that in reading these, you may find a spark that leads you down a path of improving something in your EMS system. So, it is now 2025, and these notes were created while attending in San Diego. It is probably worth noting that I left six inches of snow on the ground in Indiana to travel to the Pacific and Palm trees which I am sure garnered some guttural hatred from some I left behind.
In a world of 10-to-30-minute lectures, it is difficult to
capture a lot of the detail that these excellent minds of EMS convey. And of
course, being typed as I am listening to each speaker, there could be errors.
The usual disclaimer: These are my raw notes; other than a grammar and spell
check (of which I am sure that these did not catch everything), they are as presented. I also was unable, due to multiple tracks and
some needed networking time, to attend and deliver notes on every lecture. If
someone finds an error, please let me know and I will correct. Please feel free
to distribute these notes as well.
Introductions aside, here are the notes:
Day One
2025 NAEMSP President’s Address – Cabanas – Welcome to San
Diego. Notes the significant fire emergency in the Los Angeles area and our
affected colleagues. NAEMSP has been doing great work in advancing the mission
of EMS. Goal is to foster EMS leadership and elevate the practice of medicine.
NAEMSP advocates for EMS needs within state and federal governments. Consensus
statement was published on behavioral emergencies. The NAEMSP 2024 annual
report is now available. NAEMSP is now celebrating its 40th anniversary.
Tribute to Ronald Stewart, MD and his impact on EMS. He passed away recently.
We are driving meaningful change to impact patient care. Working on a
comprehensive manual on trauma consensus statements. Looking at legislation on
drug shortages, reimbursement, treatment in place, blood, and reimbursement for
medical direction. NAEMSP does have a political action committee. This is used
to support legislators who support the NAEMSP goals. 1,800 attendees at this
conference. Partnership established with American Red Cross on ensuring all
populations have the ability to learn CPR. Let’s connect, celebrate the gift of
our work, and reaffirm our commitment to excellence in emergency medicine.
Showed video message from Ron Stewart on the privilege to practice medicine. We
need to be able to look back and say we did our best.
Quote: “To teach is to learn twice.” – Walt Stoy
Physician Wellness and Addiction: How a Month in Alcohol
Rehab Restored My Joy in My Joy in My Work and Made Me a Better Doctor –
Humphries – She was on dispatched on a flight call close to base. Oddly close,
curt dispatch info, and was a police officer hit by car and with CPR in
progress. They performed their skills and loaded into the helicopter. This was
like working family. She was pronounced dead shortly after arrival. They said
they were fine, but the dispatcher silently took them out of service. Now what?
Went back to work. We deal with hard things. We must allow time to allow things
to process. Found herself replaying the event and having an elevated heart rate
and breathing every time she thought about it. Finally decided that her
reactions could be PTSD. 10% of all newcomer first responders show symptoms
meeting PTSD. In the US this is closer to 20%. PTSD decreases quality of life
and increases mortality. She cannot remember most of the week following the
accident. She took to drinking with a plan to pass out each time. Described the
funeral. Internalized the outcome of the call. “Each thank you was a knife in
my heart.” She felt she was a failure for not conjuring a miracle. At the fourteen-day
point, she sought professional help. She was coming to work hungover. She was
never drunk at work. Several months later she called her therapist while drunk
and the truth came out. This was during the pandemic which had helped her hide
her drinking. Drinking alone is a dangerous option. She couldn’t take the phone
call back and this helped save her life. Most data on mental health for
physicians and first responders is from the 1980’s. Study’s show a strong
relationship between PTSD and behavioral comorbidities with substance abuse.
Many do not see a problem with their substance abuse patterns. She thought that
everyone else was drinking as badly as she was. Women are at higher risk of
alcohol abuse. Suicidal ideation is as high as 30%. We are not that different
and not to far off from our patients. 400 American physicians die by suicide
each year. This is believed to be a conservative estimate. Firefighters that
respond to medical calls are 6 times more likely to die by suicide than those
that respond to fires alone. 40% of physicians in a recent survey stated they
were afraid to seek behavioral care due to fear of licensure issues. Research
shows that first responders absolutely have a higher rate of suicide risk than
the general public. We cannot self-care ourselves out of burnout, behavioral
issues, and suicide. Consensus recommendations: Screen our patients for
behavioral issues. Advocacy must be made to remove licensure concerns with
treatment (licensure boards questioning is highly varied). Diagnosis does not
equate to impairment. Once a problem was identified. Initially was adamant that
her residency program know nothing about this. She started outpatient rehab. A
colleague stated concern (which she did not see coming). She was concerned that
she might be able to keep and maintain a license as she was at the end of her
residency. She was told she needed to report herself to the state monitoring
board. She was told she would have to take a 72-hour inpatient program to be
able to retain her credentials. She went into the evaluation thinking it was
not that bad. She thought it would be 72 hours and done. Her own denial ended
up getting her what she needed. At the end of her 72-hour evaluation, it was
recommended that she spend a month in rehab. She did not handle this with grace
and not ready to learn from the experience. She thought she had to be
physically dependent on alcohol to be an alcoholic. It is not how often you
drink, but it is what happens when you do. Alcoholism is a disease, and it has
features. Alcoholism is a progressive disease. Treatment takes time. The
mandated break from practice saved her life. Being the patient made her a
better doctor. Keep your patients informed. It is important to give your
patient even the smallest pieces of information. Pillows matter. Have a little
grace. We meet people on the worst of their days. This occurred between March
and June of 2020. She was three weeks late to her residency program. No one
used her background against her. On completion of the program, she entered the
monitoring phase. Research shows those with professional monitoring have a
greater success rate. Knowing it was the best way to protect her license was
incentive to succeed. It is OK to not be OK. There is no timeline for getting
back in the saddle. Recovering from trauma is hard work, PTSD is re-experiencing
trauma, hyperarousal, and may other symptoms. French research shows that there
is also a partial PTSD as some have disabling symptoms without meeting minimal
criteria. Trauma looks different for everyone. It is highly variable in
questionnaire surveys. 57% of public safety PTSD has an initial event in their
personal life. On this event, she kept reliving the radio call. She also
fixated on points of care where she felt she failed. Used EMDR. EMDR is not
voodoo. It is supported in the literature. EMDR disrupts memory and lessens
severity of memories. EMDR is better than talk therapy or group sessions.
