A Concise Regurgitation of my Facebook Posts from the EMS State of the Sciences 2014 Meeting

Let me start by saying that I also plan to post my notes from the NAEMSP meeting in January, but... I never really promised the NAEMSP notes to anyone and I have promised these to many, so we shall do these first!

And, given that the closest LCMS church is about 100 blocks away and I am sans vehicle in a Dallas, Texas hotel, Sunday worship has already been completed in the hotel lobby with some streaming hymns through an Android App on my phone... and, there exist about three hours until I meet with Kevin Hendrickson to head to the Scareport (where the scareplanes land... to quote Scotty Whitfield) about 20 miles away... followed by about two more hours of waiting... for a 1.25 hour flight into the current ice storm that is Evansville, and... you get the picture... getting the picture? That may not have been the longest run on sentence I ever wrote, but its close and it conveys the emotion of the moment.

So, here is a copy (with a few edits) of all of my Facebook posts concerning the Eagle's Annual Meeting, less trailing comments, except where needed for clarification. Suitable for printing but not for framing (too much coffee this morning?):

• Once again I will be posting updates for the next two days from the US Metropolitan

  

  Eagle's Day One

  Consortium of Medical Director's EMS State of the Sciences Conference for all of you EMS peeps out there... stay tuned!
• Epi alone does not improve neuro intact survival in arrest. Epi+Vaso+Steroid increases ROSC by 19%. 3x neuro intact survival! Also... stopping all pauses in compressions must be a continued focus. - Slovis, Nashville.
• Oxygen is detrimental in CVA, AMI, COPD and Sepsis. No target of 98-100%. New norm should be 92-94%. COPD target is 89-92%. Slovis-Nashville.
• Follow the Eagles key points at "@eaglesgather" or "#GatheringEagles14"
• Boston Marathon bombing response shows that training works and planning works. "Chance favors the prepared mind." -Louis Pasteur. EMS units in urban cities should have no less than 4 touniquets on every ambulance. Dyer-Boston.
• Local EMS mitigated emergency patients and accomplished nursing home evacuation prior to task force arrival at the West, Texas explosion. 60% of patients were transported by private vehicle as several ambulances were destroyed. Medical Director was injured and lost house in blast. Lesson: do what is needed to do to make it work. Understand the basics. Be involved in preparedness. Kidd-San Antonio.
• Plan or plans will be made for you.
• Active Shooter Response. 50% shooting still in progress when police arrive. 98% single shooter. Medium sized communities. Shooter shifts to targeting police on police arrival or kills self. When officer alone, must engage shooter 75% of time. If engaged, officer shot 33% of time. New focus, engage fast rather than prep for entry. Stops incident fsster. See Hartford Consensus. Fabbri-FBI.
• Active shooter LE will most likely no longer wait for SWAT under Hartford Consensus and FEMA active shooter guidelines. This is a joint police, fire and EMS response. Paramedics should deploy with police into cleared, but not secured areas. Treatment MUST begin in warm zone using TECC guidelines. In the second in, rescue team concept (RAMS), Police serves as security for EMS on RAMS team. All Philadelphia fire medics are now trained for entry with appropriate equipment. Mechem-Philadelphia.
• "For the life of the flesh is in the blood..." Leviticus 17:11. They just unveiled an EB guideline for hemorrhage control by consensus of ACS-COT, NASEMSO, NAEMSP, ECRI and AMR: Direct pressure, tourniquet or hemostatic dressing if not an appendage.
• Sometimes big is big and big is bad... there is no "take it all in first" action in a massive tornado. Goodloe-Tulsa.
• Asiana crash. Regular emergencies do not stop. Have your initial procedures baked in place. Walking wounded were very badly hurt and were not green. Great response videos. Yeh- San Francisco.
• Just a note. This remains the go to conference of the year for EMS. I have been to none consistently better.
• "We have failed to educate physicians on what EMS is and where EMS is going." Blackwell-Greenville. All first year South Carolina med students must complete and certify as NREMT and work one shift a month on ambulance.
• Recipe for simulation vomit... Campbell's chunky vegetable soup with two shots Jack Daniels... shake well. Blackwell (blame him).
• Kudos to Neil Richmond’s Louisville, Kentucky EMS medics who assisted with registration last night to keep flow going here at Eagles in Dallas.
• 53 urban, federal agency and international medical directors now on stage... let the audience questions begin.
• Pay attention to the medicine in your system. Keep the radio under your pillow 24 hours a day.
• Michael Copass wins 2014 National Excellence in EMS Award. Many of the medical directors present from across the nation trained under him in Seattle or took sage advice from him.
• 1) Had the pleasure of lunch with the Medical Director of FDNY and several other EMS professionals. Good discussions on EB use of spine boards and also arrest management. 2) 
• Where I keep being mistaken for a Physician when teaching... I have now been bestowed with an AAS degree via my name tag... thank you very much UT Southwest... LOL
• Low dose Ketamine very effective for pain control without many side effects. 0.1mg-0.5mg/kg IV. Can be given intranasal. Costello-ACEP.
• Intranasal Fentanyl very effective and safe in Peds. 20% of EMS calls involve pain. Taillac-NASEMSO. Fits with AMR Evansville protocol and experience.
