing conditions and fewer reserves. Most common complaint is a fall. Age is a significant determinant of EMS use and is associated with longer scene times. 18% have repeat transport within 30 days in many cases. Dyspnea is highest number of medical complaints. Falls are 50% of trauma calls in the elderly. A fall in an elderly patient without transport is a sentinel event as death can statistically occur within months of a fall. 49% of those not transported need medical call within two weeks of the call. What caused the fall? Dehydration, delirium, infection? Normal vitals should NOT be a reassurance of normalcy. Vitals affected by medications (beta blockers for example). 14% increase in falls for each medication above 4. Newly started medications cause changes that can lead to falls/incidents. Coming to a hospital near you: There are now accredited geriatric emergency departments. Respect the significance of our geriatric interactions in EMS. They benefit from progressive care.

 

A Bleed Indeed is a Bleed in Need! How Accurate is a New Screening Test for Detecting
Subarachnoid Hemorrhage? – Banerjee – Polk County, Florida –  37.5% mortality rate of hemorrhagic strokes at 30 days. 97% have severe headache. 33% have no symptoms except for a headache. SAH Protocol is used in patients over age 15. CTHEAD anacronym used. How accurate is the index? 96.6% accurate in Polk County.

 

Can We Save the Triage Day? The TBI Biomarker Way? - Kupas – NAEMT/NAESMP – There is a lot of transport for CT scans post fall. Anticoagulant use is a factor as is age. Biomarkers released after brain injury, UCH-L1 and GFAP. Used to have to spin down sample to test from plasma. www.tbibreakthrough.com  only uses a single drop of blood. Results in 15 minutes. Sensitivity is 97.6%. Negative predictive value was 99.6%. 1959 patients, only 3 where test was negative, and the CT was positive. In those three there was not a significant bleed (small). Biomarkers are for specific circumstances. This one is for falls with a head strike. The assay works well in this sub-group. Can be combined with other assessment tools like the Wake County Fall Screen and the Canadian CT Rule. What are the goals of care? This tool would support a treat in place EMS model. About $1,300 per unit. Lots of discussion on this topic and the device. Could be even more of a benefit where long transport times to an appropriate facility exist. Sounds like a great treat in place tool.

 

Senior Moments and Getting Old Remarks: A Brief Discussion on Trauma Triage, Special Precautions and Special Needs – Colwell, Banerjee, Kupas, Gaither – There is a great risk of oversimplifying the geriatric issue. Some studies state that 25% of patients die within a week of a lift assist occurring. We have to do better. The factor that many geriatrics do not wish to be transported is prevalent. Should we take all geriatric injuries to a trauma center? Will this overwhelm trauma centers? Possibly? ACEP is looking into criteria for geriatric specific trauma centers.

 

For the Life of All Flesh is in the Blood Thereof (Leviticus 17:14) – LONG LIST OF PANEL PARTICIPANTS – EMS is an extension of the hospital emergency release program for blood products which is uncross matched blood. Showed map of prehospital EMS locations carrying blood. Need more blood donors. AABB is working on out of hospital blood standards. The standards are currently open for comment. Key questions for EMS blood administration being developed as well. “This could save more American lives than any other initiative in our lifetime.” 4 pillar approach to increasing blood use in the field: 1) Reimbursement for blood, 2) EMS scope of practice changes, 3) Strategic preparedness and 4) outreach to support increasing involvement. Is it time to introduce ARC (Advanced Resuscitative Care) into thecivilian population? This would be adding O negative blood, 10% Calcium Chloride 2gm, and TXA 2gm, into the trauma care prehospital phase. One study on penetrating trauma showed this dropped mortality rate. Use XABCDEF as the treatment priority list. Every minute matters. Even with short transport times, this care shows improvement in outcome. Prehospital blood administration averages a savings of 19 minutes over waiting to start transfusion at the hospital. Having to have the “magic armband” at the hospital delays blood administration at the hospital. Infusion start takes less than two minutes with EMS. Washington DC reports that they are completing transfusions before arrival at the ED. Patients are actually waking up prior to arrival at ED after transfusion. Standardization of tubing and warming cartridges can decrease costs. Some areas report a decrease in hospital transfusions due to EMS completing what is needed before arrival at the ED. One area reports creating a group of dedicated donors from public safety (includes females who are type O that have never been pregnant). Systems report expanding from just trauma to medical hemorrhage patients. Medical patients can be 25% of the administrations. There needs to be more blood available for strategic preparedness. Demonstration shown on process of using a field donor to use for a field recipient. Six-year-old pediatric recipient of an EMS blood transfusion was honored on stage. Mother of patient states that she did not understand the impact until she so the change in her daughters’ condition immediately following the blood administration.  Whole blood is the best treatment for a bleeding patient. Crystalloid fluid is “tradition,” NOT “evidence-based medicine.” Build your program as you would build it to take care of one of your own. Do not exclude kids from your EMS blood program. There is no valid reason to exclude pediatrics from an EMS blood program.

 

ID-Me: What are the Latest Infectious Disease threats Du Jour? And Why Should You Care? – Jui (Portland) and Marty (Eagles ID Consultant) – Influenza A is still prevalent. Children can be contagious 3 to 4 days prior to symptoms. Influenza A can live on stainless steel for up to 7 days. Comparison given of Influenza A, B, C and D. A and B are the most significant and dangerous. Influenza A is very zoonotic and likes to jump around. USA has been the source of three major Influenza pandemics since germ theory was recognized. 2009 flu pandemic killed 18 million people. There is an evolving menace of H5N1. In 1997, H5N1 took less than one year to transition from birds to humans. In 2020, H5N1 is on all continents except Australia. It has devastated bird populations and jumped to 16 mammalian species. Dairy herds are being affected in the United States. H5N1 is only two changes away from going from low transmission rate in humans to a high transmission rate. Antiviral treatment options: So far there have been none that have been overly efficacious in treating influenza. New ones are Favipiravir was designed for flu but is more used for other viruses. It works against the flu it is not yet approved in the US. Baloxavir has been approved for oral pill use against influenza. Cytokine storm must be stopped to prevent death from influenza. Tamiflu does help and is worthwhile if severely ill. Recombinant vaccines tend to be the most stable. Moderna has two additional flu vaccines coming out.

 

Are You Ready Teddy? What is the US Preparing for in Threat Preparedness Nowadays? – Hunt – US Department of Health and Human Services – ASPR is now its own division of the Department of Health and Human Services. Working on hospital preparedness, disaster response systems, national special pathogen system and workforce capacity and capability. Looking at regions as being more than just state based for disaster systems. The national special pathogens system is designed for black swan events.  Four levels of treatment centers. There are currently 13 regional treatment centers (RESPTC) in the US (considered to level 1 hubs). How do we transport patients for biocontainment. Currently only one agency available through the state department for transport. They are building two prototype mobile biocontainment units (PBCU – Portable Biocontainment Unit). Those working on workforce capacity and capability cross multiple partner associations and agencies. We are in a very tricky time nationally when it comes to a pandemic. The momentum to pull things together quickly is there.

 

Eagle’s Member Medical Directors On-Stage – Introductions to the audience.

 

Droning On: How is FDNY Using Robotics? – Aseda – NYC – Opening discussion on implementation of technology and also the impact of when the technology fails. Technology is great but we need to be ready for when technology fails. FDNY used tether drones for scene observation of major scenes. They now have tethered and untethered drones. Drones are also being used in water accidents to get flotation devices to someone in the water. Can drones be used to deliver blood to the scene. Robodogs were used by NYPD but were too intimidating to the public. FDNY now has robodogs for unsafe building entry (painted like a dalmatian), named “spot.” There is a remote-controlled flotation device that is coming as well.

 

The AED for the Active Bleed: What is the utility of the Automated Tourniquet? – Antevy – Coral Springs/Parkland – Dr. Antevy gives history of Davie tourniquet project and invitation to White House with Stop the Bleed history. Presentation on an inventor’s device that automates the tourniquet. Called AutoTQ. www.goldenhourmedical.com Tourniquets are frequently applied incorrectly. Stress can cause incorrect application of the tourniquet. The AutoTQ is to bleeding victims as the AED is to cardiac arrest victims. Currently an 84% failure of appropriate tourniquet application (CAT). Skill in application must be refreshed. One button inflation. Device gives verbal instruction just like an AED. Control box is reusable, strap is single use. $400 per kit (3 cuffs + Inflation unit), replacement cuffs are $40 each.

 

Depletions, Repletions ad Deletions Galore – Augustine – Eagle’s Librarian – The issue is that US manufacturers are not keeping up with obligations to produce needed medications. Some strategies are to create partnerships to get medications easier. We can sometimes substitute medications (some substitutions could be oral or inhalation). Use of expired medication requires official extensions. There is also the possibility of compounding. We should also advise the public that certain therapies are in short supply when the shortages occur. There is a new manufacturer called CivicaRX that was created due to shortages in hospitals. The drug shortage is considered a national security issue. There is currently a call for action.

 

Bringing Up Players from The Pharm Team: What is the Role and Value of an EMS Pharmacist? – Simpson (Minneapolis) and Kazan (LA County) – A pharmacist that is used alongside medical directors and protocol implementations can help identify treatment strategies, assessing new literature, logistics of drug supply and can be a resource for the paramedics. The pharmacist can be utilized in shortage mitigation as they understand usage across the entire healthcare system. They add another layer of validity to EMS treatment decisions for protocols. Can be used to review current protocols. LA County wanted automated drug systems like Pyxis. When a pharmacist looked at their existing system, she found better ways to distribute Epinephrine to EMS units. They were able to get some Epi direct from the manufacturer through their liaison pharmacist. Looked at actual utilization and adjusted supply levels to prevent expiration and reduce waste. Eliminated $300k in waste on medications. Cut expirations by 75% to 80%. Bringing in the expertise shows you what you have been doing wrong all along. Shortages are taken care of upstream from those that give the meds.

 

Long Distance STEMI Care: What is the role of Super Aspirin 23ba in Acute Coronary Syndromes – Levy – Anchorage – Zalunfiban is a new drug that is going to be used for STEMI. It is a next generation GPIIb/IIIa inhibitor that blocks platelet aggregation irrespective of pathway of activation. Given SQ and works within 15 minutes. It is out of the system in two hours. Trials are going on in Europe and US trials starting soon. There is a consent form and checklist to enter the trial. Drug may be very well suited for EMS use. Enrolling in other countries as well. It is potent with a short half-life.

 

What is the RX for AF: Considerations for Safety Treating the Quivering Atrium – Gilmore – St. Louis – Advocates for AF with RVR to be a rate of 120 plus. Should patients with AF RVR be treated in the field? Last fall, an article showed better outcomes with AF RVR patients that were treated in the field. NNT numbers were actually very low to show a positive outcome. Is Diltiazem appropriate? 27% decreased rate. 63% had clinical improvement. Nothing significant between bolus vs bolus and infusion. Slightly less hypotension if on a drip.

 

Rebuking the Puking: Efforts for Weeding Out Treatment of Cannabinoid Hyperemesis – Gilmore – St. Louis – How common is CHS? More common in states that have legalized marijuana. Acute management prevents dehydration and furthering of downstream effects of dehydration. Capsaicin tends to work. Ondansetron and Promethazine do not work well with CHS. Haloperidol and Midazolam may also hold some effect as well.

 

Five Reasons Why You Should Use Ketamine in Status Epilepticus – Scheppke – West Palm Beach and Palm Beach County Florida – Lateral tongue bite occurs in 30% of seizures (great diagnostic finding if not seizing on arrival). What do we do when Midazolam does not work? 15% of seizure patients will experience status. Benzos work through GABA receptors. GABA receptors are the “off switch.” NMDA receptors are the “on switch.” If you block the on switch it becomes the off switch. Ketamine is the Swiss army knife of medications. 100% of the Ketamine usages in the study terminated seizures in adults (82% in pediatrics). No Ketamine associated untoward effects. Benzos remain the first line therapy. Give complete doses of Ketamine.

 

Cerebrovascular Accidents are Waiting to Happen: What is the Latest Advice on Stroke Identification, Triage and Transportation Destinations – Antevy – (Davie) – Where are your stroke centers? If you are within 30 minutes of a CSC, you should bypass the PSC. 30 minutes should be the target for TPA in stroke. Many stroke centers do not report openly outcomes. RACE scale training, looking at data, and bypassing PSCs to go to CSCs improved outcomes. There is now a stroke registry and legislative to mandate reporting and show dashboards. What are each hospitals’ outcomes? Time to TPA? State level attestation had to go for established accreditation.

 

A Hat Trick That Clicks: What are the Latest Results on the Helmet Technology to Diagnose LVO? – Dunne – Detroit – We need an ECG equivalent for strokes. We are seeing more strokes than ever with the aging population base. Thrombolytics are only 10% - 20% effective in large vessel occlusion. Cranial Accelerometry measures blood flow by looking at associated vibrations in the skull. There is more vibration when there is an occlusion. 21-month study in 11 cities. Head trauma excluded. 594 subjects. 313 consented. 25 had degraded readings on initial device. Compared to LAMS score at 40% predictive value, the device was over 85%. It only missed four patients out of 158. Device is far better than a scoring system alone. Device data has been submitted for approval to the FDA.