Coworker support is a common factor in resiliency. Lack of supervisor support
negatively affects resiliency. The hits keep coming. More research is showing
that PTSD is becoming more common. As we see more it interferes with our
ability to recover. CPTSD is much more common than just PTSD. 20% of healthcare
workers drink to hazardous levels. This rose to 30% after COVID. 18% engage in
binge drinking. First responders with PTSD showed alcohol abuse as the most
common variable. Someone needs help. They can recover. If concerned, say
something. You must report them if it affects patient care. Know signs and
symptoms, know your next move, and be an advocate. Assume that someone is
watching.
Injuries at the US-Mexico Border – Berndtson – Shows picture
of those climbing the high border wall. Now we are seeing those from south and
central American, northern India, and Kazakhstan coming through the border. The
border crossing south of San Diego is the busiest port of entry in the Western
Hemisphere. 90,000 legal one-way
crossings from each side daily. Worldwide displacement numbers go every year.
This includes every continent. The US is the biggest destination for
immigration. Gave history of the border wall from 1990 till now. Height
increased in 1994 and again in 2006 (which also increased the length). In 2016,
the fence types began being layered. In 2017 more length and height was added.
Annual apprehensions are at the highest numbers ever. Seeing more and more
trauma from the 30-foot fall from the top of the border fence. Many expulsions
in 2020 due to Title 42 activation under COVID. Who are those trying to get in?
People from Mexico (30%), Cuba, Columbia, Peru, Ukraine, and China. There are also
those running from Russian conscription to fight against Ukraine. Languages:
Spanish, Somali, English, and Punjabi are common. Russian is common as well
(and hard to find interpreters). 78% of patients were men, but women crossing
the border is increasing. Many fly into Tijuana from all over the world to
enter the US there. Many come on foot through the Darian gap. Many have other
medical conditions related to their travel before they incur trauma. There is a
lot of misinformation amongst the migrants on how to legally get into the US.
You must have the CBP One app on a smartphone to apply for entry. There are
only 1,450 appointments on CBP One daily. Many do not know of the legal options
for entry. Many do not know you can ask for asylum. There is a steady business
of those transporting people to proximity of the wall “coyote.” US is putting
up billboards in Mexico for people not to trust the Coyotes. Why do they come?
War, fleeing crime, better life, fear of ability to live where they are, and
family in the US. Even people with injuries state that they would try it again
(48.6%). Injuries seen are mostly orthopedic. Ankle, tib fib, heel and spine
are common. Calcaneus fractures are very debilitating. 86% of patients are
non-ambulatory on discharge. Many times, they are permanently disabled from a
fall from an attempt to climb the wall. There is no follow-up as they are just
passing through San Diego. Six spinal injuries a month. There is also an
increase of head injuries with TBI. Most are sub-dural hemorrhages. 245 minutes
from injury to ER admission is the average as they are coming from very rural
areas. Many of them need surgeries for the TBI and do not get follow-up. There
is also obstetrical trauma. Many have premature births following being seen
following an injury. There are also thoracic injuries. There are also drownings
from those trying to come around the wall in the Pacific. There is
environmental exposure and injuries as it is the desert. Impact in keeping
operating rooms full and busy. Drastic increase in unpaid healthcare. 20% of
trauma service patients are from border interactions. Now doing scheduled
surgeries on weekends. Hospital stay is longer as they have no were to go when
released. Only 15% stay in the San Diego area. Some go on to Canada. Wat too
many to go to Border Patrol Custody. Transportation out of the hospital is a
problem. Many do not have IDs and are trying a claim for asylum. Hospital does
get MediCal rates for migrant care. 100 admissions in 2019. 2024 totals were
above 900. The entry rules are changing quickly. No one knows what will happen
with the new administration. It also depends on what is happening in Mexico (as
they guard the border as well. There is a research group on this issue.
NASEMSO Update – Kamin – National leadership organization
attempting to connect silos between states. They have a new website. There is a
medical director council that currently has 39 state EMS medical directors.
NASEMSO provides a forum for communication, interaction, and networking between
peers, other national organizations, clinical efforts and federal agencies.
Nationwide promotion of evidence-based medicine efforts. Looking forward to V4
of the National Clinical guidelines.
NREMT Update – (did not catch the name of the speaker) –
They have updated their purpose, vision and mission. The NREMT is there to
support partnerships to improve EMS and protect the public. Much of this is
done through assessment. This is done through educators, certification, sates
and medical directors. Slide shown of certification current totals. New exam
implemented in July 2024 with a heavy emphasis on clinical judgement. There has
been a slight increase in pass rates for paramedic and a significant increase
in pass rates for AEMT. They have overhauled technology, examinations and a
renewed focus on continued competency. There are significant opportunities to
improve ongoing competency. There is an agenda for continued competency that
will be published later this year.
ABEM Update – Isakov – ABEM EMS Core Content survey coming
regarding what needs to be in the board specialty examination. There are now
1,243 now board certified in EMS. There is now a recertification process that
can be used instead of the Q10 high stakes exam.
NEMSAC National EMS Advisory Council Update – Wijetunge – NEMSAC created in 2007, written into law in 2012. 25-member council of national representative with EMS expertise. Charter renewed every two years. Current charter is good through April 27, 2025. The charter is the directive on how NEMSAC completes its public work. NEMSAC advises the federal government and provides a forum to deliberate issues of national significance. Provides a conduit for public input to the federal government. See www.EMS.gov for advisories. There are subcommittees on things from adaptability and innovation, Equitable patient care, to sustainability and efficiency. There is a NEMSAC public comment portal.
Menegazzi Poster Sessions Oral Abstracts – 1) Alternative
defib strategies: Vector change is just as effective as double sequential
defib. 2) Vasopressor or Advanced Airway First in OOHCA: PART Trial.