• Neither psychology nor data show length based tape resuscitation in Peds is actually correct or works. Great lecture on how the brain thinks. Call to remove length based tape from practice. Antevy-Broward. How many of us have said this for many years? www.pediatricemergencystandards.com
• Clawson presented little used EMD protocols on stuck accelerator and also sinking vehicle. Played audio of EMDs failing to use protocol. Tragic. You only get one chance at this before death. Clawson-NAED.
• Fairly common for Bravo level EMD responses to become or be arrests on or after arrival. Advocates first responder response. Less than that showed only 23% of true Echo responses received FR response. N. Richmond-Louisville. (I have seen this way too often).
• 95% of training is for 5% of calls. Everything we do has to be in line with the IHI Triple Aim. Beeson-Ft. Worth.
• A vision without resources is a delusion. Beeson- Ft. Worth.
• Albuquerque study shows double medic crews make more errors. Crews of EMT/Paramedic faster at clearing scene. Harrell-Albuquerque.
• Paramedics are extremely good at identifying very ill patients. Paramedics are also very good at identifying patients who are perfectly fine. It’s the ones in the middle that are difficult. Isaacs-Dallas.
• During lightning round discussions, one city medical director has ordered tourniquets placed in every public AED box. I know what this comment may stimulate... what about tourniquet over use by limited training individuals? I do not believe that is the case. 1) Tourniquets are now proven to not cause harm so it really is not an issue if it is applied as overkill by the public. 2) when needed it is a proven life saver. (I am going to make a shout out that we need tourniquets in every classroom for teachers as part of active shooter response planning... please don't give me any flack about the training level, it's simple and would save lives).
• One European medical director commented that they have found the new IT clamp to be very effective in controlling scalp lacerations.
• Alaska has a state grant that will allow every 8th grader to be certified in CPR state-wide. Levy-Anchorage.
• There appears to be quite a bit of support from several medical directors dealing with large patient volumes who are transitioning from King and Combi-tube to the I-Gel stating raving reviews from crews. London Ambulance Service has also transitioned to the I-Gel. (Have to look at that!).
• Frequent flyers now being called Super Users. Top 20 patients in LA accounted for 2100 EMS calls and 1900 transports. The median age was 51. 80% had a payer source, but only 10% resulted in reimbursement. In most cases ER was not appropriate for their care. Heavy burden on EMS system infrastructure and cost. Sometimes multiple transports in a single day. Impacts availability of EMS and increases ER load thus increasing ER wait times. Shortage of primary care physicians. ACA may make ERs much more busy. EMS turn around time or "wall time" is increasing. Hospitals cannot hire more staff as reimbursement dwindles. ER patient volume is seeing more patients who are not admitted. Resulting in mid-level providers in the field and need for mobile integrated health (still needs payer source). EMS systems should become more tiered in response (I agree!). Radical change is ahead. Eckstein/Los Angeles.
• EMS care at the end of life is increasing. EMS needs guidance and training in this area. Yancey-Atlanta.
• Ft. Worth system notifies hospice of 911 responses to hospice patients so that they are involved from dispatch. They also offer the caller the community paramedic to come to house instead of ambulance if desired. The key is an innovative partnership that works well for end of life care and helps prevent hospice revocation. Helps decrease the effect of the panic response at time of 911 activation. Beeson/Ft. Worth.
• Up to 48,000 Afghan and Iraq theater veterans are homeless. Phoenix fire implemented a training program for EMS to be aware of what some veterans are experiencing. Also initiated dispatcher training for veteran interaction during crisis. Overviews stressors, PTSD and available resources. 81% reported having been attacked during duty. 79% had seen dead bodies. 9% of the Arizona population are veterans. Played videos of live combat to show environment experienced and IED detonations (not that it compares to being there). IED explosions were huge, including one that erupted 30 feet of asphalt directly up in the air as if a monster was coming up out of the road. The question was asked.... if you had seventy near fatal car accidents in one year between ages 18 and 19, would it mess you up? Combat Operational Stress First Aid was lightly referenced. In some cases, more suicides have occurred than number lost in combat in a single year. Be respectful of deployment experience. VA working hard to identify and offer treatment. Phoenix was the first US city to house all identified homeless veterans. Gallagher-Phoenix.
• Salt Lake has program triaging some psych patients directly to psych facilities to decrease ER load and deliver appropriate care. Youngquist/Salt Lake.
• Substance abuse and mental health is the largest area of need in mobile integrated health. They are screening for psych facility transport as well (Wake County). Their advanced practice paramedics are trained in breathalyzer use. "If the patient is suicidal, you can make a pretty good case that they need to see a psychiatrist not a trauma center." Myers-Raleigh.
• Tomorrow: Spine Board discussions, resuscitation, street drugs and trauma! STAY TUNED! Heading to dinner.... phew!!! (had to interject that one as I was getting texts asking why the updates had stopped after 6pm!).