 

The Nobility of Mobility: What Are the Economics, Benefits and Findings from Mobile Stroke Units? – Lowe (Columbus), Persse (Houston), and Bronsky (Colorado Springs) – Good breakdown of usage of stroke units including unit downtime. Houston reports cost of over $2.4 million annually. Part can be recovered in hospital systems by downstream income from stroke patients. Annually generated about $800k in revenue for the hospital (does not include income from consults, etc. Net is about $1.6 million. If the hospital is operating the unit they really want the patient to come back to them and this becomes an issue of fairness. Some data dis show a decrease in time to thrombolytic treatment with a large number receiving TPA within one hour. EMS medical direction has to be an integral part of development of a stroke unit. Houston is putting together a consortium so that everyone is at the table. Houston reports 45% treated in the first hour of symptoms. Houston is a fire department project using union firefighters partnered with hospital RNs and CT techs. An NYC attendee indicated that in NYC, Stroke is a BLS call type. Columbus uses a neurologist via telemedicine. Each of these systems only have one stroke unit. One set of data indicated that it received requests while already on another stroke call. The Colorado unit was splitting time between Colorado Springs and Aurora initially (there is now a unit in each city). Houston is adding a second unit and potentially a third.

 

No Entiendo Stroke?  Well Then Try This Very Useful CVA Assessment Tool, Por Favor! – Banjeree – Polk County Florida – 12.5% of the US population has Spanish as a primary language. This cultural group has a higher incidence of stroke. AHORA is the Spanish anacronym. Andar, Hablar, Ojos, Rostro and Ambos brazos o piernas. This mirrors the content of stroke assessment tools for the public that are written in English.

 

Not Lost in Translation: Can an On-scene Video App Get You the Right Interpreter ASAP? – Simpson – Minneapolis – Utilizing a video application with field crews with interpreters. Used for multiple languages and dialects. Did training on use within a simulation lab. Last month this was used 2608 minutes in their system. Do we need this? “Probably.” Is it feasible? Yes. The app does not record, it is real time only. Cost is a per minute fee along with a subscription fee to the program.

 

How Good Are Paramedics at Shadowboxing? Our first 3000 Ultrasounds In the field – Simpson – Minneapolis – Storage of images is important (Can use cloud or local). Feedback is important. Use champions of the program to create more educational materials. The program is now mature, and they have ultrasound on all units and every paramedic is trained in ultrasound. You need champions, storage, and feedback to have a thriving ultrasound program.

 

Why Did We Have to De-Train the Trainees? Lessons Learned from 100 Prehospital Videoed Intubations – Lowe – Columbus – Intubation success rate was improved so they wanted to do a deeper dive into what they had learned. What had to be trained out Don’t sweep the tongue, review anatomy, and what is an OK view as compared to a good view? Needed to re-emphasize the importance of suction.

 

Land of Enchanting Education: Novel Approaches to Statewide Education in New Mexico –Pruett – Albuquerque – Extend the dinner table conversations. Tell the stories of the difficult cases and rescues. What did you see? What did you think? What approach did you take to treatment? They have now produced 42 videos of these type discussions for statewide use. They are also trying to get physician residents more interactive with EMS training. Follow up is education, but getting follow can be difficult. They are having residents complete a form to send feedback to EMS crews. Producing BLS educational distance learning programs for rural and tribal EMS (twice a month - Project Echo). Users can interact with each other on the platform. This usage resulted in three caregivers present at a mass shooting integrating with each other seamlessly.

 

Scaling Up De-escalation Preparedness: Improving Force Protection Through Specialized Training – Holman and Dunne (Detroit) – Dunne: How do we teach what we learn so the future caregivers feel safe and more protected. We want to prevent escalation. One study showed reduction in aggression from 37% to 3% by instituting preventative training. They use Verbal Judo and other programs. They also do hot wash and performance improvement following incidents. Get peer support involved with training and incidents. Protective gear was assessed. Reeducated on medical restraint. Better integration with social workers and LEO. Looking at staging issues and improving dispatch issues and alerts. Continued focus on situational awareness. Holman: Used simulation labs while in Washington to teach conflict resolution. Showed video of a simulation of conflict between crew members.

 

Agitation Mitigation Nation: What Do We Do When Things Get Outta Hand? Numerous presenters – Pruett, Lowe, Colwell, Gaither, Nacht, Calhoun – Extreme agitation (regardless of term used) will usually require chemical intervention. It is a medical emergency, and you must treat it. Typically, there is profound metabolic acidosis in play and if we do not intervene it may end in cardiac arrest. Options are Benzodiazepines, Droperidol, Haloperidol, Ketamine, and others. Benzos work well when cocaine or methamphetamines are involved (be careful when there is alcohol involvement. Droperidol is good for everything else. Droperidol can be used for nausea as well. No adverse cardiac events noted with Droperidol. Haldol is also an option. Ketamine is good for the extreme agitation case as a first line agent. It is safe in medical hands. Ketamine increases MAP in head injury. Joint statement is out that supports Ketamine use in trauma. Dexmedetomidine mentioned as another potential medication to look at. Physical restraint of patients: How should you select a restraint device? Restraint for agitated patients must be made safer. Everyone must work together on this topic. One agency using the “Wrap Device.” Simulate each device that you consider. Devices must have policies for use. When does EMS care start and when does LEO care end? Define EMS

responsibilities. There must be a QI process to assure compliance with policy and usage. Agitated patients have poor morbidity and mortality. Some tips: 1) Never meet a colleague for the first time in a disaster. 2) Why it was done matters a lot. 3) One size does not fit all when dealing with people. Customize it to your system. 4) There must be a culture of empowerment (everyone must be able to point out issues). Post sedation monitoring and resuscitation: Maintain airway, give oxygen, monitor ETCO2 and SPO2, full vitals and repeated assessment. Is there a good score? One agency (Columbus) uses the Sedation Assessment Tool (they stratify sedation dosing based upon level of the score. New Mexico uses the Behavioral Severity Index. Standardize language and dosing. Improve documentation. Create and publish QI reports. “The best EMS spit mask is a non-rebreather with oxygen.” Geodon and Droperidol are extremely safe (but like any agent, you must watch the airway). Need for EMS body cameras noted by one physician. Discussion regarding Aurora’s consent decree. https://www.auroragov.org/residents/public_safety/commitment_to_progress/consent_decree_progress

 

Day Two

 

Some Highlights from the Past Year’s Eagle’s Surveys and Weekly Zoom Rooms – Augustine – Eagles Librarian – There is a feeling that change is occurring faster than usual. This is followed by three years where there was little change. Another issue is that the patterns of substance use differ widely across our country. Within the Eagles there were 40 major discussion threads that were not COVID in the past year. 120 Eagles members who are medical directors covering about 24 million EMS responses (there are about 36 million transports each year with about 37% being admitted after ED). People was one of the biggest topics. Discussions on recruiting and retention. Discussions held on academies and college degrees. EMS is fertile ground for developing people and that is a very productive use of EMS. We have a responsibility to prepare people for a career. On going supply chain issues. Something different every week. Transport ventilators are now present in 40% of agencies. Need better restraint systems for behavioral patients. Secretions getting into ETCO2 probes when using SGA’s. Tourniquets need to be stored with AEDs for public access. Cyanide antidote now available 70% of the time to fire scenes.  More use of selective BLS on low acuity calls is happening. Sedation usage reviewed with Midazolam being the primary and Ketamine the second most used. Elevator incidents are becoming more common. There have been more uses of dedicated and public busses for MCI transport. More services now have internal crisis management resources. Community paramedicine for low acuity and lift assist calls. Treat in place and alternative destinations are becoming more common. Sporting events are asking for more dedicated services. 75% of services have cricothyrotomy now. Sharing practices is a great practice.

 

Approach to the CBRN Event: A Framework for Patient Care and Movement – Margolis – US Secret Service – Most of EMS is focused on the singular person. Why are we talking about CBRN? If you were the bad guy, what would you do to maximize a attack?  The New England Journal of Medicine has reported on potential chemical agents that might be seen in an attack. Nerve agents, Asphyxiants and Opioids are the top three potential agents that could be used. Does a framework for response exist? MARCHE2. Mask up. Antidotes. Rapid Spot Decon. Countermeasures. Hypothermia prevention. Extrication. The framework will be used in the zones of care (hot, warm, cold). Antidotes: Duodote, Atropine, Naloxone, Amyl Nitrate, Diazepam, Hydroxocobalamin, Calcium Gluconate, Bronchodilators. Life threatening hemorrhage may be present and must be managed. Chemicals must be neutralized. Tourniquets applied in the hot zone may be a source of ongoing contamination. PEEP may be needed in patients with respiratory complaints. The patient will be naked and wet after decon and hypothermia must be prevented. Additional monitoring and transport will occur from the cold zone. Decon is a medical countermeasure. MARCHE2 is dynamic.

 

Premature Launches: What are the Considerations for EMS Crews Faced with a Precipitous Delivery? – Colwell – San Francisco – For the most part these go just fine. Standard process used by EMS works in most cases. Breech, Shoulder Dystocia, and Prolapsed cord are the three to worry about. Breech: Don’t pull. Hands off until umbilicus seen. Then you can move and turn to remove. Shoulder Dystocia: 3% of vaginal delivery. Turtle sign (baby retracts back during contraction. Mom back flat and hyperflex the thighs. Flex elbow and move over infant face and two other maneuvers. Prolapsed cord: Cord compression creates hypoxia. Raise the head off the cord and you are there until arrival. Must hold head off the umbilicus. Think and train before this happens and do not forget post-delivery care.

 

It Ain’t over till it’s over: Consider post-partem lethal states (REWORD) – Miramontes (San Antonio) and Weston (Milwaukee) – Miramontes: Preeclampsia can sneak up on you. Deaths are common. There are numerous risk factors. 1.4% of deliveries have eclampsia. Prevent seizures by using Magnesium. If BP is over 160 Systolic do seizure prevention. Treat the blood pressure (“Treat the damn blood pressure!”). Weston: Preeclampsia can occur up to six weeks after delivery. Out of 1575 pregnancies, 504 are hypertensive, 75 will be severe, but only 1 will have hypertension as the primary complaint. Miramontes: A BP of 140 systolic is not normal in pregnancy.  BP must be managed if at 160 or higher “Be aggressive. Be. Be Aggressive!” Transport with Magnesium prophylaxis.

 

How My Crew Does “bu”! Opioid issues – Weston, Youngquist, Miramontes, Jui, Mechem, Scheppke – Cartel drug production is up. Overdoses are up. Relapse rates are high. “You can’t help someone if they are dead.” Treatment lowers HIV and Hepatitis rates as well as decreases crime. 20% mortality with detox. Buprenorphine is effective in preventing withdrawal symptoms. Two to three days of BU treatment makes the patient a much different person. San Antonio has a field BU program. BU can last greater than 24 hours. The first 24-48 hours after an overdose is when they are most likely to die. If BU is given you may be preventing another OD for at least 24 hours. Don’t be deterred, take the first step. BU is not going to get them high, and they will not OD on it. Giving BU has a great impact potential. Oregon provider has an aftercare team. Just starting. Have 18 patients enrolled. Transporting to a clinic and not the ED. Currently reducing withdrawal patient symptoms. Philadelphia has had an opioid response team for 5 years. Warm handoffs to rehab. Able to place 1313 people into treatment programs. Chance or overdose reduced by 85% after contact with the opioid unit. Good political support in Philadelphia. Florida has the CORE network in place. There is a centralized, tax funded addiction stabilization center. Overdose rates virtually eliminated after treatment. With proper treatment, people stop using.

 

Panel On Ambulance Parking, Ambulance Ramping, Extended Wall Time, APOD or Whatever You Call It!  Kazan, Obert, Stone, Goodloe, Asaeda, Scheppke and others – “EMS is just dumping patients on the hospitals,” was heard in one venue. This is not a new problem. ED overcrowding first discussed in 1974, diversions discussed in 1994. Hospitals have had decades to figure it out. Ambulances should be out on the street not stuck at hospitals. ED and EMS utilization are both up dramatically. About a 5% increase annually in EMS volume. California has mandated RN to patient ratios that have created a nursing shortage. Beds must close if staffing is lean. “Inmates are running the asylum.” Facilities will stay open to patients while multiple ambulances are on the wall. Who is responsible for the patient? CMS has weighed in. EMTALA obligation at the hospital begins on arrival. Hospital responsibility begins before the wheels of the ambulance stop. Hospitals do not like this. Holding ambulances become a free tool ED’s use during surge. EMS did not speak up soon enough on the issue. Pandemic caused this to be a tipping point. Hospital problems cannot be used to crush the EMS systems. Medical literature shows that diversion does not work. The hospitals need to hire LPNs or some level to sit with patients. This is patient advocacy. In Canada, at a provider in Vancouver, they have created waiting room criteria so that patients can be moved there, and the unit can go available. There are exclusion criteria. EMS also bills hospitals for offload delays. A supervisor escalation is used if unit cannot drop patient and return to service. Crew can activate an immediate need protocol when there are no units available, and the hospital must release the unit. There have been no patient safety events reported. Communicate early and communicate often. Maryland is unique in that they had the longest offloading delays. The wall time issue is multifactorial. Wall time is an extreme patient dissatisfier.  Set boundaries with the ED. Share data on the issue (both ways). Direct to triage when you can. Escalate if wait time is longer than expected. Some use of alternative destinations. “We will not normalize EMS wall times. EMS personnel will not act as surrogates for ED staff.”  $31,519.85 in waste with wall time in that system. The NYC approach: They do 4500 EMS calls a day. 1.6 million calls a year. 1 million patients transported annually. 60 receiving ED’s. They want low turnaround times, but they are averaging 40 to 45 minutes. Ambulances are redirected if ambulances are already stuck at a receiving facility for more than 20 minutes. Treat in place and alternative destinations have been explored. Light duty EMTs and medics are y=used for ambulance handoff so crew can leave in some cases. The on-site EMT/paramedic then hands off to hospital. Successful when things are running well. Scheppke: Wall time is not an EMS issue. It is not our problem. It is the hospitals problem. Show the data and place the shame. Pepe: Once we are there it is their patient, period.