Multicenter trial. Looked at time frames from first vasopressor and also
whether or not there was an advanced airway placed. Vasopressor first was not
associated with better ROSC or outcomes. A study in Japan that did not allow IO
use showed better one month survival with vasopressor first. Does vasopressor –
airway sequence matter? We will need a controlled trial find out. 3) View
Adequacy and Compression Delays During CPR: Carotid vs. Cardiac Ultrasound in
OOHCA Arrest: Manual pulse checks are terrible in all care environments. POCUS
may improve pulse check accuracy. Cardiac POCUS has been associated with
increased CPR pauses. Use of POCUS for carotid artery observation may be an
alternative. Study used alternating observations using both methods. 94
patients yielded 196 POCUS videos. Carotid view had less lengthy pauses and
more adequate view for blood flow. Further prospective work is warranted.
Outcomes were not measured, This study was a view and timeframe study only. 4)
Differences in ALS vs. BLS Outcomes in the treatment of OOHCA in Detroit:
Retrospective study. Looked at ALS anytime in shockable and non-shockable and
BLS only in shockable and non-shockable rhythms. Looked at favorable outcomes
as CPC1 or CPC2. Shockable rhythms have better outcomes than non-shockable
rhythms. ALS doubled the ROSC rates in both. ALS provided better outcomes than
BLS. Using this data to justify improving number of paramedics. 5) EMS Training
Priorities for OB Emergencies: A Qualitative Analysis: OB emergencies are rare
but high acuity events. Maternal death rate is high. Little known on education
gaps or priorities in EMS. 17% delivery complications in EMS. What are the
training priorities? 17 experts form EM, EMS and OB utilized. Reviewed national
EMS criteria by the education standards. Eclampsia was common in discussions. Word
cloud creation for expert consensus as opposed to curricula did not match. Top
items were hypertensive disorders of pregnancy, postpartum hemorrhage, and
deliveries.
Microaggressions – Gorgens: Stop Talk and Roll. Must flesh
this out.
Peri-Intubation Resuscitation – Canning – Raising awareness
and red flags associated with adverse reactions when it comes to endotracheal
intubation. Maximize oxygenation by using a NRB at 15 lpm for 3 minutes for
breathing patients. 15 lpm O2 via NC for apneic pre-intubation oxygenation.
Manage BP. Increase BP with fluid bolus, norepinephrine or epinephrine if
hypotensive (blood for trauma) before intubation. Use the proper medication.
Pick your induction agent, consider reduced dose sedative, and use a paralytic.
After intubating manage pain, maintain BP support, and continue
oxygenation/ventilation. Deep sedation is prudent. Manage BP with the
appropriate agent for the cause of low blood pressure (fluid, pressors, or
blood). Secure the victory
post-intubation.
Turning Crisis into Opportunity – Cantwell-Frank – Big
increases in Opioid Use Disorder (OUD). A percent that survives an opioid OD,
they have a 5% higher chance of dying in the next year. Many within a few days.
Non-transport of opioid OD survivors has risen to 44% recently. Buprenorphine
is an option. One dose can protect for 36-48 hours. Patients who received
Buprenorphine in the field had a 12% higher engagement with treatment at 30
days. little precipitated withdrawal noted. Safe enough to be given without
online medical control. Protocol shared. Administration is based upon
withdrawal symptoms. Discuss what the medicine provides with the patient.
Administration does not have to delay scene time. Should even be given in
refusal situations as it will give extended protection. Safe, easy and
effective.
Protocol of the Wild: Developing EMS Protocols for
Backcountry Care – Dreyfus – Speaker has developed protocols for the remote
areas surrounding Salt Lake City. Overlap of urban and wilderness settings.
Looked for those with frame of reference to the subject on what they had done.
Medical considerations, operational challenges, do more or do less? You will
not have a cardiac monitor with your first people to contact a patient with
chest pain in the wilderness. WFA or WAFA, WFR, and WEMT. Wilderness Medicine
Educational Collaborative is the group concentrating on educational standards.
Distance and time are both factors affecting decisions. Most NPS SAR teams have
at least 99% or their members at some level of medical training.
But First Airway: Prioritizing Key Interventions During
Prehospital Neonatal Emergencies – Redmond – Speaker states that CPR is rare in
the neonatal care world. This is because it all revolves on care with the
airway and ventilation prior to arrest. Focus on the airway during the first
minute of contact and then to continue to obsess on the airway. You are doing a
good job with the airway when the heart rate improves. Even when the heart rate
is zero, lean efforts into the airway. Baby should be made to be dry and warm.
Put a hat on baby. Put baby on a warm surface. Clear the airway if needed. Use
plastic bag up to neck to keep baby warm. Tube must be held secure as only a
couple of millimeters movement will cause extubation.
The Link Between Polypharmacy and Falls: Prehospital Care
Considerations – Wen-Han Su – If on more than five medications at a time falls
are 1.5 to 2 X more common. Case study of lightheadedness and fall. Systolic BP
is 94/60. Patient is on a new medicine that causes lightheadedness. Transport
or treat and release? The NAEMT has the Gems Diamond that can be used for
geriatric assessment. Note what patient medications actually do. Talk to those
on scene about the patient. Use vial of life programs. DMIST reports for
patient handoff. Communicate high risk medications to the hospital at handoff.
Medication lists are not always a match to what is currently being taken.
Prehospital Breaking Bad News – Tillett – Many EMS personnel
have no training in giving families bad news. If leaving a deceased subject on
scene, you may be the only clinician to speak with the family. Developed a
curriculum for breaking bad news. How do you prepare the family for a bad
outcome? How do you address angry family members? Take cases and have crews
work through the scenarios on each. When surveyed, one department had 41% who
had no training on this subject. People reported satisfaction and use after
being trained in breaking bad news. Course is available for free.