  

  A foggy start to Day Two...

• Day 2 posts from Eagles will begin within the hour. Please feel free to use the Facebook SHARE feature to spread anything interesting. This is the kind of information that leads to changes in patient population outcomes. (some of these posts had up to 30 shares per post).
• 58% of medical directors still feel prehospital therapeutic hypothermia is valid and are continuing. 85% believe in motorcycle helmet removal. 60% believe in sports helmet removal. 80% call codes in the field. 55% feel Ketamine should be used in EMS. 39% use device med dispension for EMS at hospital. 25% still respond to all 911 calls lights and siren. 83% allow permissive hypotension in trauma. This is reported from the Eagles library threads. They are going to make these 78 threads available for public viewing this year as 10 topic areas. Local studies will be available as well as survey results. Augustine-Eagles Librarian. I will advise site when revealed.
• Chicago fire presented how they used the CARES database to improve OHCA outcomes. Weber-Chicago. I will reiterate this again. If your EMS system is not enrolled and participating in CARES you are are missing out on a very kow cost tool for comparison on OHCA success. Not very time consumptive to play in this arena. I know that in 2013, Evansville was the only player in Indiana. We need the whole state involved. You don't know what you don't know... measure and benchmark. (In comments it was noted that Harrison County EMS has now started CARES entry for 2014, Gary Kleeman and Mike Hunter who used to work in Evansville. Great job!).
• First question to always ask... how does this apply to my system? (This is why I hate state and regional protocol sets). 40% better outcome with intubation over superglottic airway in OHCA. Trust, professionalism and perfection is what every patient expects every time... this applies to airway also. Waveform (not colormetric) capnography on every airway as the FIRST mechanism to confirm and monitor placement and effectiveness. BVM alone for some patients with difficult airways could be more beneficial than intubation or SGA. paramedic must have ability to choose by patient presentation. McMullan - Cincinnati.
• No ventilations during 1st 6 minutes on scene of OHCA in Witchita. All are worked on scene. Have judged that ventilation and drugs are secondary to assure 90% of time is spent doing compressions. Systems must do whatever is beeded to decrease perishock pauses in compressions. Look up the Japanese words Seiton, Seisou, Seiketsu ans Shitsuke... and apply to how you manage arrests. Start compressions immediately following shock. They have reduced perishock pauses from 31 seconds to 5 seconds. Braithwaite-Witchita.
• Video taping cardiac arrests in Anchorage. They put GoPro cameras on every LP15. Seen only by medical director then file is destroyed. Too many bags and equipment on scene is a distraction and hinders movement and care. Video allows feedback that you may not see yourself. Ethics and legal on this are still undetermined. Not used for discipline. Levy-Anchorage.
• Compression fraction is the number one effector of OHCA survival. ROSC is the number one predictor of survival. Work them where the drop. If the rearrest in unit STOP. If there is not enough room to work them in unit pull them out. Let nothing impact compressions. They have used PDSA cycles to improve this process in Austin/Travis. Hinchey-Austin.
• Memphis has had a dramatic increase in ROSC with use of LUCAS but no outcome info is available regarding survival to discharge. Jury still out on mechanical CPR. Holley-Memphis. I still think that the only valid reason for mechanical CPR is long transports with prolonged CPR for crew safety in transit.
• NAEMSP is publishing position on when to terminate arrest soon. Wake County data shows predicted survival probability in VF and PEA lend toward the 40-50 minute range to capture 90% of survivors with 70% neuro intact. Asystole very short in comparison. 20 minutes. If capno is good.... keep working it. Myers-Raleigh.
• Colorado is seeing increasing excited delerium issues with Black Mamba Cannabis since legalization. Epidemic levels. Dangerous for user and very dangerous for caregivers. Ketamine being used in this situation. 5mg/kg IM. Less proved to need redosing. Hefty dose. 33% required intubation. Shorter ER stay with Ketamine. Had higher intubation occurence with Midazolam. Ketamine works. Collwell/Denver.
• 1013 fentanyl related deaths 2005-2007. Now seeing fentanyl laced Heroin in Philly. Most effected cities are Chicago, Philadelphia and Detroit. Detroit had 12 deaths in one day. Public narcan administration seems to be helping. Carfentanyl is 100x more powerful than fentanyl if that is used. Always give lowest amount of Narcan needed to improve respiratory status. Mechem-Philadelphia.
• Naloxone is not a benign drug. Medicine changes rapidly. If it was benign we would not be discussing opiate withdrawl. If they are breathing adequately Narcan should never be used. What is really needed? Naloxone in this case? No. What is arrival difference between LEO and medic unit. Program should not happen until this is measured and found to be an issue. Four minute difference not enough to warrant LEO Narcan. Goodloe-Tulsa/OKC. My thought is this... we just need to measure need and make an EBM decision rather than be reactionary. If found to be a real issue so be it.