 

Nursing the 9-1-1 Call: Success of a Triage Line to Re-direct Low Risk Patients – Holman – Washington DC – Six years. 74,300 calls triaged. 35,000 patients diverted. 62% of those diverted stay out of ED for at least 7 days. Lyft is utilized if transport is needed. Components: Self-care, clinics, telehealth, and urgent care. NTL is supported by medical literature. Field referral empowers crews to be clinicians. DC believes that 26% of their calls should be sent to NTL. DC dispatch not sending all that they should to NTL. Trying to fix the issue. Trying to get CMS funding support for NTL in the future.

 

Show Me the Money: Funding MIH and Outcome Tracking – Miramontes (San Antonio and Holman (Washington DC) – Miramontes: Multiple MIH service lines in play. Some hospice entities actually pay for MIH. Hospice does not want ambulance transport in most cases. Manage the patient on scene. Number one issue faced is that families do not know how to use a 1ml syringe. They can remedy that.  The goal is to work with the family, treat pain and symptoms and NOT transport. Molina sends MIH patients that are costing them large sums due to non-compliance. MIH works to get them what they need, and MIH is paid to keep them out of the ER. This stabilizes the patient. Using homeless shelter care stations (decreasing responses).  Holman: DC received a state plan amendment for Medicaid and was able to bill using actual costs. They will receive supplemental Medicaid payments. This will be used to develop new initiatives to create better patient care. Rules for this differ by state. Agency must qualify before entering this Medicaid program. Document best practices so that you have the information to support doing more.

 

No Small Matter: MIH for Kids! – Pruett – Albuquerque – Train MIH providers on peds respiratory distress. There should be a clinical rotation in peds ER. Review OTC med dosing for fever. Train how and when to suction. Assure food security, home safety, car seats and safe sleep. With program, 23 patients sent home on O2 since 8/23 with only one return to ED.

 

Can REBOA Catheters Be Readily Used for Cardiac Arrest? – Youngquist – Salt Lake City – Case study of REBOA at 70 minutes of arrest. There have been 10 performed so far with 6 ROSC and 1 discharged neuro intact. Main skill is cannulation of the femoral artery. Looking at REBOA combined with the neuroprotective bundle (HUCPR). More to come.

 

Who CARES? Why should We Use a National CA Registry to Enhance Survival? – Weston (Washington DC) – Are you using the data internally? Are you making it public? Do you know where your arrests are occurring? Who is it witnessed by? How many received bystander CPR? Knowing these things can target care. If you have the data share it and use it.

 

A Heads-Up and C.A.R.E.S. – Bachista - Augustine – Heads up CPR showing better outcome data in non-shockable rhythms. 3% improvement in outcome with PEA and Asystole. 42.5% improvement in neuro good outcome in all arrests (looked to be about a 5% improvement in neuro intact discharge). More to come.

 

Not Dead – Just Mostly Dead: Resurrecting Those with Asystole and Unwitnessed Arrest – Schorz – Witness Protection Program – Is there something else we can do? Medical literature supporting use of neuroprotective bundle for cardiac arrest to improve neuro intact outcomes. So, what about Asystole? There are physiological limitations of conventional supine CPR. We know that ACD + and ITD improve neuro intact survival by up to 50%. What about raising the head? You just cannot raise it all at once. Must be primed supine and then raise head slowly. Cerebral perfusion is near normal using this method. Again, what about Asystole in unwitnessed arrest? Individual system low improvement still means thousands of lives saved nationally. HUCPR does improve survival in this group over standard CPR.

 

Drain Those Brains and See the Gains: Updates from Tennessee and Oklahoma – Holley (Memphis)– Looked at 87 patients and isolated CPC1 survival with HUCPR. Greatest improvement was in the groups that rarely show survival.

 

Some Shocking and Non-Shocking Outcomes – Bachista (St. John’s County) and Antevy (Palm Beach County) – Neuroprotective Bundle is BLS. Case study presented with HUCPR. Young patient. 21 years old. Single shock and the HUCPR with ROSC. CPC1 discharge. Next is a 70-year-old, short of breath, dizzy. Wife cannot get him out of chair. Took four minutes to get him to floor. Unable to do bystander or DACPR. Got neuroprotective bundle on arrival. Refractory VF. 12 defibs with 8 being DSD. Epi, Amiodarone and Mag. 38 minutes on scene. Transported with HUCPR. No ROSC with EMS. In arrest for 72 minutes before ROSC. Went to Cath lab. Extubated 3 days later. Discharged neuro intact. Neuroprotective CPR protected brain function. Three weeks later, patient met the EMS crew. “Why do we do what we do? THIS is why we do want we do.” It is all about perfusion. Antevy: Next, EMS, fire crew and patient (and family) involved in a tennis court arrest came on stage. Covered timeline of event. Esmolol used in this arrest. Time to first defib was 2 minutes 22 seconds. ICU nurse follows up with patient (voluntarily) at home. Patient went home CPC1. Patient speaks to the audience clearly and with many accolades for everyone involved. He plans to get back to playing tennis. He wants to be the oldest person to win the U. S. Open. Crew received awards on stage. They also thanked Dr. Pepe and Dr. Scheppke for their “mad scientist dreams” making this possible. Another note: Dr. Antevy’s father-in-law was playing tennis on the court next to this event and he got his number to the family, and Dr. Antevy followed this case as well and helped get resources for the post-arrest care. Dr. Antevy states, “How can we make care equitable so that everyone can get the right resources and care?”

 

Gilding the Chain of Survival: Progress on Creating Resuscitation Centers in Florida – Kuhlman – Orlando – Healthcare is relationships and full-time trust. All emergency departments are not created equal. Resuscitation centers must be able to do emergent caths and have interventional neuro. The CMO of the hospital is the one to meet with in creating a resuscitation center and who you would share the criteria with. Multiple departments of the facility must be involved. Comment by Scheppke: Mimic what processes trauma centers do to build a resuscitation center.

 

Sudden Death Clean-up on Aisle 5: Is Systemwide Deployment of AEDs In a Large Supermarket Chain Worthwhile? – Scheppke (Florida Department of Health) and Pepe (Eagles) – Public access AEDs exist but they are hard to find. Large southern US supermarket chain trained employees and placed the AED in the same place in every store. Deployment is commonplace in public, but actual use is infrequent. Goal was to track usage across one supermarket chain. Barriers to an AED program can be fear of liability and upkeep cost including training. The supermarket in question made the decision to do the right thing. The very first use was a Publix employee. 1,335 locations (847 in Florida), all with training and AED. Data comes from Florida locations. Data from Publix internal reports is being matched with state EMS data reports. Six years of data. 342 times the AED was retrieved. 80% inside, 20% outside. 109 cases of shocks delivered. Median age was 60. Median female age was 55. 68% of shocks were men. Of those, the percentage of those they could get outcome data on that had discharge from hospital was 85%. 33 of the total AED cases proved to be of substance use origin. Publix has 1 to 2 shockable cases each month. Increases chance of survival for non-elderly customers (low median age). Casinos may indeed have similar numbers (from a comment).

 

Dengue Fever – Marty - A zoonotic disease. Multiple species can carry. Incidence has doubled each decade since 1990. Now doubling yearly. It is in the Americas. This year 7.6 million cases already. 1706 cases in US and protectorates/territories. There are four serotypes (DENV 1 through 4). The warmer the climate gets, advances mosquito population time frame and at the same time the amount of virus in each mosquito grows. Can be transmitted from mother to baby, possibly even through breast feeding. Look at mental status, hemodynamic status, hydration status and signs/symptoms of plasma leakage or bleeding. There are rashes and possibly flushing of face. Rash may blanch when touched. After bite, it can take 3 to 14 days to show symptoms. Fever is 2 to 5 days. Severe phase is after fever phase. Nausea, joint and bone pain, leukopenia. Severe abdominal pain in the critical phase along with persistent vomiting. May have liver enlargement and clinical fluid accumulation. Can have flank pain and respiratory distress. About 30% have mild bleeding in gums and urine. Severe cases can have massive GI bleeding. Diagnosing Dengue can be difficult. Rapid diagnostic test for NS1 antigen. Blood glucose and ECG should be assessed. At hospital look at WBC and Hematocrit. IV saline is appropriate. Fresh whole blood may be helpful (must watch for transfusion reactions).

 

Advancing to the Basics: Can BLS Providers Use SGAs and Epi? – Youngquist – Salt Lake City – BVM alone can be ineffective. Ineffective but due to technique air is not going where it is needed. Other than emesis in tube, Igel had less complications than BVM alone. Early Epi shows benefit. Could IM Epi be useful in arrest by EMTs prior to medic IV access and administration? Work in progress but IM Epi seems to affect data positively through discharge neuro intact.

 

It’s Less About the Lane, More About How We train: What are the Pros and Cons of Various SGAs? – Holley – Memphis – Is the tool we are using the best one? Data presented in comparison. Compared against ET tube. The King still struggles and has the weakest presentation in the data presented. SGAs have improved. Ballon devices seem to be weakest in general.

 

Seeing is Achieving: A Visionary EMS Systems Experience with VDL – Jui – Portland – Initial premise is that there is no improvement in success with video laryngoscopy. However, in ICU and infants in hospital there was greater success with video laryngoscopy. How does this translate to field patients in Oregon. System has a mandatory difficult airway course for paramedics. Twice a year mandatory training also. Two pass rule in place for ET intubation then use Igel. Overall success was 85% to 90% with direct laryngoscopy. Video laryngoscopy went to overall of 93%. EMS personnel must be able to use both DL and VL. Training is key. VL is a major paradigm change.

 

IO Where Do We Go: What Are Outcomes in Comparing Humeral vs. Tibial Sites in Cardiac Arrest – Jui – Portland – Humoral is superior to tibial in cardiac arrest. Does the route make a difference for Epi? Early Epi is important. In swine, Epi plasma levels are highest/quickest with IV over all IO routes and ET. May not be statistically significant. Humeral IO does tend to beat the tibial IO. Upper extremity IO was superior in ROSC and discharge over lower extremity IO.

 

Why the Thigh: What is the rationale for Using Femoral IV Route (Especially in Kids!) – Antevy – Florida NAEMSP – Should we use the distal femur in adults? Should we abandon IO Amiodarone and Lidocaine? Should we abandon tibial IO? Femur location is much more stable. Malpositioning is VERY common in the tibia. Pediatric Landmark is 1 to 2 CM above the patella. Get rid of pink needles in Peds. A large green 65mm needles is coming later this year also. Success is far better in using the femoral site. What about Ami and Lido (for arrest) in IO? These meds are worthless if given via IO. Much better if given IV. If you use Amiodarone IO, the rate of death is double. Get rid of tibial IO. Can we use femoral IO? Yes. Abandon Amiodarone IO? Yes. Miramontes: You must immobilize the leg if you use Femoral IO.

 

Putting Pressure on the Little Ones: Can CPAP Be Applied Properly to Children? – Lowe – Columbus – The awakening moment was a ped with asthma where the father was a medic. He recommended CPAP at the hospital, and it worked well. This posed the question of why do we not do this? In peds this uses a mask covering the entire face in hospitals. CPAP not for croup. Lower BP limit is 90 systolic (less than 70 in those under 10). Have had six cases. Five were respiratory and one drowning. They were already carrying peds masks for small adults. Has had great patient response.

 

A Festive Day Gone Far Astray: What Did I Take Away from the October 7^th Massacre Day? – Mechem – Philadelphia – Hamas launched an attack. 1,143 killed. Largest terrorist attack in Israel history. 3000 Gazans breached the security fence while many wore body cams.  Targeted towns and Israel Defense Force sites. “Kill as many people and take as many hostages as possible” was the Hamas goal found on dead fighters. 364 attendees were killed at the Supernova Music festival with 40 taken hostage. Those not killed on site were killed in their cars while trying to escape on Route 232. National EMS System is Magen David Adom. There is also a volunteer agency. Staging areas were used as there were not enough transport resources. Emergency supply of blood was released. 1612 dispatches that day. 22 locations. The attack went on for days. EMS were in body armor and being targeted. Fighting escalated as police and IDF arrived. Most care was BLS and load and go as extraction was highly dangerous. AK47s, RPG and knives used. Central command centers helped coordinate resources and supplies. One medical center received 626 casualties. Multiple, dispersed attacks. Civilians attacked with military tactics and weapons. Antevy comments: His family is from Israel. He had family members injured and killed in this attack. One was kidnapped and killed. This needs to be exposed. These things must stop. The attacks were against innocent people. Pepe: There is a text available on Mass Casualty Medicine.