Prehospital Neonatal Resuscitation – Diggs – Use of a
gestational age determination tool. If fingers/toes fused they are under 22
weeks. Translucent skin, less than 24 weeks. Eyes fused, less than 26 weeks. If
family says greater than or equal to 22 weeks. Resuscitate. If gestational date
is unknow and fingers/toes fused, do not resuscitate. If they are not fused
resuscitate. How common are out of prehospital births? 62,228 in 2017 (1% of
total births in the US). Paramedics have about 15 hours of neonatal/pediatric
resuscitation and continuing education varies by agency. Performance: Only 2%
warmed infants. Small percentages for drying infant as well. Study on
prehospital births being conducted in Texas. Providers were also surveyed about
prehospital deliveries and associated emergencies. 33% felt confident. Future
goals are to validate the gestational age tool, and secure funding.
Spinal Motion Restriction in Children – Adelgais – Looked at
outcomes of spinal immobilization in children. 7,500 patients in cohort. Some
different in racial demographics for SMR applications. Patient criticality also
resulted in decreased SMR. Use of radiologic studies were higher if there was a
c-collar or LSB used. No deaths in cohort. C-collar and/or long spine were
associated with higher admissions and surgeries. More study is needed.
Language Barriers to Telecommunicator CPR: A Process
Analysis - ? – Performed this study in San Francisco which is a multi-language
community. Used their CARES data as part of study. MPDS Version 13.3. Language
is crucial even in the first steps of recognize a cardiac arrest as well as for
the caller to be able to understand TCPR instructions. English speaking callers
were more highly likely to already be doing CPR at time of call. English
speaking callers much more likely to take action based on instructions.
However, there was not really a time difference in starting CPR with or without
language barriers. Would benefit from more multi-lingual call takers. Need
focus on multi-cultural CPR classes. A rapid dispatch protocol when information
cannot be confirmed is beneficial. There were actually very few non-English
speaking calls noted.
Missed Hypoxia in Prehospital Care of Major Traumatic Brain
Injury: Discrepancies Between Continuous Monitor Data and Clinical
Documentation – Spaite – Three H-Bombs of TBI: Hypoxemia, Hypotension, and
Hyperventilation. The EPIC data showed even greater harm from Hypoxia that
thought. If you have one incidence of a SPO@ below 90% your odds are seven
times higher for death. How accurate is what is documented compared to
continuous monitoring of SPO2? If you met TBI criteria you were in the study.
36.7% detected hypoxia from the monitor, where only 6.7% were detected looking
at the documentation. Three runs had SPO2 on the monitor but not in the PCR.
All were agencies that have good QI functions. It is impossible to state the
importance of prehospital oxygenation in TBI. Are we missing 80% of hypoxic
cases? This means literature may understate how detrimental hypoxia is to TBI
outcome. This means the true adjusted odds of death from hypoxia is 6. Is
hypoxia simply being missed? Are we ever distracted (rhetorical)? Need alerts
for hypoxia from the monitor. We need real time feedback.
Prehospital Performance of the PCARN Cervical Spine Injury
Prediction Rule in Injured Children – Browne – We know that EMS can accurately
screen for CSI in adults. Use in children has not been proven. Children in
study were less than age 18. Secondary analysis was limited to those
transported by EMS. 7,721 patients in study. Sensitivity 88.5%, Specificity was
63.1%. If PECARN rule is used, it will decrease SMR with c-collar in children
slightly and with LSB significantly.
Left Behind? Unhoused Patients and EMS Transportation –
Mullen – 181, 399 unhoused Californians (28% of the national homeless
population). There are significant disparities in care and mortality of medical
conditions between the housed and the unhoused. 464, 059 runs of housed and
unhoused ambulance runs used in study. Housed patients were transported less
regardless of race or season. Data was from ImageTrend database. Policy in some
areas may require transportation of unhoused patients. Conclusion is that there
are disparities in healthcare.
Examining the Reliability and Validity of the ALS
Certification Examinations with the Inclusion of Clinical Judgement: An Update
on the ALS Examination Redesign – Stevenor – Clinical judgement is essential
for prehospital care. ALS exam has been redesigned to evaluate clinical
judgement. 20,136 tests evaluated. Both the paramedic and AEMT exams displayed
nearly the same level of reliability. The assessment of clinical judgement is
now more robust without making the exam harder. This reflects entry-level ALS
knowledge.
Effectiveness of Sodium Bicarbonate Administration in
OOHCA’s: An Updated Systematic Review and Meta-Analysis – Zaffari – Sodium
Bicarb currently not recommended by AHA in OOHCA, based on an animal study.
Acidosis is a reversible cause of cardiac arrest. Removal of Sodium Bicarb has
been controversial. Literature review. Studies covered over 126,000 patients. 9
observational studies and 2 RCTs. No higher ROSC with SB. Survival to Hospital
discharge no significant change with SB. Same with hospital admission. Good
neuro outcome also had no significant outcome difference. A randomized,
controlled trial is needed.
Day Two
Data-Driven and Patient Centered: How the NAEMSP Quality and Safety Course is Quietly Transforming the EMS Industry – Redlener, Bourn, Dorsett, Little – The typical approach to QI is finding the bad apple and fixing the person. It is a negative approach based in fear. There
The Changing Legal Landscape for EMS and EMS Medical
Direction – Levy, Jaeger – Contracts and contract language are a topic of
discussion. Discussed medical director contracts needing cybersecurity clauses,
workers compensation and vehicle insurance. Some insurance coverage simply is
not available. Indemnification clauses (should not be unilateral). You can push
back before signing. The medical director should not hold the agency/entity
harmless. If anything, it should be the other way around. Workers comp insurance
should not be a part of a medical director contract. General liability and auto
liability coverage are sometimes being asked for. Online medical control needs.
There is an increase of civil and criminal liability cases in EMS. The risk is
going up. Video evidence is becoming more available form vest cams and
smartphones. “Video refusals” are a good supportive tool. Refusal video can be
embedded in the EPCR. They continue to see increases in medication error cases.