• Science is good. Technology is great. Unless you can socialize it... its dead in the water. It means you talk the talk and walk the walk. What have we learned at Eagles? You can learn more in 10 minutes than in 60. Humor and slapstick make it stick. In order to move forward you dont have to be organized. Change is rapid and consistent... but not necessarily organized. No fluff. Cut to the chase. Give the data and go. People pay attention to quirky... use that! Eagles presents successes and failures in a peer environment. What sounds ridiculous ends up being good ideas. Leave here wondering how well you are doing at changing your system. This is art and science. If you suck at art you can't implement the science. Evidence must translate to implementation or it is useless. Eagles is the fertile soil for evaluating small tests of change. (Resounding applause for this). Shame on us if we do not become transparent, accountable practices of medicine. Racht-AMR. My note... fits perfectly with the IHI Triple Aim and small tests of change. How do we get EMS to embrace this?
• Lightning round... how many have non-EMS narcan programs? About 20-25%. How many have streets littered with dead bodies of heroin addicts? Not a single hand came up... I do not know the answer... is there a measured/assessed need?
• Lightning round... TXA use? If used it should be EB for individual communities based on need and measurement. My note: Once again... medicine application is a local issue. The broader applied the more lowest common denominator it becomes and the more resistant to change.
• I am laughing... Peter Antevy just said that because many ERs do not have waveform capnography it is all the more reason to work the arrest in the field. GIVE THAT MAN A COOKIE! Great perspective.
• Several states now have policies allowing extension of drug expiration dates in times of shortage. (REMEMBER TO FOLLOW WHAT HAS BEEN SAID IN YOUR STATE).
• Video honoring EMS line of duty deaths during last year in the nation. Lives given serving others are never truly lost. My note: Always remember that sometimes we don't come home... we go Home. One shown as a youth in his BSA uniform... OA Brotherhood and Eagle Scout. Just touched me... Singing Auld Lang Syne...
• Several cities including San Francisco have Sobering Centers to take load off ERs. Other major cities looking at the concept. This would mean inebriated individuals would be taken to a quasi-medical facility to sober up under medical supervision when they met safety criteria. Isaacs-Dallas
• 10-12% of physicians will develop a substance abuse addiction during their career. "The insanity of the disease is that it tells you that you work hard... you have a right to play hard." They do the same thing over and over again expecting a different outcome.... the very definition of insanity. Eventually a point is reached where you do not want to live without drinking and using, but you don't want to stop either. Rehab is the worst thing they will ever go through and the best thing that could happen. YOU CAN SAVE THE LIFE OF A COLLEAGUE OR LOVED ONE by not covering for them and helping them access programs to help them. You can help build programs to help them. Quote: "Not everyone can be a hero but everyone can be great, because greatness is determined by service." - Martin Luther King, Jr. Don't be afraid to help. "It is by God's grace that I stand before you today... sober for 5 years" -Isaacs-Dallas (Standing Ovation). Pepe added... it is hard to deal with those involved in substance abuse, but they are all the same human beings. They all need help and need redirected, whether they are on the street or a physician.
• My opinion only... just hit the first less than favorable lecture this year. I think someone needs to look at GCS as a scoring/documentation tool rather than trying to classify it strictly as an assessment tool and comparing it to AVPU. Use has grown far past its original intent as an evaluation of TBI. A lot of shaking heads in the audience.
• "Larry Miller will personally be responsible for saving the lives of hundreds of thousands of people across the planet." ...in reference to the inventor of the Vidacare EZIO. Frascone-St. Paul
• 250,000 central line infections every year, costing over 2.3 billion dollars. IO's are central lines without all the complications. Presented that hemodynamic monitoring can occur through the bone marrow, meaning IO could be used for monitoring, decreasing need for central lines. Now doing human trails on this. Presenter convinced this will prove better than central lines. Frascone-St. Paul... I will go there... imagine the applications... like MAP recognition of fluid resuscitation targets rather than the magical, mythical systolic 90?
• It is now known that clotting the superior vena cava is most often caused by central and PICC lines. Fowler.
• PPV and hyperventilation continues to be the devil. Every increase of 1mm/hg decreased
  cerebral blood flow by 4%. Hyperventilation is assassination unless herniating. Alteration in ventilation, perfusion and cellular metabolism will affect CO2. USE ETCO2 WHEN VENTILATING In significant trauma without head injury, Hypocapnea is an indicator of shock. McMullan-Cincinnatti.
• Intelligent Conveyance. London: 8.2 million population. 620 square miles. 767,000
  