 

Active Shooter: It’s Not Over Till It’s Over – Pepe – Eagles – Dallas police Ambush July 7, 2016. Perpetrator was a 25-year-old. Look for the sniper. The sniper may shoot after deploying something to make people panic and run. FFL Airport Shooting January 6, 2017. Targeted people in the baggage claim area. Marjory Stoneman Douglas Shooting on Valentine’s Day. Antevy was on the outside looking in. Half a century of ACLS “Alternative Clinical Life Style.” There is a review of mass gathering event attacks in the Mass Casualty Medicine text. Text on Mass gathering medicine? In a traditional, MCI what percentage of patients are critically injured? 5% to 10%. What is manifested emotionally by survivors and caregivers? Guilt. Use alternative triage management in a major event. Advanced Disaster Life Support can be useful. It is tough to make predictions. ICS function failed at Parkland. Protracted suicides are hard on EMS personnel with long periods of time and speculation causing fatigue. Second pass phenomenon and secondary devices are predictable. One site is a distractor for another. The IRA used the tactic of one bomb to draw everyone to the scene and then set off the bigger bomb or ambush. Las Vegas October 1, 2017, showed us ricochet can cause many severe casualties. Be prepared as any of this can happen anywhere at any time. This impacts our families as much as it impacts us. Colwell: There are immediate effects, some are weeks later, and others are years in how everyone is affected by these events. We do not like to keep talking about it, but it is a must to keep in mind. Antevy: On site internal peer resources are a must. Health and safety must have a focus on what affects us.

 

The Done-Got Poisoned Blues: What Do We Need To remember About Cyanide? – Calhoun – Cincinnati – Why is this an issue? What are we looking for? What should we do? When many things in normal life burn, they produce cyanide. Heating some substances and post-fire items can still off gas cyanide. 30% to 90% of fire related deaths have cyanide at toxic levels (depending on data source). Cyanide gas is also absorbed through the skin. You cannot fix fire related cardiac arrest without correcting cyanide poisoning. If the neuro system or cardiovascular system is compromised, cyanide poisoning should be considered to be a cause. If antidote cannot be brought to scene, transport should not be delayed. If using cyanokit understand that it is complicated, so have a reference card. Case study by Asaeda from FDNY: Fire response. Interior attack crew calls a mayday and firefighter pulls his mask off. They leave internal attack. Medics activate protocol as the firefighter is in respiratory arrest and gave antidote. Both firefighters were dived in hyperbaric chambers. Both get better. FDNY has given over 500 administrations.

 

Hazardous Judgements: What Kind of Decision Making Should We Anticipate in Haz-mat Response? – Augustine – Lee County Florida – Over time we have cycled through various threats including nuclear. It is very rare that there is an isolated exposure without injury or burns. Decon is based upon the agent in play. Bad stuff in patient eyes requires irrigation as the ultimate priority. Gasoline can be decontaminated after treatment of life-threatening injuries (must get off skin and get clothing off). Isolate the airway and cover wounds and decontaminate. Nuclear is only an issue if they have the material on them. Biological agents require varied response and decontamination. There should be designated EDs used and contaminate as few EDs as possible. Patients expect care as fast as possible. Talk then through the process. Work with industry to assure processes are closed in a timely manner.

 

Rehabbing Rehab: 2024 Ways to Manage Fire Ground Rescue – Dunne – Detroit – Modern fires burn faster than traditional materials. Most common cause of death is inhalation of noxious gases and not thermal injury. Airway burns: expect difficulty and use all your tools, time is not your friend. Carbon Monoxide: just assume it is a factor, use CO monitoring. There may be a combination of CO and CN. Cyanide: antidote should be utilized. There must be comprehensive rehab. Rehab requires protocols. Manage airway with a cuffed ET tube if there is inhalation injury.

 

Eagles Take the Stage – Eagles Electrical Storm – All medical directors on stage – Short discussion on how they learn from each other by sharing. 1) Cyanide antidotes are best given in the field as there are more barriers at the hospital. 2) One person in audience mentions they would like to do better dosing on Droperidol and implement Lucas. 3) Discussion on carrying both direct and video laryngoscopy. Consensus is not to take one tool away for another. Carry both. McGrath can do both video and DL. DL has a definitive role in vomiting patients. Miramontes states VL works great for those wearing reading glasses. Why has it taken so long for VL to be adopted? The stakeholder group weighs things before adopting. Adaptive behaviors come into play. 4) What to use for AF? Most support Diltiazem.  If Esmolol is used the patient may have to go to CCU/ICU. LA County says that Diltiazem seldom drops BP. One medical director stated that if they are unstable just shock them, if not unstable just transport rather than do the math. If cardioverted, someone along the line needs to give Lovenox to prevent a clot in the next 48 hours. 5) A New Jersey hospital is asking providers to bypass other hospitals with cardiac arrest patients so that they can do ECMO. Pepe says the number of cardiac arrest patients needing ECMO is probably less than 5%. Miramontes: ECMO takes a lot of hoops to jump through to get started upon arrival at ED. Many things are looked at closely before going on ECMO. When it fits, the results are “miraculous.” He does not support bypassing facilities just because one facility wants to do ECMO. Valenzuela: Make the hospitals get together and decide what they all can agree to on this issue. Cohen: You must have mechanical CPR if transporting to receive ECMO (it is a safety issue for crews transporting). Antevy: Predicts that there will be one shock then move to DSD, then there will probably be one area ECMO center for transport. Scheppke: We need resuscitation centers of excellence. Not everyone will need ECMO, but the receiving hospital for cardiac arrest needs to be the best possible. Gaither: It is easy to put someone on ECMO. It is hard to take them off and have the conversation with families. ICU docs need to be part of those decisions. Antevy: Used stroke ambulances as an example. He disagrees with stroke ambulances because they exist only because hospitals cannot get their act together. Hospitals need to be able to deliver needed care. States that locally there are now five cases where the medics have run the code in the ED as they are in their element, and it is collaborative. Gaither: CPR is of poor quality in many hospitals, even teaching hospitals. 6) Question from attendee from Alaska: States she is encouraged being here at the changes that can be taken home. She points to Doctor Pruett’s lecture as speaking to her on child advocacy. Another attendee states he loves the collaboration at this meeting. He points out that the Eagles group cares. There is a lot of mutual respect inside this group. Miramontes: Get the people in the people in the room and fix the problem instead of pointing fingers (he suggests coffee and tacos). Get everyone talking.

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Well, that is it from Eagles XXV. Hope these notes help you spur progress and create ideas at your EMS provider. Thank you for reading.

An additional flooding photo from Ft. Lauderdale Airport

"Welcome back my friends to the show that never ends. " - Paul Pepe

I can never pass one of these up for a conference breakfast.

Eagles XXIV: Notes from the 2023 EMS State of The Sciences Meeting

 

The Eagles (U. S. Consortium of Metropolitan EMS Medical Directors) gathering XXIV was held 15-16 June, 2023 in Hollywood, Florida. This s one of the best evidence-based, data driven conferences that I look forward to annually. The format is very short, reality and data driven lectures straight from the medical directors of major EMS agencies from all over the country (and in some cases around the world). At the time of writing this introduction, I am stuck in an airport in Charlotte, North Carolina due to a few different delays getting home. A special thank you to Dr. Peter Antevy for helping me get these notes out to all who may be interested.

 

As with each year’s notes, please remember that these are rapidly taken notes that are paraphrased to try and relay the most content. These are raw notes that have been spell c and grammar checked at a 10,000 foot level for speed in posting. Please forgive lapses in grammar and spelling and potentially content. Without further delay, here are the notes. Enjoy!

 

Eagles Day 1

 

Paul Pepe opens the conference. “Welcome back my friends to the show that never ends. So glad you could attend, come inside, come inside...”

 

Peter Antevy states Paul Pepe and Ken Scheppke have been great mentors to him. He thanks Ken for bringing him into EMS medical direction in 2015. Ken Scheppke states that this is his favorite conference of the year. It takes a decade to implement changes in evidence-based medicine. The Eagle’s group short circuits that timeframe. The Eagles are an international group of drivers in EMS medicine. This meeting brings cutting edge medicine into real time.

 

Slovis – Nashville – The Pentagon Papers: The Five Most Important Publications of the Past Year – One and Done Epi, DSD, Optimal TQ Pacer Pad Placement, Nitro in Inferior and RV AMI, Optimal BP in TBI. 1) Epi in cardiac arrest: 1690 cardiac arrest patients in Paramedic II Trial. Epi vs. Placebo. 1mg once to 1mg every 3-5 minutes compared. More Epi gets more ROSC, but survival to hospital discharge and with good neuro there is no difference. Needs a large multi-center trial. 2) Double Sequential Defibrillation: Compares DS to AP placement after three AL shocks. AP placement and DSD better that routine defib. Always switch from AL to AP or DSD after 2-3 shocks. 3) Transcutaneous Pacing:  20 patients in a crossover trial; 13 completed trial. AP pacing uses less energy and is less painful. 4) NTG to inferior MI: Five causes of acute hypotension. There are more NTG complications with all other MI's than with Inferior. Give them NTG! It is safe in all cases unless they are already borderline hypotensive or have tachycardia. 5) Optimal SBP in TBI: Mortality increases by 19% for every 10 mm/hg decrease in SBP. We need 120 to 130 SBP in TBI. Our job: Secure the ABCs, but how to secure them keeps changing.

 

Levy – Anchorage – Strike While the Energy is Still Hot: Rationale for Delivering Multiple Shocks Upfront? – What is the metabolic consequence of being in VF? Is chest compression fraction really the biggest issue? How we do our job

matters. Refractory VF is rare. Recurrent VF is common. Hearts in VF consume more oxygen. Case study presented where VF covered up by compressions. Advocates for a pause after defibrillation with short cycles of compressions between shocks if in VF (up to five times). This is done with charging prior to pulse check, shock, short pause. Vf is salvageable. Only electricity fixes VF. CPR does not. Electricity gets you out of VF but cannot keep you from going back. Amiodarone needed (presenter points out they use Lidocaine and Emolol could also be a potential approach. Goes to discussion on synchronized cardioversion. Make sure that the sync marker is on the QRS and NOT the T wave. If it is sensing T wave, switch to another lead. How much energy? Consider 200J as a starting dose for synchronized cardioversion.

 

Gilmore – St. Louis – Tempest in the T Waves: Righting the Ship During a Cardiac Electrical Storm – Cardiac Electrical Storm is a syndrome of recurrent dysrhythmia. What about beta blockade? Esmolol? 2014 study showed a better chance of survival if Esmolol was given (although after traditional ACLS exhausted). Esmolol studies are all small. What about ECMO? Maybe, maybe not good outcomes with no statistical difference so far. As they pool larger numbers, ECMO does seem to improve outcome. Do not forget to change pad placement.

 

Donofrio-Odmann – San Diego & Sanko – Los Angeles - Destined to Have Extraordinary Extracorporeal Destinations – What is a receiving facility? – Out of hospital cardiac arrest is kind of EMSs thing, right? ECMO can keep circulation going while we figure out what is causing the cardiac arrest. The system of care is time dependent. ECMO/ECPR extends that time frame. Minnesota has very good neuro intact survival over longer time periods with ECMO/ECPR. If ECMO could be done on all arrest patients meeting Utstein criteria, the save rate would dramatically increase. San Diego is implementing designated ECPR centers. Who will go there? 18 – 70 years of age with witnessed arrest and bystander CPR, and at least two shocks meet criteria. EMS uses LUCAS to maintain quality CPR to the ECPR designated facility. Looked at different system approaches on EMS LUCAS application and which department for initial cannulation (ED vs. Cath Lab). High save rates with neuro intact discharge at CPC1 noted in Los Angeles with this approach. This must be a system of care. It cannot survive in EMS or facility alone. Both must work together. Must have quality CPR and appropriate ventilation.

 

Calhoun – Cincinnati – Correcting Some Existential Deficiencies with Better Interventional Efficiencies – Why should I care about a few seconds? Where are the seconds going and what can we do about it? Pauses matter. Pauses in defibrillation have a dramatic impact on outcome as the seconds tick away. Why do we pause CPR? Movement, rhythm analysis, defib, pulse checks, compressor change, airway management, ventilation, venous access, etc. Make decisions and move on. The only thing worse than a pause is another pause. Pre-charge defibrillators. Know the first role you are going to play in the arrest AND the second role you will play. Currently doing a small trial on shocking asystole.

 

Pepe – Course Director, Lurie – Minneapolis & Bachista – St. Augustine – The Latest Heads Up on Neuroprotective CPR (Head Up CPR), the News Keeps Getting Better – What is the best head position before, during and after CPR to save the brain? Case study of a head-up CPR survivor. What is new in 2023? Faster time to elevation may lead to improved outcome (specifies controlled elevation). Pig study on immediate versus delayed head elevation showed immediate was drastically better. Sonner is better. Bundle has head up CPR, LUCAS, SGA and ITD. Elevate head in the first four minutes. Arrest ETCO2 levels improved with head up CPR over supine. This process pulls more venous blood from the brain helping to eliminate CO2. Dramatic improvement in neuro intact outcome even in non-shockable rhythms. PEA = 9.8% vs. 2.8%, Asystole = 4% vs. 1.5% (neuro intact discharge). Best position before CPR? Is it flat? Case study on an arrest victim that had head elevated in someone’s lap prior to CPR (24-year-old victim here at conference and spoke to the group. She had been in arrest for 34 minutes. CPC1, finished semester of college with a 4.0 GPA). It is possible that elevated prior to CPR could be effective as well. During CPR? Elevated. What is the best position of the body after ROSC? If MAP greater than 70, elevated.