Discussed the “Swiss cheese” alignment approach to errors. Crosscheck is still
a good thing for medication administrations. Crosscheck can actually be with
the patient. Showed video from the Elijah McLean case on testimony. Video did
not match testimony. We need to think about informative EMS (verbalize
everything you are doing on scene). People take video and photos frequently
today. This is the world we live in now. Insurance concerns about lack of due
process. Contracts: you need to negotiate and not just do boilerplate. Refusals
are currently becoming more of an issue. There is impact of video recording on
legal issues.
Where EMS and EM Intersect: Clarksville, Tennessee EF-3
Tornado – Huff – Air Evac Medical Director. Lessons learned from an EF-3
tornado response. Community hospitals are not prepared for disasters. One main
ED and one free-standing ED. Every bed was used, and oxygen tanks were running
out. She felt something was wrong with the weather when getting off shift. She
had taken disaster training during residency. December 9, 2023, was the date of
the tornado. There were 8 different tornados in the area. The tornado was on
the ground for about an hour and 50 miles. Around 1,000 houses damaged. There
was limited access to the damaged area. Hospitalists helped move patients that
were already in the ER upstairs to clear ER for incoming patients. Disaster
overflow is on the other side of the hospital, 2 blocks away. Made the waiting
room the green tag area. Hospitalists took care of the non-trauma patients, and
the ER docs took care of the trauma patients. Orders were written on glass
doors of bays. Radios for all team leaders. Reminded everyone to eat, drink,
and rest between waves. She was told by CEO to be sure and step back from
patient care and lead the team as soon as possible. Some of the sickest
patients ended up arriving by private vehicles. Put a surgeon on the task of
ding FAST exams. EMS communication was difficult. PSAP was overwhelmed. There
was a tech issue that caused all of the ambulances in town not to be able to communicate
with the hospitals. The hospital was also the official storm shelter for the homes
next door. This caused families to bring pets and there were lots of dogs. No
EMS units were available to transport patients outside of the community to
trauma centers. Got in touch with unified command through GMR contacts and got
units on the way to move patients. You also need to account for teams and their
families. Assign someone not involved in patient care to start tracking
accountability of team members and their families. Focus on the end from the
beginning. What are your triggers for winding down? Team support and
appreciation must be shown. Showed a challenge coin for those who worked the
event. Provide emotional support. 58 patients from the event with 9 critical.
Spin up to wind down was 4 hours. Show up and figure it out.
Why Advocacy Affects You! – Tan – Advocacy is the long game.
90% of it is showing up. There is a government relations academy. If you go to
the GRA, they try to pair you with your legislators. We have to get legislators to see what really
happens beneath the iceberg. Nothing worth having was ever achieved without
effort – Theodore Roosevelt. Currently working on the DEA delays with
controlled substances regulations. Supporting initiatives within NEMSAC. Persistence
in the long game will help reaffirm our mission and values. NAEMSP has a PAC.
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| Indiana Physicians Gardner and Yazel |
probably get pushback. Once it is legislated, funding becomes more of an obligation and an easier discussion. There is more public understanding of EMS than before. Alternative destinations are becoming more common. It is a good time to have the conversations. Critical shortages of personnel exist with almost no surge capacity. What does a well-funded system look like. You want speed, quality and low cost. Eliminate unfunded state mandates from the start. Accountability must be defined. Who is responsible for assuring EMS is provided. Only 14 states and DC have EMS as an essential service. What is the funding stream? Indiana has no teeth to its essential service status with no funding attached. Weakly worded. No accountability is designated. It becomes a hot potato. Who is responsible (state? Local?)? What is “service provision?” 4.5 million Americans live in ambulance deserts (more than 25 minutes from an ambulance). Volunteer fire departments are having shortage of personnel issues as well. We tend to use the same legislators for goals. It is very important to get new voices to add to supporting the issues. Indiana formed an Indiana EMS 2025 group to develop a game plan for the next few years. Legislated a survey of each county on EMS on coverage and subsidies. County commissioners were responsible for responding to the survey. The next step is to pressure counties to submit a formal plan for EMS that will make it their responsibility. Wording legislation is very important. There is a big difference between “may” and “shall.” Work with legislators on wording. What you get in the legislation is more important than the word “essential.” Coupled with essential service legislation is the discussion timing for funding streams. There is room for a federal component in this as well.
Charting the Uncharted: A Visual Odyssey through EMS Data –
Stemerman – How do you translate data into something meaningful? Mix data
analysis, creativity and patience. Bear boxes are a good example. They have to
be built to keep out the smartest bear but allow the stupidest human to use
them. Turn clinical and operational data into an integrated view. Humans think
in a very time-based fashion. Some graphs and displays are crimes against data.
What are we answering? Used a graph of unit availability over time. Looked at a
heat map of coverage gaps. Where you want to be is in the projection realm,
like “Predicted EMS Growth and Ambulance Needs (2020-2030).” When you visualize
a large number of abdominal pain calls with an ED primary diagnosis of STEMI,
it tells you where to concentrate your QI efforts. Distribution of refusal
calls by shift can be telling as well when visualized showing the disparity.
Showed use of run charts with UCL and LCL limits imposed showing progression of
a QI project. “Response Times don’t matter, stop looking at it. I will die on
that hill by the way.” Target what matters like bystander CPR. Always include
zero as you baseline in visual graphs. Use differing colors to assure everyone
can interpret. Sentiment analysis can be used to look for data in text. She
gave a good plug for the use of QI Macros inside Excel.
It's High Time for High Performance Mechanical CPR – Levy – Disclaimer
that he is not trying to sell mechanical CPR. There are a variety of devices
available. This lecture involves the Lucas device only. They are here.