  transports per year out of 1.7 million calls. Many are diverted via nurse call taker screening and instructions. 31 emergency departments. Intelligent Conveyance aim is to proactively manage London Ambulance Service surge issues on arrival at ER. Not aimed at reducing ER transports. Intelligent Conveyance desk manned by paramedics and EMDs from 0800 to 2359. This is all about decreasing ambulance turn around to keep ambulances call ready as much as possible. Hourly arrival triggers are monitored. Ambulances are identified by clinical dispatch criteria and an ambulance may be redirected to a less busy hospital after consultation with crew. Shortens wait time for patient and turn around time for crew. Dedicated talk group for Intelligent Conveyance. Specific alert level patients for stroke or STEMI are not diverted. Minor injuries suitable for urgent care are not diverted. 8650 calls have experienced IC. 39% transported to alternate facility. This has significantly reduced ERs going on diversion. There have been no clinical incidents. Fionna Moore-London Ambulance Service Medical Director. My note: I am always impressed by LAS and Fionna Moore's presentations. They have no laws saying they can take a patient where they do not want to go, but they do not pressure as it is the quickest way to a complaint. Most go along with the program.
• The more 12-leads we do the better we get. Do not limit to classical signs and symptoms. Be sure and run on atypical and aginal equivalent presentations. ALWAYS in syncope. ALWAYS in general weakness. Presentation simply reinforced some of the more odd presentations that we should have been running 12-leads on since 2000. Schrank-Miami. My note: Right sided leads and posterior leads are under utilized as well. Right sided leads should be taken any time there is Inferior STEMI or hypotension following 1st Nitro.
• Just so everyone understands the Eagle's format: Two days, 0700-1730. 49 10-15 minute data driven presentations, 4 award presentations, 4 lightning rounds with the audience doing the questioning and survey of the Eagles, and one great oppositional debate. No tracks... everyone gets to see the same presentations. Conference gets larger every year. HIGHLY RECOMMEND. Conference demographic, primarily EMS Medical Directors, EMS clinical management and paramedics.
• Who do you need to immobilize at an accident scene? The one on the phone with his attorney. Great joke to start the LSB discussion.
• NNT=1032 to prevent one bad outcome. NNH=66 to cause one harm with spine board application. LSB use must be judicious and benefit must outweigh risk. Strong muscle groups support spine in back. St. Louis Fire advocates c-collar only as the only weak non-supported area is the neck. Gilmore-St. Louis.
• The Eagle's 2014 Great Debate - Fowler vs. Valenzuela: FOWLER: 14,000 spinal cord injuries annually. 1/3 die in the accident. Axial distraction is BAD. LSB causes pain. Pressure at sacrum on board is 149mm/hg. Two fold greater disability if spine board is used. Data is empirical that LSB should not be used in penetrating trauma. Early on, immobilization on LSB only occurred due to incomplete/inaccurate assessment at the emergency department level (trickled down to EMS). Clinical criteria exists in the NAEMSP/ACS-COT 2013 position. This is an evidence-based document/criteria. We immobilize far too many people. "Anyone who objects needs to be strapped to an LSB for an hour with a full bladder." Spine boards do not immobilize the spine. Spinal injuries are rare. VALENZUELA: Keep the LSB. Significance