 

Panel: Thyme, Miramontes San Antonio), Holley (Memphis), Goodloe (Tulsa & OKC), Schepkke (West Palm beach/PBCFR/FLDOH), Colwell (San Francisco), Bachista (St. Augustine), Crowe (National Science Director for ESO), Pruett (Albuquerque) & DiBernardo (Florida Department of Health) – How About Them Non-shocking Results That Have Broken the Futility Barrier? What Pearls of Wisdom Can the Neuroprotective Panel Offer for Attendees? – Goodloe starts out by saying the number of survivors has increased to the point where they are losing track of the survivors and points out that this is a nice problem to have. Goodloe shows data on approved survival. So far in 2023, 5 VF patients (5 out of 5 so far) have been discharged as CPC1 (Edmond, OK). His system is using the ResQPump rather than LUCAS with the Elegard for head up CPR. Other medical directors spoke stating that their numbers were already high but have increased even more with the head up CPR. Miramontes states that this is a BLS skill and need to be on every first responding fire apparatus. Propensity matching can simulate randomized trials. ESO did a robust analysis. Data is very promising that this clearly improves outcomes. Colwell: “Data is clearly convincing.” Some cath labs are implementing head up CPR capability for arrests in the cath lab. Florida is rolling out a huge grant to try and get the devices for the entire state.

 

Colwell – San Francisco – Cinco de Trauma: The Five Most Important Trauma Publications of the Year – 2023 study on fluid resuscitation shows no benefit and actual harm. “Bias is to go to zero fluids but cannot accomplish that so we need to be much more comfortable with lower BPs in trauma.” We must limit crystalloid use in trauma patients. Outside of TBI, we must be permissible to lower BPs in our trauma patients. May 2023 study on prehospital blood. Prehospital transfusion was associated with lower mortality (included more than 500 children). Article June of 2023 part of PATCH. No significant difference of functional outcome at six months after TXA. He likes TXA but does not love it. He believes TXA does have a role and does not produce harm. It is not a panacea, but we are still learning what the role of TXA is. Prehospital vital signs matter. Abnormal shock index predicts higher 24 hour mortality. When we see that prehospital vital signs were abnormal in the field and normal at arrival at the ER, caregivers can get complacent, and we should not in cases of trauma. This is highly specific for identifying sick trauma patients. Needle decompression study in August of 2022 showed that those who got prehospital needle decompression had a 25% less mortality than those who did not. Prehsopital needle decompression can be lifesaving. Pain management in the field study from 2023 showed pain treatment with opioids was effective and bias does impact who gets it. Ketamine and Droperidol are other options to mitigate pain.

 

Kupas – NAEMT/NAEMSP – The Gravity Epidemic Coming in at Ground Level: How Do We Handle the Escalating Number of “Calls for Falls?” – Case study on a 90-year-old fall from a wheelchair. ER bills were over $66,000 for five falls over nine days. Multiple x-rays and CT scans. No injuries found. Is this the right way to handle this? Alternate approaches: Lift Assist Teams, Shared Decision making with families and POA, Treat in place with MIH or telemedicine. One study showed a 62% decrease in transports. Showed a POC test for TBI that may someday be utilized for helping determine if transport will be needed. One MIH vehicle has a centrifuge to spin down to be able to do this test on plasma. This may be a “dud” but only time will tell. We need a better way, or the future is bleak.

 

Marino (New Orleans), Roach (Ft. Lauderdale and Broward County), Antevy (Florida NAEMSP), Winckler (San Antonio), Hood (San Antonio), & Katz (Hollywood) – Why are Agg Assaults Up, But Murder Rates are Down? What’s Blood Got to Do with It? - Discussion on Implementing Blood Programs – All great lessons are lost over history (like making glass or beer), the military already knows how to do this. What you bleed out should be put back in. When they are bleeding out, you put blood back in. IV crystalloids just allow them to bleed out Kool-aid. OB patients are underserved by EMS and blood administration. GI bleeds are in need of blood also. 25% of blood administrations in one system are for medical issues. Having EMS and Fire use more blood has driven the communities to come on board and donate more blood. Sourcing is important. White paper coming on prehospital blood administration. One physician states that it is about $5k in cost to save each patient utilizing blood. Dr. Antevy discusses giving blood to pediatrics. He states that peds getting blood at the trauma center is too late. Peds should get 10cc blood per KG. What about TXA? TXA is given before or simultaneously with blood. Advocates for use of IO in the distal femur for TXA administration. TXA IV or IM? Just get it into the circulation.

 

Jui (Portland) & Goodloe (Tulsa & OKC) – Sharing Some Sanguine Situational Sensitivities on Starting Up a Prehospital Blood Program Today – (Jui) Starting a blood program is about relationships. You must have relationships with blood banks, surgeons, data and all stakeholders. Trying to save lives in the first 30 minutes (EMS contact). The quicker you give blood, the more you decrease mortality. Criteria is shock index greater than 1, SBP of less than 90, and other sub criteria. Transport time should be longer than 15 minutes. Chief officers carry blood to the scene. Needs a cooler, temperature indicator and a blood warmer. The blood warmer is the primary cost issue. Can use a blood refrigerator but they cost $5.8k. OB physicians fully on board. Peds consensus was easier than expected as well. (Goodloe) OKC has been up about six months on whole blood. Who are the top stakeholders? EMS, Governance, Trauma Surgeons & Blood banks. There are a lot of players. What is most common roadblock? It is not money. It is aligning the stakeholders. Project took 2.5 years longer than expected. Three units deployed with blood. Pay attention to ground level falls. OKC protocol at www.okctulomd.com

 

Pepe (Course Director) & Winckler (San Antonio) – A PSA for TXA and Calibrating the Calcium with Calculations – for Both Adults and Kids – What are the risks and benefits? 2gms up front of TXA. Out of three groups of patients, the group that got 2gms up front showed decreased mortality (15%) in TB. Mortality rates are better if TXA is given early. A study currently that shows no difference is using 1gm + 1gm later. Advocating for 2gms up front. Secondary discussion of whole blood. The time to bleed out is 17 minutes not 60. Speaker gave case study of a triple limb injury from an RPG strike where soldiers gave blood during the firefight to maintain injured soldier. Survived. Stop using crystalloids in trauma. Advocates for ROTEM/TEG in emergency rooms. Calcium should be given with blood along with TXA. Do not wait till arrival at hospital with blood running to give calcium. Doing all of this prehospital saves 15 minutes in the trauma center.

 

Raucous On-Dias Assembly of Rapscallion-Like Raptors (Metro Medical Directors Take the Stage) – Over forty medical directors on stage. Medical directors on stage cover a population of 107 million minimum. 1) Should we do compressions in post-traumatic circulatory arrest? As a group, the answer is no (more to follow later). Have good criteria as to when this would apply. Clearly define when not to do it. 2) Group advocates for initial dose of 12mg of Adenosine instead of 6mg.

 

Quote heard - “We build systems today because we all call.”

 

Lawner (Baltimore), Calhoun (Cincinatti) & Gautreau (San Jose) – Pulseless and Moribund in Maryland – What Prehospital Trauma Tricks Are Up Our Sleeves Today – Needle Decompression: Is it truly a lifesaving intervention? The challenges are knowing that it is needed and getting it in the right place. Finger thoracotomies are more accurate on placement and can also allow blood to be released. Circulatory Arrest in Trauma: The heart does not need Epi or compressions. Do we need to stop load and go type actions? If asystole prior to arrival, outcome is negligible, but if witnessed we should load and go. Tourniquets: Should they always be high and tight? Not with an isolated injury like a wrist cut at home. Do chest seals prevent tension pneumothorax? If bagging a patient, a chest seal serves no purpose. The patient must be breathing normally for a chest seal to do any good. Should needle thoracostomy only be done in the AAL? There is no good evidence to pick one site

over the other. One study shows midclavicular may be more successful. Use site that makes the most sense for that patient and environment. No solid evidence either way. Cricothyroidotomy: No needle crics, especially in adults. “Needles suck.” The kit used by the speaker’s agency contains a number 11 scalpel, a bougie and a 6.0mm ET tube. Make cut long, neat and fast. Can you do harm? Yes, but if you cut through the cartilage, it can be fixed. Get air into the air containing structure “and that is a win.” Hard to go far enough to hit the carotids.

Weston (Milwaukee), Marino (New Orleans), Levy (Baltimore) & Johannigman - Today’s Great Debate – Should you do compressions in traumatic circulatory arrest? One system does not do compressions, but New Orleans states they do. Compressions must have ventilations. If they are not in PEA, you might as well stop (meaning asystole). Must be sure this is not a medical arrest that ended up appearing like trauma (such as a cardiac arrest that then wrecks their vehicle. Another system does compressions, but it is last priority. What about Epi? There is no ATLS scenario that use Epi. In trauma, PEA is severe hypotension until proven otherwise.

 

Johannigman (Minneapolis) - Ketamine in PTSD -  TCCC looked at Ketamine and advocates for its use in trauma. Recommends starting at 0.5 to 1.5mg/kg for pain. If you give 1mg of Versed prior to Ketamine, dysphoria does not occur. Still responsive at 1mg/kg. Ketamine in PTSD: If Ketamine used in the field, incidence of PTSD is 1/3 of those who did not. Being used to treat PTSD and depression as well. Speaker feels this is significant.

 

Grossman (New Hampshire) & Wilson (UK) – When They Talk and Live – What Do

You Do If Faced with an Epidural and Your Roadways are Cut-off or Epi-Rural – Epidural Hematoma Evacuation with EZ-IO (Grossman) – Presents case with an Epi-dural hematoma in a young female patient. Patient is intubated in the ER. Helicopters were not flying to take to a trauma center due to snow. Patient was herniating. Trauma surgeon looked at CT and patient via iPad. ER physician says he will use an EZ-IO for evacuation. Surgeon directs where to place the EZ-IO. Worthy of note that the surgeon did not know what an EZ-IO was. Uses EZ-IO and nothing comes out. He then aspirated and blood came out. Evacuates 30ml of blood. Return to CT. Shows CT with IO in place. Patient's mother present today and explains what it was like for her to give consent. You have to gain trust to be able to do in the moment procedures. Patient is present also and comes on stage to show full recovery from the epi-dural and the improvised procedure using EZ-IO. Even though risky, the physician did the right thing. (Wilson) – Pre-hospital neurosurgery. He has also done EZ-IO taps. Shows video of a true burr hole being performed. Many historical references to burr holes over centuries.

 

Wilson (UK) – TBI, Hypotension and Outcomes - Discussing Hypotension in TBI. Hypotension in TBI is generally considered to be associated with poor outcomes even if it is a single episode during the course of care. “If you are not dead when we arrive, you should not die.” Our job is to reduce secondary brain injury. We must prevent hypotension and hypoxia. Covers how ICP is created and maintained.

 

Banerjee (Polk County) – Reclaim the Brain: TBI in Pediatrics – Kids tend to be sicker with TBI than adults. Two neuroprotective medicines can be given to help protect from TBI (Keppra and Hypertonic Saline). Keppra protects against seizures and hypertonic saline helps decrease ICP. In DSI, Ketamine is preferred induction agent to help limit seizures, and Lidocaine to protect from ICP spikes. Avoid hypotension.

 

Scheppke (West Palm Beach) – Calling It Quits to the Fits by Recruiting Receptive Receptors – Could We Terminate Status Epilepticus with Ketamine? – Discussed focal and generalized seizures. Seizure mimics (cardiac arrest and syncope), and eclampsia all have specific needs. Lifetime risk of status epilepticus in seizure patients is 15% with a 33% mortality. Most treatments are GABA medications. What about Ketamine? Blocking an on switch is the same as an off switch. Ketamine blocks the on switch. Resolution of status epilepticus was 95.5% with Ketamine (21/22 cases). Second study came in at 92% with larger patient population. This is second line therapy after benzodiazepines. Dose is 1mg/kg IV/IO in adults or 3mg/kg IM in adults and children.

 

Dunne (Detroit), Winckler (San Antonio) & Pruett (Albuquerque) – Strokes of Genius for CVAs: Latest Results from the Stroke Headband Study, Use of VAN Score and Follow Up Programs – (Dunne) EPISODE Trial Update Results. Accelerometers placed on a headband. They can sense blood flow in the brain. It ignores noise and vehicle movement. Device is placed in the field. Data was

blinded until after arrival. 177 patients and it is the largest prehospital device trial ever performed. Compared to stroke scales. Device was 1.8 times more sensitive than the LAMS score. Device output shows chances of type of stroke based upon its readings. Starting phase 2 of the study. (Winckler) How can we regain brain lane? 87% of strokes are ischemic and 13% hemorrhagic. Screen with BFAST and assess with VAN. Covered stroke alert criteria. System requires Primary stroke center bypass to go to Comprehensive stroke center based upon criteria for LVO. Platinum 10 minute on-scene time in stroke. Do IV and ECG en route. (Pruett) Stroke has a very high morbidity and mortality. Stroke follow ups being performed at home by local prehospital personnel. Follow up scales used. Fire and fall assessments of the home provided. They assess medication adherence. They assure follow up care is occurring such as physical therapy. Assist devices like ramps are installed. 113 enrolled and 33 have graduated. 50% reduction in return visits and a 37% decrease in mortality. 75% needed home modification of some type. There is also a stroke survivor support group. Slide deck showed therapy dog usage as well.