Mechanical CPR has landed, and the genie is not going back in the bottle. They
need to be used to the best ability. Need a rate of 100-120, 2.1” depth and
full release. Toasters toast toast, however that is not all there is to it. Does
it do what we want it to do? The data is not that great. There are a lot of
trial literature. There appears to be no improvement in outcome with MCPR. It
is not inferior but not superior either. The data is a wash. Is the glass half
full or half empty. When you get it into systems that use it frequently, you
find a bit of superiority in outcomes with MCPR. Machines are as good as humans
at CPR, but they should be better. Machines cannot give us shorter no flow
time. That is up to the operator. Pauses could be the smoking gun. The longest
pauses in MCPR is with device application. What does your data show? Things
take time. Time has to be managed. Maybe perfect CPR is not what we want. Are
we pushing in the right spot? We could be compressing on the cardiac outflow
tract. Watching ETCO2 and pleth wave
need to be used to confirm good placement. Confirm you are in the right place.
Use full crew Lucas application to shorten time. Script everyone’s role in the
application to reduce the application pause in CPR. Also script two-person
application. Continue CPR during defib charging. Video examples given. Apply
the device in phases if needed to minimize pauses. Learn – Practice – Improve.
Train on this. Review cases and give feedback. It all starts with great BLS
CPR. Wait at least two cycles before MCPR. If the machine is not doing the job,
go to manual CPR. Put the piston, not the cup, where you would put the heel of
your hand. Mark the chest to monitor for piston migration. Use all of the
straps to reduce migration.
We’re Doing It Wrong: 10 Steps to Ensure that Your Quality
Improvement Program Actually Improves Quality – Bourn – Why do we have quality
programs? We need to be much more focused than we are. Good structure increases
the likelihood of good process. Good process improves the likelihood of good
outcomes. There are many factors to defining quality including patient and
employee satisfaction. Workflow, care guidelines and communication are top
areas to work on for quality. Care providers are not good at self-assessing
their own performance accurately. We have to measure their performance and give
them feedback. Optimize and De-emphasize chart review. Improvement from chart
review only produces 4.3% improvement. Focus on quality activities. The
effectiveness can be improved by how we do it. It must be used optimally. Use
time limited specific campaigns. Use a specific process. Know why we are
reading the charts. Make yes/no criteria for meeting a process. Include
contradiction data. Identify the review population. Establish the number of
patients in the review in advance. If measuring impact of intervention time
before and after time must be equal. Optimize direct observation (ride alongs).
Do not observe for individual performance but watch the system features.
Specify desired behaviors you are looking for and set the yes/no metric. Have a
standard way to observe and record findings. Don’t forget that your people want
to do a good job. If you don’t believe that, step away from the QI job. We need
to measure system performance and not highlight individual paramedics. Measure
and monitor outcomes. What outcomes? Clinical outcomes. Any adverse events? Use
actual clinical outcomes when you have access to them. Don’t use hospital
outcomes to go back on paramedics. You cannot fatten a cow by weighing it. We
must use the science of improvement. Use PDSA cycles. Have one goal with a clear aim. What do we
want to accomplish? How will we know that a change is an improvement? What
change can we make that will result in improvement? Assemble and use a team.
What elements of our system have created current performance? Measure over
time. Start small. Use one crew, one station. Ask “What is the reason for
that?” Expand as you go. Focus your QI efforts more than you do now.
When Everything Hits the Fan: Behind the Scenes of the
Largest EMS Natural Disaster Response in History – Troutman, Gordon –
Hurricanes Milton and Helene. There is nothing more calming in difficult
moments than knowing there is someone fighting for you. GMR response to this
disaster. There were five major hospitals with minimal to no evacuations in
progress. Numerous smaller facilities and nursing homes needing evacuation.
Initial request was for 50 ALS, 10 BLS and a few paratransit vehicles. Try
always not to use in state resources as they are usually needed in normal
roles. Changed eventually to total 730 ambulances and included air assets. This
response was in motion within 24 hours of first request. Florida hit ended up
not being as severe as expected. Then backed up 911 services. As this was going
on the storm moved up to impact Tennessee, Georgia, and the Carolinas. Half of
the resources were moved north. 6,085 missions completed with over 4,000
ambulance transports. Infrastructure and assets are impacted locally and when
these resources arrive, they augment the existing assets and help decrease the
elongation of response. Assets from 48 states sent units. 86 support vehicles
were used. 151,000 meals were provided to responders. Two therapy dogs
deployed. Sent 5 peer support providers. Had 24/7 mental health professional
availability. DMORT was supported and
responders for this were selected for this task. Discussed controlled substance
access. Challenges in pre-positioning assets and moving them as well. Flight
cancellations were a challenge in getting personnel there.
Drilling Down Deep: Creating a Provider Scorecard – Peterson
– Make things better. That is the role. We create tools, checklists and
anacronyms to improve consistency and quality. Dashboards are used to monitor
performance. If dashboards are visualized frequently, they can drive behavior. They
use First Watch for data cleaning and compiling. They use Power BI for
dashboard creation. Built a scorecard for providers using data for each
providers runs. It shows success rates, reviewed runs, medication usage and
other data. Gives averages for individual comparisons. Not sure if this is
driving change yet. It is an ongoing project. Hopes for it to improve
individual accountability, reliability, consistency, and provide objective
feedback.
We Won’t Get Better by Making Things Worse: How Demanding
More is Going to Save Paramedicine – Lubbers – You may have heard it is
difficult to get people to work on an ambulance. It’s not that we don’t have
paramedics, it is just they are not working on ambulances. There is a 30-40%
turnover in EMS. 49% leave EMS, not going to another provider. Pay is an issue,
but not the only issue. There is also the impact where sometimes people just
want to do something else. Work life balance is right up there with pay. Job
stress and low job satisfaction have now passed pay on the reason while people
are leaving. What a man can be, he must be. 24 hours shifts are an issue. How
do we have belonging with others (where does EMS fit?). Self-esteem issues with
ERs that criticize care. Safety is an issue. Why would anybody want to do this
job? Have you ever thought that what we do, isn’t saving anyone? “And that is
why I am getting off the ambulance.” Making it easier will not make it better.
It is bad to devalue education ability or use caregivers with inadequate
training. It is good to show value and get people to do what they do best.