of trunk motion when head is immobilized is an issue in at least one study. If halo permits 4%, 4% must be pretty good. Halo also reported at 7% movement. Anyone saying LSB causes pain must be a drug seeker. Pressure ulcer data is from 1987. No pressure ulcers if rolled. It is significant if injury is prevented once. One study assumes Malaysia is medically sophisticated. It also collapsed patients into broad categories. Also, does not look at severity of disability or non-spinal injuries. Feels that LSB is bad is NOT supported by the data. Some studies indicate flaws and the fact that more study is needed. Compares it to a randomized controlled trial of parachute effectiveness. Showed several articles from 1950-57. These indicate presence of cord injury by movement for x-ray (could be secondary injury also). If we rule out drug and alcohol how many people are left that do not get immobilized? RESULTS (entire Eagles group): With only 14-18,000 injuries a year there may not be a randomized, controlled multi-center ever. There is a swelling component causing secondary injury that is not prevented by c-collar or LSB. Most likely the cause of "late development" of spinal injury rather than movement. Stated that Spinal clearance should be a BLS skill but must be followed consistently. Long spine boards and immobilization are not the same. Immobilization can happen without a LSB. Described case study of a hangman's fracture that was not treated and allowed to heal without intervention in a 17 year old. Young children cannot sit up and keep head supported with a c-spine injury. Also had a good outcome on a non-immobilized 1 year old with c-spine fracture (halo only). Most Eagle's believe LSB should dramatically decrease. Many de-emphasizing general LSB use as a component of immobilization. Data shows near drowning children under age 5 do not have c-spine injury. Everyone needs to stick to the protocol in their practice based on what the medical community desires based on available EBM application. Missed fractures have been inconsequential. Atlanta removing FR applied LSB in back of ambulance after evaluation. One medical director believes that fear of the nurses reaction in the ER is the only reason that anyone gets immobilized in his system. Many have three levels... no immobilization, c-collar and head to cot or full using LSB. Some have removed all immobilization. Injury reduction of caregivers lifting the "tongue depressor on steroids" (LSB) is another issue not supporting LSB use. (yeah I know… still vague… just like the position paper…).
• This concludes my attempt at relaying the information from the US Metropolitan Medical Director Consortium: EMS State of the Sciences Conference (Eagle's) for 2014. I will attempt to cut an paste all of this to my blog sometime in the near future so that it can be printed or referred to in one place. I will also post the link to the PowerPoints once available from the Eagle's group. Feel free to share my comments. Can't wait to see home tomorrow!

So here I now sit in the hotel… Kevin and I hoping that the direct flight to Evansville is not cancelled due to the ice storm. All things said, this was a great trip. Every Paramedic should attend this meeting at least once. If you are a medical director or are involved with EMS clinical practice, you should be here every year. The same goes for NAEMSP annual meeting.

Below are a few pics from the trip...

Till next time! May His peace be with you.

The Cafe Pacifica

Dr. Fouts Photobombing the Ferrari

The Evansville group at Dinner after Day One