 

Asaeda (NYC), Mechem (Philadelphia) & Margolis (US Secret Service) – What Happens When Our Mass Gatherings Get Dignified? What is the EMS Impact of VIPs, Celebrities and Dignitaries on Mass Gathering Medicine – and what are Some Recommendations? – (Mechem) Challenges: Impact of security on event, need for privacy and discretion, background checks, interaction with their own teams and impact on the community. Covered examples of many mass gatherings in Philadelphia. Focused on 2015 Papal visit as an example. Expected a crown of 1 to 3 million in the crowd. Not enough medical staff for on scene and same with ambulances (when combined with needs of the city). Security perimeter enclosed city center and hospitals. When Pope on scene all movement was required to stop. Mass casualty plans made. Large numbers of law enforcement used, and everyone had to go through security checkpoints. Over 120 EMS transports from within the box with over 400 responses. (Asaeda) NYC experiences are similar. Plans must be adaptable because nothing ever goes by the book. NYC has a Dignitary Protection Unit (DPU). Special training with the US Secret Service. Goal is to be out of site and come into play when needed. Hospital selection can be challenging in NYC. It can be difficult to get to routine patients due to security restrictions. United Nations Grounds are extraterritorial. Some dignitaries within the UN cannot cross paths or be in the same room. (Margolis) What designates a national security event? The governor of the state has to apply to the federal government for the event designation. The decision is made by the Secretary of DHS. US Secret Service, the FBI and FEMA have to work together on planning. There can be multiple planning subcommittees. The one that affects EMS is the Health and Medical subcommittee. It is a NO FAIL mission. On scene medical direction is important. Outside agency use is common. There is a multi-agency communications center that is utilized so all the players have a seat at the table. Situational awareness is a must.

 

Mechem (Philadelphia) – The Escalating Challenge of Street-racing and Social Media-Driven Youthful Gatherings – Recent street racing on June 4^th. Hundreds of cars and spectators moving to various sites within the city. T 0330 in the morning troopers responded to I-95 being blocked by the racers with shots fired. Ended up with an officer involved shooting killing a driver (car tried to ram officers). Multiple events and groups doing the racing and they have a big internet presence. Events have resulted in multiple crashes and deaths. Coordinated through social media. There is an anti-drifting bill beng considered. Law enforcement monitoring social media. Events are spontaneous, and unpredictable and mobile. EMS units can become trapped. Agencies need a civil disturbance protocol. There must be a safety-first consideration.

 

Dunne (Detroit) – Special Needs in Preparing for, and Medically Managing, a Major Motorsports Event – Detroit Grand Prix. Footprint was urban for the racecourse. Nothing like they had ever done before. Used Indy car resources. Personnel in appropriate racing PPE. Water rescue resources were anticipated due to one turn by the river. They had one spectator cardiac arrests. Six transports. 140 minor care incidents (some heat related).

 

Calhoun (Cincinnati) – Black Flags and Lightning Threats at Marathons and Other Events – Flying Pig Marathon: Scale of event and temperature make a big difference. Hard to stop a foot race based on weather. Ended up having a 30-minute shelter in place (most people ignore it). Medical staff had to obey shelter in place, but spectators and racers ignored it. Had a weather team in the command center. Decide what medical staff will do if there is a shelter in place or black flag. Where do you shelter and know the locations. There is no single answer. There are no uniform decisions and the race community is not well organized as a group.

 

Mackey & Saari (Sacramento) – Acing the A.C.E.: A Suggested Response Approach to Intentional MCI Events – What is the role of triage tags? How are you going to move victims? Who goes to the hospital first? Is it a slow or fast MCI? Is it simple or complex? Active shooter events are fast. Triage tags are unlikely to be helpful. Rapid evacuation should consider the Foxtrot Sked. Very little stabilization before movement. Tourniquet and chest wound management are two things that may require treatment before moving. They are victims and they become patients at casualty collection points. Abdomen wounds go out first, then chest (we can do more for chest on scene than abdomen), then extremities. Incident occurred: 19 victims over 5 block area. All patients off scene in 34 minutes. 100% survival of those not dead on scene at start of incident. Simplicity is the key to brilliance.

 

Dyer (Boston), Levy (Stop the Bleed), Mackey & Saari (Sacramento), Antevy and others – Tag – You’re Not It! Sorting Through and Challenging the Numerous Colors and Acronyms We Use in Triage – General discussion on differences between fast moving and slow-moving MCIs. Do what will save the most lives in the long run. If getting people out saves more lives then concentrate there. When there is an MCI, experience teaches that you either have those killed outright or walking wounded but not much in between. Rules change significantly when there are a lot of critically wounded who are not dead on scene. There is a lot of emotion connected to the continued use of triage tags, but it is usually by those who have not used them. At the Parkland shooting it was decided early on not to use triage tags and 17 lives were saved. They loaded vehicles with patients and transported. Mutual aid is essential. Antevy uses RAMP Triage model. Slovis discusses Nashville shooting. You do not believe it will happen to you until it happens to you. Slovis points out multi-agency drills are important and essential. Triage tags “aren’t worth dick.” You do not need pulse, respirations, or GCS to triage patients. Triage must change as the processes and tags absolutely do not work. Israel is using anatomic triage. If we do it right, we can get to one standard that is simple on a national level.

 

Jui (Portland) – Stairways and Fairways to Better Airways – Part I – Metrics and Training Requirements – It is about airway management and NOT the device. Type of airway usually does not make a difference in outcome. Some things are game changers though like the Ducanto Catheter. Covered statistics on airway control in Portland. I-Gel is a very good airway. VL needs to be the standard for intubation.

 

Lawner (Baltimore) - Stairways and Fairways to Better Airways – Part II – Can Airway Choice Be Decided By the Patient? – Where is the patient? Crew skillset? Sedation and paralysis give you best chance of success. Risk factors do not change for airway compromise and are very common. Integrating checklists with thinking about the patient can be challenging. No survival benefit with intubation over SGA or BVM. If continuing to intubate, transition to VL. Work to avoid hypoxia and hypotension. Intubating during critical care transports can be necessary.

 

Holley (Memphis) - Stairways and Fairways to Better Airways – Part III – What is

the Latest Update on SGA Comparison? – SGAs with ITD. Variable negative chest pressure. Balloon airways like Combitube and King did not create deep vacuum needed. King and Combitube are problematic. SGAs are closer to intubation (i-Gel, etc). C-collars impact carotid flow in cardiac arrest if too tight (ICP goes up and brain perfusion goes down).

Gilmore (St. Louis) – Revisiting the Visual Arts: What’s the DL on the VL vs. the DL? – With intubation, why do we need to get it right the first time? First pass and overall success both increased with VL in Texas, but the Pennsylvania study showed the exact opposite. Wisconsin then showed first pass going up. Australia showed it going up as well with VL. Meta-analysis favors DL over VL. As patient numbers studied go up, it is leaning toward VL. Only one study compares devices for VL. That study was stopped.

 

Levy (Anchorage) – The Closing Arguments: Are First Pass Successes Truly the First priority? – “I’ll pass on ALWAYS First Pass.” The journey and the destination are different. Even though first pass success may be preferred it may not be best for the patient if it causes hypoxia. Gives a case study on a two attempt intubation where the paramedic focused on preventing hypoxia instead of first pass success with much better oxygenation. Shows another one where concentration was on success rather than preventing hypoxia and saturation crashed. It is better to abort an attempt to prevent hypoxia (by ventilating) without repercussion than forcing first pass success compliance. Excellent points!

 

Day one adjourns...

 

Eagles Day 2...

 

Augustine (Eagles Librarian) - Eagle’s Discussions from the Last Year – We need to fill the gaps left by COVID. There is an ongoing responsibility to prepare individuals for careers in healthcare. How can we recruit and retain providers? Adding BLS units has been a positive to increasing the attraction of ALS to providers. Using Explorers to recruit youth into EMS careers. Supply chain issues across many drugs are common. 106 medications are currently unavailable. Extending dates on Duodote and similar agents. Some meds in chem packs are twenty years old with extended dates. More community paramedicine is being used. EMS QI staffs are growing and getting new tools with technology. Defibrillation of Asystole is a current topic. Ambulance delays or “no response” is common in almost all jurisdictions.  Civil protest with people supergluing themselves to a site is common and use of de-gluing agents. Wall time at ERs is becoming common again. ET3 options are becoming more and more attractive. Discussion on audio recording cardiac arrest scenes. Sharing best practices is a great process.

 

Miramontes (San Antonio) & Weston (Milwaukee) – It Ain’t Over Till It’s Over: Why Does EMS Always Need to Consider the Potentially Lethal Post-Partum State in the DDX? – (Miramontes) Why are pregnant and post-partum women dying? US has horrible numbers on this and rising when the rest of the world is decreasing. Preeclampsia is part of the reason. Greater than 140/90, then 160/110 becomes time sensitive. Eclampsia and preeclampsia can occur up to six weeks after delivery. One study showed that 32% of women treated by EMS were hypertensive. It is the most common preventable cause of mortality and morbidity in pregnant women.

 

Moore (UK) – O.B. Wand Kenobi’s: What is the rationale and Value of Midwifery Consultants for EMS in the UK? – OB Led. Some stand alone Midwife led units. The have seen an increase in out of hospital births. Poor outcomes and poor communications along with failure to learn from incidents with a high occurrence in minority groups. EMS has employed a Midwife to do simulation training with EMS crews. Trained in high-risk deliveries and presentations. Trained in assessment of preterm births. They do not attempt resuscitation if under 22 weeks. Sensitive to handling of remains in preterm births (wraps and respect). Case studies shown shoulder dystocia and massive post-partum hemorrhage. Training is regular. Maternal calls are considered one of the most stressful calls on EMS.

 

Mechem (Philadelphia) – What is an AR4? - Can the pregnancy related deaths be prevented. AR4 (Alterative Response Unit 4) is a collaboration between the fire department, heath department and a health system. It will be used for referral for prenatal and post-partum care. It will help patients navigate health insurance for care. It will focus on preventable causes of pregnancy related deaths.

 

Miramontes (San Antonio) – Preeclampsia – His mantra is “be aggressive.” They start preeclampsia treatment at 140 SBP. They use Labetalol, Hydralazine and Nifedipine. They utilize Magnesium for the seizures and to reduce recurrent seizures. They also use Magnesium for seizure prophylaxis. It will not hurt anyone. Be aware of high-risk groups. A BP of >140 systolic is not normal in pregnancy. Just do it. Manage the BP and give the Magnesium.

Donofrio-Odmann (San Diego) – Passing Along a Potpourri of Precious Pediatric Pearls from the PECARN: Benzo Doses, Routes, Spinal Clearance, etc – Pediatric Emergency Care Applied Research Network. There are centers for pediatric emergency research. The group answers major questions dealing with the emergency management of pediatrics.  Key EMS takeaways? Pain control by EMS with opioid tends to direct continued ER care and continued pain management. <50% of kids with pain receive opioid pain relief. Sickle Cell pain treated with IN Fentanyl is less likely to be admitted. Do not wait to give Benzos for seizures in kids till you have a blood sugar. Give the Benzo. You do not need an IV in a seizing kid. Give midazolam IN or IM. PediDOSE study still shows med errors. C-spine and c-collars: C-spine injury is very rare in kids. Huge forces to the chest or head are necessary for c-spine along with axial loading and other factors. Does TXA work well in kids? We do not know. Trial on pediatric TXA (TiC-ToC). More to come.

 

Antevy (Florida NAEMSP) – Premier Practices and Practicalities for Pragmatic Prehospital Professionals: Abx, Fem IO, Defib Vectors, Blood, etc – Five protocol changes you are too afraid to make – 1) RSI vs. DSI. Must change to DSI. Sequence must be slow. Pre-oxygenation is very important.  2) Refractory Status Epilepticus. Use Ketamine. Termination rate is high. 3) Whole Blood. Do it. He states $1000 per patient. Survival rate is 90%. Make it happen. 4) DSD for refractory VF. Doubles neuro intact survival in VF cases. 5) Femoral IO in kids. Again, just do it. No excuses. Miss rate is far less than the tibia.

 

Antevy (Florida NAEMSP) – Practice Changing Studies That You Should Ignore and Throw Out the Door – “The Landmark Papers.” 1) Ventilations in pediatric patients. Should we rapidly ventilate peds cardiac arrest? Field of patients in study does not apply. Only 47 kids in the study. 74% were already bradycardic. DO NOT rapidly ventilate kids. Burn the study. Do not follow AHA guidelines on this. 1 breath every 10 seconds should be utilized. 2) Fluids in sepsis. “Reasonable” to give fluids in shock. Only 3% of kids in shock get fluids from EMS. Study was on kids with malaria. Hemoglobin was already low. Fluid bolus group had higher mortality due to malaria. Give the fluids. 3) Whole blood. Study says no. Blood was given late in the study. Mortality is time dependent. Give the blood. 4) Antibiotics in EMS: Study says no. Study had weird presumptions to begin with. Only 3% in study were in septic shock. Give the antibiotics. 5) Epi in shockable rhythms: JAMA study. Dog study. Sequencing was delayed in study. Unfortunately, there is a ton of studies that show Epi in VF is harmful. Epi does not help in VF and is harmful. NOTE: I had a sidebar conversation with Dr. Antevy at break as I was unclear on point 2, fluid in sepsis. He states absolutely fluid at 20ml/kg boluses. Studies are flawed as they were performed on already fluid overloaded children already in ICUs. Children who had already been fluid resuscitated with good outcomes were excluded.