NEMSAC has an advisory recommendation for the Paramedic Practitioner. A
clinical ladder is being developed for the paramedic hoping to reduce non-reimbursed
care. What would a PP do? The job would be clinical but not focused on
transport. A good example would be treating a CHF patient, doing ECG, point of
care labs, and checking with physicians. Then giving care and following up four
hours later without transporting. The paramedic of today needs more education
to be a practitioner. It can be made safe by making it safe through design.
This is not the solution, but a solution. More value to patients, payors, and
workforce with a more fulfilling experience. It would also make a longer career
path. It would also increase autonomy. This would help start the transition to
paying for care instead of transport. If it’s not for you, it doesn’t affect
you at all. Making it easier to make a paramedic is not an improvement.
Recalibrating the Design of Protocols: A Cognitive Systems
Engineering Approach – Misasi – Paramedic education is substantial. There is no
consistency between medical protocols. Some are policies and some allow for
judgement. Displayed 10 different protocols (types) for anaphylaxis. When more
than one protocol applies to a situation, there will be conflicts in the
protocol set. There is a difference between how work is imagined and how work
is done. Nothing has a greater impact on the paramedic and care that the
medical protocols. Algorithms can impair development and expertise. You cannot
promote clinical judgement and chastise for not following a protocol. It is not
clear as to what protocols actually provide. Speaker used decision centered
design. Surveyed paramedics on protocol design by evaluating them. Evaluation
was between tabular and algorithmic designs. Survey showed paramedics did not
use protocols for care guidance, destination guidance, or medication selection.
Algorithmic did not fare as well as a tabular design. Paramedics were asked how
they used protocols during a call. Interviewed for time flow and tools (job
aids) used during a call. They want a menu of options, not restrictions. What
is the dose and am I authorized were the biggest usage. Speaker provides
“Misasi’s 15” points of what a protocol should provide. Likes two versions, a
desk reference version and a quick access version. If you want critical
thinking and good judgement, use a good model. Google the Calgary Black Book as
a design tool. Let the field of human factors guide you on what field aids to
use.
Together We Rise: The Power of an EMS Driven Stroke Registry
in Shaping Florida’s Stroke Outcomes – Antevy – The Florida Stroke Registry story.
Florida Stroke Registry is a groundbreaking initiative. Process began in 2012.
They have mandated hospital participation. Using data and leveraging hospital
participation has dramatically improve stroke outcomes. Data is powerful when
shared and accessible. It has also elevated the standards of care. The
transparent sharing of data is important to help systems improve and hold
systems accountable for stroke care outcomes and progress. Benchmarking was
used. Dr. Antevy feels that this model is very scalable and could be used for
national replication to improve stroke care.
Day Three
Workforce Crisis in EMS: Reconciling Clinician Sources with Opposing Forecasts – Gage – Not only do we have staffing deserts, but we now have long response times in a lot of urban areas. The forecasts on medics from HRSA are high, but not on EMTs. Are these projections correct? We know certified numbers from NREMT. US Census misses a lot of EMS clinicians.
NREMT data misses those who are only state certified. EPCRs miss non-care positions. We have those entering, staying and leaving. Different reasons for staying and leaving. Are changes in EMS causing people to leave? 911 seems to be the area where people stay. 7-10% of EMS people work in clinical settings other than field EMS. But even 911 has seen a 14% decrease due to those going to other areas. Those entering the workforce still has program attrition or they do not get certified. 21% of EMS students do not complete the program. Another 11% fail out. Testing has gone up by 3.5% annually. Number certified has increased by 4.5% annually. What is happening on the leaving side? They leave for different careers, leave a sate, provider jump, or maintain a card and do not work. Every state has a leaving challenge. Entry is keeping the workforce going. We must fix the leaving problem. Urban has the highest attrition. Not working in a 911 service has a high rate of leaving as well. Turnover is probably at 15% annually. Interventions? Job satisfaction, dissatisfaction leads to a huge group leaving. Satisfaction is hugely protective. Clan culture has the least odds of leaving. We need better info. We need to use individual national EMS ID numbers. Manage the leaving issue. One question asked about the effect of volume. Needs to be assessed. Volunteer EMS is being affected as well.
Safety in Numbers! Strategically Prioritizing EMS System
Response by Call Type and Patient Acuity Analysis – Protecting Those That
Protect Patients – Goodloe – Reduction of lights and siren response is possible
and safe. Improves safety. Reduces EMS accidents and wake effect accidents.
Improves mental health of clinicians. Promotes medical oversight for EMS in
making good decisions on response mode. Leverages the science. It brings to the
table our true value in EMS which is evidence-based medicine. We reduce lights
and siren responses without any outcome deficit. Must have relentless clinical
capacity and quality. Must be concerned with the safety of the public. The
quality of an EMS system is more than just getting there fast... or is it?
Response time for speaker’s system: Priority 1 is 10:59. Priority 2 is 24:59
requirements. 67% of responses are now non red lights and siren. No instances
of adverse events since November 1, 2013. Zero instances. Less than 10% lights
and siren transports. Gives example of how they make the decision by EMD coding
and review. BLS codes identified for BLS only response. ALS activations on
these are less than 10%. RLS transport of BLS patients is less than 1%. Using
BLS increases capacity of the ALS system. Use of BLS promotes EMTs becoming
interested in becoming paramedics.
Support for/from the Prehospital Blood Transfusion
Initiative Coalition – Krohmer – The coalition started about two years ago with
a discussion between four or five individuals. The military is over a century
into using blood transfusions in trauma. The first prehospital use of blood
products was in a service outside of Houston, TX. The coalition is agnostic to
the use of the variety of blood products. Blood products are a precious
commodity. Plasma may be the better component for patients with TBI. Packed cells
and plasma can be use as opposed to whole blood. Whole blood may be the hardest
product to find. Scope of practice, reimbursement and availability of blood
products are barriers in some cases. 42 states allow for EMS initiation of
blood products. All states allow for transport of existing blood products.
There are about 210 agencies doing transfusion programs. There was an attempt
to get blood listed as an ALS2 approved charge in 2024. Submit claims for ALS2
for blood products. We need to file claims so we can see who is paying and who
is denying claims based upon blood products. Use proper data elements in the
EPCR to document blood products, NOT the narrative. Use proper procedure code
and assure the blood component is listed in data of the EPCR. There has been
significant forward motion on prehospital blood product administration in the
last 12 months. The AABB will release EMS standards soon. If you are already
doing this, you will easily meet these standards. We need to work on the blood
supply (donation).
Double Sequential External Defibrillation for Refractory VF:
One Year Later – Cheskes – Randomized trial. March 2018 to May 2022. DSED was
superior to VC and Standard. There is much interest in this topic. It is rare
that a prehospital change affects change in the hospital. This is the case with
DSED. AHA/ERC has not made a statement on DSED. AP path covers more of the
ventricular tissue. Impedance is also an issue. 30% drop in impedance with AP
pad placement. Impedance is even more important with the Stryker LP15. DSED
timing is important. DSED is not simultaneous. Keeping people out of VF is
important. DSED produces better ROSC. Simultaneous damages defibrillators, NOT
sequential. If you use AP placement for the second set of pads and assure
sequential shocks, you cannot damage the defibrillators. DSED provides better
neuro intact survival. Vector is important, but sometimes more energy is needed
as well. Vector change is acceptable for calls where only one defibrillator is
available.
The Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART)
– The Next Chapter in Prehospital Airway Science – Wang - Airway is one of the
most important skills in EMS. Should we abandon ET Intubation for supraglottic
airways? There is some evidence that there is no difference in outcomes in
cardiac arrest in adults between ETI and SGA. But what about kids? Pediatric
ETI had some scientific review before adult ETI in EMS. Skeptics scoffed at the
early information that ETI may be detrimental in pediatrics. There are
challenges in an airway trial in kids as there are a lot more opportunities and
needs for airway control in kids broader than just cardiac arrest. There has
never been a head-to-head trial between pediatric ETI and pediatric SGA.
Pedi-PART is looking at a head-to-head comparison. Goal is to determine the
best airway strategies in pediatrics for paramedics. Primarily looking at i-Gel
as the SGA component. Multicenter, randomly controlled trial. Stage 1 is BVM
versus SGA. The winner will be compared against ETI. They have a budget of
3,000 patients with 1,500 in each stage. If stage 1 shows an earlier winner,
stage 2 will start early. The trial uses an odd/even day strategy. Looking at
chest compression and ventilation data from the continuous data from the
monitor. The trial design started in 2018 and is continuing. No results
presented but are coming. Dr. Peter Antevy asked about ventilatory rates being
used. The answer was that this would be in adherence to local protocol based on
national guidelines.
“From Hello to Dispo” Understanding the Association Between
Emergency Medical Dispatch Call Determinants, Prehospital Time-Critical
Interventions and Patient Outcomes – Levy, Crowe, Meyers – This is about
correlation between EMD condition codes and patient outcomes. IAED protocols
have been studied but need an in-depth link to outcomes. Retrospective review
model. Prior research has been on how to send (ALS vs. BLS, use of RLS),
whether to send (how do you hold a call based on medical evidence). What happens
at the hospital after the call? What is the outcome? Is it safe to triage/hold
the call? Looking to determine the probability of a time critical or urgent
situation based on dispatch chief complaint and acuity. Looking at hospital
data exchange to see outcomes to see presence or absence of critical or urgent
situations. All dispatch centers reviewed were IAED accredited. Eight agencies
selected from multiple states. Does the alpha through echo EMD determinants predict
what happens on scene or at the hospital ED? 543,883 cases were able to be
linked between EMD and hospital outcomes. 12% had time critical ED outcomes.
Proportion of time critical increased with determinant level. 30 met safe to
hold in queue (8%). 7 Alpha codes showed as unsafe for hold. There were several
high acuity codes deemed safe for hold. Note study in PEC on Dispatch
Categories and Indicators of OOH Time Critical Interventions and Associated
Emergency Department Outcomes. There is room for discussion regarding ALS/BLS
vs. Telehealth, nurse advice, and alternative destinations. Not all alphas are
the same. One audience member questioned ability of callers to accurately relay
to dispatch what is really going on. Peter Antevy is asking if this data can
help break the thinking that response times equal quality of EMS. Myers
answered that this could give a method of monitoring impact of response time by
EMD code. This allows for risk assessment in an evidence-based way.
Key Takeaways from the 2025 NAEMSP Prehospital Trauma
Compendium – Colwell, Lyng – Large working group with 110 people involved. Four
collaborating organizations. Over 14,000 articles screened. 1,440 articles
summarized. Comprised of a prologue, a methodology and 16 topic specific
papers. The prologue contains hemorrhage control, trauma airway/ventilation
management, TBI, analgesia, and trauma related triage. Topics covered: 1) Entrapped,
entangled, and crushed patients. 2) IV fluid management in trauma. 3) Traumatic
pneumothorax. 4) Antibiotics in trauma. 5) Pregnant patients. 6) Pediatric
trauma. 7) Vasopressors for traumatic injuries. 8) Adult TOHCA patients. 9) TXA
in trauma injuries. 10) Femur fractures. 11) Blood products in trauma. 12) Pediatric
TOHCA. 13) Spine injuries. 14) Pelvis fractures. 15) Geriatric trauma. 16)
Medically directed rescue. Several of the topics are joint entity positions. There
are quite a few recommendations listed. https://www.tandfonline.com/doi/full/10.1080/10903127.2024.2425821
Links to specific articles at the end of the article in the link. It was
strongly noted that knowledge gaps exist.
That is all for the 2025 meeting. I hope you found these
notes beneficial. Till the next event... be safe and continue to grow.
I leave you with some pictures from the trip.
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| San Diego |
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| A winged croissant thief on the breakfast balcony at NAEMSP |
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| Lobster Sliders at Sea Port Village |
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| The Bar from Top Gun |
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| The Piano played in Top Gun |
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| Leaving San Diego (with Coronado Island below) |