 

Moore (UK) – Instrumental Instrumentation: Can Early Insertion of Arterial Lines by EMS Significantly Influence Subsequent Management? – Is invasive BP a potential benefit to a subset of patients? Medical or traumatic brain injury? Cord Injury? ROSC? Patients who are being ventilated interfacility? 84% success rate on arterial line insertion. 65% of patients were brain injury. 80% first attempt success. 20 minutes median on scene till start of arterial line. Two patients with complications. Currently using radial, looking at going to femoral lines.

 

Kupas (NAEMT/NAEMSP) & Banerjee (Polk County) – Drugs for Bugs Among the Pharmaceuticals We Lug: What is the Rationale and Benefit and downside of EMS Antibiotics? – Are antibiotics in your scope of practice? Open fractures are a time-sensitive disease. There are no trauma surgeons who believe that antibiotics are not needed. It is very important to cover the wound. Covering the open fracture has a significant reduction in infection. EAST Guidelines for trauma show this as a time sensitive illness. EAST suggests antibiotics as soon as possible after the open fracture. IV antibiotics need to be started within 60 minutes of hospital arrival (EMS was ignored). Antibiotics in open fractures should be viewed as Aspirin is viewed with chest pain. Cefazolin for Type I and Type II fractures. Type III still uses Cefazolin, but hospital can add additional coverage. Cefazolin is cheap and effective. 1gm under 50 kg, 2gm over 50kg. So what about sepsis? Sepsis mortality is higher than those dying of most cancers. Time matters. Every hour delay in antibiotic causes a 7.6% increase in mortality. Speaker uses Rocephin 1gm IV. Give early as possible especially in context of hypotension. Most cultures are false positives. Can we give antibiotics before cultures? Yes. No difference in outcomes, and sensitive for cultures an hour after antibiotics. 50% decrease in mortality in Polk County with Antibiotics in Polk County. ETCO2 is lower in shock but not a lot of data on actual limits.

 

Levy (Anchorage) – Keeping Pace During Emergency Department Turnovers: Why Does EMS Need to Improve ED Transitions with Pacemakers? – Trying to keep the ER from killing a patient we have resuscitated. The transition at the ER is very important. Discusses Electrical and Mechanical capture as review. Discusses alternative pad placement. Use sedation. The handoff is a danger zone. There cannot be a minute or two in the transition off patient. This can and does kill patients. Place patches of ER monitor and be prepared to increase the ER monitor Ma while decreasing EMS pacer Ma. Very rapid switch. Practice this with ER.

 

Sanko (Los Angeles) – Remarkable Remarks: What Might the Bystanders and Cardiac Arrest Survivors Be Telling You But Only If You Ask? –  “Mi CASA es tu CASA.” CASA = Cardiac Arrest Survivor Alliance. A new community for all affected by cardiac arrest. Created a virtual, multiple city support mechanism. It is a free service. Protected information. The Sudden Cardiac Arrest Foundation is a 501c3. CASA is a program of this foundation. There are subgroup forums for young survivors and family members. Case study of a cardiac arrest after a marathon. Resuscitated on scene. Neuro intact survival. Patient now has spoken to caregivers and is part of this online group and sharing. Cognitive changes can be discussed such as this person not remembering the half marathon that he took part in before the arrest. Patients can discuss what to expect in the future with those who have already experienced it. It helps other patients understand and heal. They can visit those who helped save them including dispatch centers. They can promote CPR and community impact. They have an annual survivor meeting annually. They use film schools to chronicle survivor and family stories. Refer your survivors to CASA.

 

Mackey (Sacramento) & Scheppke (West Palm Beach) – Hitting the Wall with Wall Time: Improving the Metrics and Measurements of Patient Off-loading for EMS and the Public at Large – (Mackey) How do you measure the wall? How much does the wall cost? EMS measures wall time accurately due to transfer of care. APOT Time Trial. Time of Arrival starts clock and transfer of care stops it. EMS time measurement is more accurate than hospital measurement of wall time. EMS calculated cost of wall time. FEMA rate for EMS strike teams is $210/hr. Used that as a metric. Speakers’ system had a wall cost of $110k a month. (Scheppke) They shamed their system by putting wall times for all hospitals out. It worked. Add another nuclear option: Diverting to hospitals with better wall time. Fixed their issues.

 

Weston (Milwaukee) – Dashing Through the Know: What Are the Data Dashboards that EMS Agencies Should Consider, including Key Demographics? – Create dashboards with usable data. Make dashboards that people can understand and are easily explained. Cardiac arrest heat maps. Mutual aid usage. Tracking diversions and making public. Tracking diversions keeps hospitals accountable. Know your audience. There are known knowns, known unknowns, and unknown unknowns (data is key to knowing).

 

 

Lowe (Columbus) – Engineering a Systematic System Size-up Systematically: CQI From an Engineers Point of View – We say start without blame... but how does one approach from a system perspective? Complex systems are intrinsically hazardous systems. Catastrophe is always just around the corner. Errors are gifts. Embrace near misses and learn from them to reduce actual failure. Human error is NOT synonymous with human fault. Collect data all the time. Collect everything, every time. Re-read the protocol, the textbook and listen to tapes of the call. The call and traffic will give you a better picture of what was going on in the head of those involved. Responsibility to the patient, the medic, and the organization. Start with a case where you think you know the answer and start from there and maximize crew buy-in. Use for medication errors, narcotic management, and other issues.

 

Marty (Miami) – This One Will Not Be So Anti-Climactic: How Climate Change and Related Factors Will Significantly Impact EMS and Society – Changing of the climate is a normal process. Changes in climate can cause various changes in infectious diseases, increased trauma from severe weather, affects upon farming and food availability. Pathogens can become amplified. Water availability can be variable. Range of hot zones can change. All of this can cause human stress as well. Wars can come based upon resources. Respiratory illnesses may be triggered. Mold can be increased. Organisms that thrive in warmer environments will become more prevalent. Strength of storms will become stronger causing more human and infrastructure impact. The five categories for hurricanes may need to be revised. Since 1980, there have been six hurricanes that exceed category five criteria. Droughts and water quality have direct human and food supply impact. When the climate varies, vectors come closer to humans. Pathogens can become much stronger. 58% of pathogens have a stronger prevalence in heat while only 8% have a decrease. Mosquito life cycle is shorter in warmer environments meaning more mosquitos. Humans have a propensity to ignore the obvious and generate bias. Climate change, even if cyclic, affects what we do in EMS.

 

Jui (Portland) – The Whether (or not) Forecast: What Do the Infectious Disease Experts Predict for Us in 2023 and 2024? – This is like forecasting the weather. Wants to highlight where things may be going. COVID is on the increase again. More variants are coming. China will again be the epicenter. Africa will be another center as well. COVID variants are very frequent. Higher mortality may decrease virulence. The US is doing very well due to herd immunity and/or vaccinations. 96.4% of blood doners are showing positive for COVID antibodies in the US. COVID is approaching the virulence of Measles. Do not throw out your PPE yet. Updated vaccination recommendations have come out. Efficacy of COVID bivalent Boosters offered 30-50% more protection. Deltacron variant is the one everyone is worried about. Forecasting microspikes in COVID in the US. Transition to discussion on human Metapneumovirus. Keep an eye on this. Monkey Pox is still here, and you can take it home to your family. Predicting an outbreak. Keep an eye on Ebola and Marberg (hemorrhagic fevers) as they will be active the rest of our lives. Worried about bird flu. Vectoring can cause a repeat of the 1918 pandemic.

 

Katz (Hollywood) – Death and Dysaurea: Why Does EMS Need To Know About a Fungus Among Us Like Candida Auris? – It is a serious problem in hospitals. This has been in the background for a while but overshadowed by COVID. Humans are already resistant to existing treatments. 65-70% mortality. Easily transmitted to caregivers. Antifungal decon (Oxivir) or bleach must be used for cleaning. See map of current spread. The infection is the tip of the iceberg, there are more asymptomatic infections by far. Hollywood, Florida 2020-2023, 75% of the C. Auris infections were brought in by EMS. LTAC, ALF and SNF facilities are hotbeds. Use PPE and decon. Trach and dialysis patients are common carriers of C. Auris. Surface wipe down is important in vehicle decon.

 

Sanko (Los Angeles), Abramson (Long Beach) & Winckler (San Antonio) – Homing In On PEH Demographic – Escalating problem of Homelessness – (Sanko) 63% of LAFD transports are homeless individuals. Affects wall time. A state of emergency was declared by the mayor and freed up some funding. What does radically patient focused care look like? Generating ideas. Engagement training on trauma informed care, patient led care, and de-escalation. Hand offs to patient advocates on scene explored. Dispatch asks shirt color of the patient to help identify patient on scene. Alternatives to transport such as sobering units and other services. Some MIH options include advanced practice providers and therapeutic vans. Skid Row in LA is 40% of opioid responses. Identifying individuals who are at a priority for housing. Multiple agencies and organizations involved. (Winckler) Texas also has a homelessness escalation as well. The term “homeless” makes finding a home a priority. Mental Health system assessment has been money well spent. Medical paths of care are solid. Mental paths of care are wobbly. Funding of mental health is critical and an assessment helps get the funding. Collaborations build systems and gain funding. Haven for Hope Shelter houses up to 4,000 families a night. 1,500 911 calls a year to that shelter. They put a medic in the shelter to care for the patients. A hotel was used for COVID homeless patients, and a paramedic was placed there also. Medic on site gives out BP medications and minor injury care. Call volume to the shelter is now about 700 a year.

 

Kang (ACEP) & Cabanas (NAEMSP) – What Are the Prevailing Priorities, Precedents, Premonitions, and Predictions Pre-Occupying the Prescient Presidents of Our Premier Practice Professions? – (Cabanas) NAEMSP Update. NAEMSP fosters excellence in patient care. NAESMP Advocacy is important. Recently gathered in Washington, DC to advocate for EMS legislation. These actions were crucial in the 2017 controlled substances legislation. After legislation passes, rule writing takes years. 6 years later the rules are still not complete on the medications act. PAHPA Reauthorization is due by the end of September this year. This is crucial to pandemic preparedness. Currently working on drug supply chain issues. There are ongoing efforts to legislate the practice of medicine (such as patient restraint). We cannot remain silent. This is bad for patient care. Advocacy matters as there is competition for funding and resources. Voicing your opinions to government is important. (Kang) What is ACEP doing for you? What is the role of ACEP to EMS? Leading priorities. The last three years have been surreal, and everything is unstable. Focus is on collaboration and advocacy.  They are also focused on advocacy of the emergency specialty. Boarding in Er is a problem and at a critical level. Workforce issues are widespread. Mental health of caregivers with a focus on a happy career. Physician burnout is at an all time high. We need full insurance of ground ambulance as a focus.

 

Staging a Coup’ Dilettante: An On-Dias Assembly of Rapid Answering Raptors and Heavy Clappers – The Metro Med Directors and Friends Rise Up on the Risers – Eagles take the stage. About 35 physician medical directors on stage. NYC FDNY does 4,200 EMS responses a day (population of 8.5 million). No questions from the audience (that is a first in my experience). Short discussion on differences between urban and rural EMS. Problems are the same, only the scale changes (Jarvis). Dr. Antevy recognized this note taking effort and Dr. Peter Stevenson’s financial commitment to getting Evansville area paramedics to this conference.

 

Asaeda (NYC) – Assaulting Batteries: How Lithium Batteries Have Flared Up on E Bikes Creating Bad Hallway Fires and Trapped Persons in NYC – Lithium battery fires have escalated in number to the point that there is one every 40 hours. Seen with electric bikes, scooters, hover boards, and many other devices. Bikes stored in hallways of apartment complexes are catching on fire and starting building fires trapping individual. The battery overheats and the battery catches on fire due to short circuiting. Rough handling can also cause this. Small fires can be put out with water, but larger fires need foam or dry chemical. If not cooled down enough it may reignite. Electric vehicle fires can take a large amount of water to put out. Non-UL listed batteries have higher short-circuiting potential. Charging beyond 100% can cause overheating. The cheap extension cord you buy that says UL Listed probably is not and forged. Same with Lithium batteries. Lithium batteries may produce toxic gasses as well (potentially hydrofluoric gasses).

 

Mackey (Sacramento) – A Cool Approach: Using 20-CRW to Assuage Burns – Cutting edge burn care. Apply 20 minutes cool running water to the burn within 3 hours of injury. Study showed 63% odds reduction of full thickness burns. 46% odds of skin grafting. 36% odds reduction of any surgeries. Wound healing is 1 to 3 days sooner. No difference in mortality. Drastic reduction in burn center admissions. Speaker visited burn center in Australia, and it was empty. The treatment there is common knowledge. What about Hypothermia? 80% of burn patients in the US are less than 10% TBSA. Keep the patient warm but cool the burn. Great lecture.

 

Dunne (Detroit) – Rehabbing Rehab: 2023 Ways to Manage Fire Ground Rescue – Fires are faster and produce more smoke than in the past due to use of synthetic materials. Most common cause of fire deaths is smoke inhalation not thermal burns. Hazards? Focused on airway burns and inhalation of gasses. Plan for the hazards. Think about surgical airway early. Have everything ready to do what you need to do. Points out Bougie use in surgical airway. CO monitoring helps to quantify exposure. Hydrogen Cyanide and Carbon Monoxide both prevent cells from working. Both can kill you very quickly. Cyanide antidote should be at the front line. Intubate early. Know your local fire demographics.

Holman (Washington, DC) (delivered by Marino) - Part One: Surveying the Survey: What Did a Longitudinal Behavioral Health Study of EMS Personnel Reveal? – Does this clarify the issue? Screened for Depression, Anxiety and PTSD. What was found? Increase in all three with DC fire/EMS. Significant amounts of all three. All three much higher than general population on standardized assessment tools. Overall healthcare workers showed high as well, but EMS was higher. The damage of the pandemic is not over. These findings are much worse than what was expected.

 

Marino (New Orleans) – Part Two: Assessing the Mental Well-Being of EMS Crews: How the DC Survey Applies to New Orleans “3^rd Service – Depression is common in New Orleans EMS. Looked at literature. EMS personnel are at higher risk. Perceived threat to life makes it worse. Perceived lack of support drives depression as well. Actions have been taken on the support. Jobs are very stressful. She was talking with everyone as deputy medical director but when she moved to director, her people stopped talking to her. They hired a full-time therapist who now talks with the crews and takes their calls. Therapist has experience with EMS. Implemented a therapy dog. Started CISM and Peer Support. Code Lavender can be called to allow for downtime after a difficult call. They can call for therapist support or simple downtime related to a bad call. EAPs did not understand what the job was.

 

Augustine (Lee County) – Part Three: Managing the Well-Being of EMS Crews: What Did Lee County FL Do To Help Their Crews? – There are no EMS job openings in Lee County. This after three years of a pandemic and a Category five hurricane. Employee Support Unit mission changed from COVID support and testing to a crew care program. Set up tents on hospital property to allow food and documentation areas when the hospitals would not allow people to stay in the building due to COVID. Therapy dog program implemented as well. Did suicide prevention and peer training. Started coordinating LODD functions. Hurricane Ian wiped out crew member homes and required direct support of department members. They have everyday great operations, novel programs meeting staff needs consistent dedication and direct focused support of employees.

 

Goodloe (Tulsa & OKC) – Is Anger Really a Four-Letter Word? Delicately Dealing with Difficult Dilemmas, Dubious Diagnoses and “Don’t Wanna-Go’s” – Dealing with the difficult in EMS. Is anger really the primary emotion behind difficult patient encounters? How do you turn the “No!” into “I’ll go.” ERs are very busy. EMS is very busy. Emotions are on the rise. How do we defuse difficult patients? It is about self-control. “Clear the mechanism.” When you can feel your emotions and BP rising, clear the mechanism. Bring it back down. Do not forget the basics. ANGER is really spelled FEAR. “What took you so long?” Really means “I am afraid for my loved one.” A phrase that helps is “I see you are upset. Help me understand the situation.” Get down on the patient level. Gain patient agreement on facts by stating them. Learn why they are being difficult. Then you have a reason that you can work on. Do not lie to patients. Turn no into yes. Winning is going home happy, not a patient altercation.

 

Jui (Portland) – Therapeutics for Significant Staff Infections: What Is the multi-component Approach to EMS Staffing Shortages in the Rose City? – How many in the room have a staffing challenge? 90% of the room. Only 8-10% of 911 calls are critical. Dispatch is an inexact science. Not every 911 call requires an EMS response, let alone an ALS response. Deploying BLS ambulances. MPDS Alpha calls go to BLS and they advise the patient of the ambulance ETA. A handful of calls upgraded. This is equivalent to the hospital waiting room. DC is using nurse triage line to decrease responses. We need to explore alternative ways of responding. There is also a community crisis team response. Frequent users are identified and managed.  Telehealth will be integrated in the future. LA is doing advanced provider projects. Some patients just need a ride (so the level of ride should be appropriate and maybe not an ambulance). We need an EMS “Emergency Severity Index.” Why does EMS have staffing issues? They are burned out. Must work on recruiting and retention.

 

Jarvis (Ft. Worth) – Improving Appropriate 9-1-1 Response with Great Dispatch: What is the Ft. Worth / Tarrant County Experience to Date with Augmented BLS Response Components? – Improving dispatch accuracy. Call volumes are skyrocketing, and most are BLS. If a paramedic is looking at an ankle, they are not available for a cardiac arrest. 7% of patients need something significant. EMD determinants are being mirrored to patient status and vitals. Critical incident? Unstable vitals? How did that correlate to EMD determinant? There is no literature on this. They built a system around their data. Dropped number of emergency responses. Accuracy of data to EMD went from 30% to 68%.

 

Dunne (Detroit) – Hybriding Detroit Wheels: Can Private Agencies Be Used to Offload 911 Volume Load and Increase Paramedic Availability? – 2023 shows more calls, fewer personnel (attrition, retirement, training time, peak response increases, budgeting). Had very limited number of paramedic units. PPERS is a group of four private providers that provide additional ambulances to the system. There is a negotiated subsidy for the private providers. Privates are covering peak times. Private units are issued Detroit radios and call signs. Dispatched by Detroit. Supervised under Detroit Supervisors. Integrated response plans. Data shared weekly. Now having BLS do more than ever. Now 9-12 ALS units and 24-30 BLS units daily. Maximizing what BLS can do.

 

Cabanas (Raleigh/NAEMSP) – A BLS Rally in Raleigh: What Has Raleigh and Wake County Learned from Their Successful Tiering Experience? – Added BLS units. Traditionally an all-ALS system. Stepped into this with two BLS units and then added more. EMS is currently disrupted by major forces. The future is to diversify options for care. BLS units add capacity. Do an analysis of care to EMD code. Link low acuity calls to EMD code by using patient data. Crews must know scope of practice. CAD configured to swap ALS and BLS units as needed. Staffing challenges at BLS level as well. Extreme value seen with BLS units in your system. Script what happens if a BLS unit finds an ALS patient. One physician makes the point after this lecture that many IV accesses were being made only to keep nurses at the ER happy. Procedures alone do not tell patient need. We need to look at patient data to determine need for ALS. There may be some paramedic skill dilution with more BLS, but the answer is in the number of paramedics not increasing skill opportunity. Pepe comments that the two cities with the highest save rates in OHCA are tiered systems. Boston runs more BLS units during peak hours (Dyer).

 

Goodloe (Tulsa & OKC) – Advancing Through the Basics: Impressive Results, Better Morale and Better Care – Looking to predict what you can safely send what you can send a BLS unit on and make timely care for the truly critical patients. Increasing staffing challenges. Which EMD codes convey patient safety

applicable to BLS. The correlation here is that it will highly specify that ones that need the ALS service line. Tulsa allows BLS to call for ALS but not ALS to downgrade to BLS. BLS assignment must make clinical sense. Criteria determined for making he process. Data indicates that more could be assigned to BLS than what has been due to BLS unit capability (some still being made by ALS). They use 60 days of data for analysis. Lack of BLS units in OKC because the EMTs are sitting in Paramedic class (BLS responses get EMTs to want to be paramedics!). 26A08 is most common BLS call and has a high transport rate. 23B02 is almost 90% refusals (so role BLS). BLS responses have helped response time compliance. Adding BLS ambulances increases availability of ALS and gets ALS to those who need it the most.

 

Pruett (Albuquerque) – Pre-ED of the Pedi OD: How has the explosion of Fentanyl Use in New Mexico Affected Young Children and EMS Protocol? -  Pediatric opioid exposures increasing. Kids getting into Fentanyl (and Suboxone). 96 Opioid exposures last year. The calls do not come in as drug related. They come out as unconscious, seizures, respiratory, decreased LOC, etc. Cannot count on pupil size but you can count on respiratory rate. Consider opioid OD in young children. Give Narcan to unconscious kids.

 

Mechem (Philadelphia) - Vetting the Vet-Drug: How Far Has the Explosion of Xylazine Use Affected EMS and OD Management?  - Non-opioid veterinary tranquilizer. In 2021, it was present in 90% of opioid overdoses. Users say they can tell when it is in their dope as it gives a funny taste in their mouth. It produces a zombie like gait in the walk. People come out from under the drug not knowing where they are. Trauma from skin popping (can lead to amputation). Lasts longer than Fentanyl so it prolongs the high. Not a federally controlled substance (yet). When in doubt, give Narcan, but it does not work on Xylazine. Skin wounds can prevent rehab admissions due to needed wound care. A growing problem around the country. Wounds are difficult to manage long term.

 

Katz (Hollywood) – Putting Out the Welcome M.A.T. – Can Medication-assisted-treatment Be Provided Out of Hospital? Opiates flood the brain with Dopamine causing euphoria. Treatment with medication must be applied just as we would any medical condition. Telling them to stop just does not work. 70% abstinence at one year of treatment. Decreased mortality rate. Buprenorphine is used to bind the receptor. The patient does not get high but also does not get the craving. You cannot help them if they are dead. Reduces HIV transmission. Reduces infant mortality. Reduces OD call volume for OD. Also serves to reduce crime. They have treated over 200 pregnant women with 90% drug free at birth. Started this program in the ER. They utilize post-addict peer specialists. ER starts therapy and refers to opioid clinic. If the relapse and come back, they restart the program. Not always a one and done. Program is seeing fewer of these patients. Could be from program but is probably multi-factorial. Potential is there for EMS to do this treatment. Cannot just give the drug. The patient has to be introduced to a network of care.

 

Miramontes (San Antonio) – Disarming the Harm: How Has the Alamo City Approached the Opioid Epidemic? – Harm reduction is the goal. It takes a village. Multi-organizational approach. They use overtime medics. Full ALS response vehicle is used. First Watch identifies the patients, and they go see them the next day. They use Buprenorphine strips. They do an opioid withdrawal scale. Full treatment plan with Zofran, Benadryl, Imodium, and the Buprenorphine. If less than 24 hours since last use they may also add Clonidine. Exclusion criteria Chronic pain, pregnancy and others. Law Enforcement overuse of Narcan can cause withdrawal but make the patient want to get back on Buprenorphine. Buprenorphine reduces withdrawal symptoms. Quotes Camden, NJ results of their program. It is doable. Replicated in multiple systems. San Antonio has been doing this for four years. May have three generations of drug users in one house.

 

Scheppke (Florida Department of Health) – Reaching the CORe of the Matter: Could a Statewide Coordinated Opioid Recovery Program Be Facilitated By EMS? – Substance use disorder patients do not look forward to seeing healthcare because they are typically treated poorly. There are chronic brain changes with addiction. Addiction is a brain disease. M.A.T. requires a physician to write the prescription or order. Treatment without M.A.T. is rarely effective. Relapse rates are at the same rate as chronic diseases. Palm Beach modeled their system after the trauma care system. Use outcome measures to assess whether programs work. You fix this disease, you affect HIV, Hepatitis, crime, mortality, etc. Provides lifesaving care, specialized stabilization, and sustainable recovery. 13 counties involved and expanding to 30 counties. Program includes dental care and career training. Much different from what a detox center does. Detox centers not providing outcomes at this level or even close.

 

Dunne (Detroit) – The 4-1-1 and 6-1-1 on 9-1-1 BHEs: Multi-Disciplinary Approaches to Behavioral Health Emergencies Impacting EMS – You cannot change what you cannot measure. You need data. Everyone has data but it is all in separate silos. What is the reality of the services used by frequent users? EMS? Hospitals? Jail? People call 911 due to inability to cope with a presenting problem. Looked at 339 people who were responsible for 39,000 EMS runs over five years. Using a CIT Team to get appropriate care and keep the patient out of the hospital. Resources in dispatch to decrease EMS response on identified individuals.

 

Mechem (Philadelphia) – EMS Getting Psyched-In: How is the City of Brotherly Love Is Delivering Mental Health Emergency Services – Behavioral health navigator placed in dispatch. Screened calls. Trained call takers in behavioral emergencies. CIT training for ALL officers on how to interact and how to get them to care instead of jail. If call gets to fire dispatch, the EMD 25 card is used, and an ambulance is sent. AR3 is the specific specialty ALS unit sent with crew being CIT trained. AR3 can self dispatch. AR3 can respond to external requests as well from other agencies. Some involve medically frail or elderly individuals so AR3 can request a paratransit van or ambulance if needed. 9-8-8 is used to call for behavioral crisis which implements a tailored response based on need.

 

Morshedi (Little Rock) – Pediatric Psychiatric Care – How do we get these to direct care and NOT to ERs? – Over the last decade, pediatric behavioral patients in ER have increased 13%. EMS partnered with five partner facilities for direct transport. To date, 193 patients went direct to peds psych facilities. Number would have been higher if bed availability had been there. No 911 return calls.

 

The Eagles Gather and Chatter – Eagles on stage for Q&A – 1) Discussion on decreasing lights and siren transports. It will take a cultural shift. Multiple systems are also looking at changing response time requirements to decrease lights and siren responses as well. Detroit only uses lights and siren on Echo and Delta calls and only sends fire support on Echo and Delta calls. NYC and LA have also decreased lights and siren use. It does produce longer response times but is far safer. Penalty structures for response times do not support safe responses. Technology will eventually decrease need for lights and siren responses.

 

That is it for Eagles XXIV 2023... I shall leave a few pictures from the trip below. Till next time...