It was suggested to me this year that I offer up these notes for everyone to read again, so here they are. Please understand that what appears below is one lecture or statement composed as a single paragraph note. These were originally designed to be my note taking and to be somewhat sentence structure compromised to be concise in a social media context.
These are my notes and interpretations. Hopefully you will find them useful. If you want to explore more, the PowerPoint presentations are usually placed on the Eagle’s group website shortly after the conference at www.gatheringofeagles.us
Keep in mind that these are my notes...
DAY 1
Here we go... I will give pertinent updates as they are delivered from the 2015 EMS State of the Sciences Conference here in Dallas...
I will follow each comment today with a XXX/YYY format with the first being the last name of the speaker or MD and the last being the city of origin.
The five most important topics in publication over the last year: 1) Valsalva - Valsalva works significantly better if performed when patient is flat or in reverse Trendelenburg. Bear down for at least 15 seconds. 2) STEMI and MS - 15% vomited, only 2% vomited without MS. MS increased platelet activity. Consider Fentanyl or use antiemetic with MS. 3) Epi in Arrest - In all current studies EPI DOES NOT WORK. However switching to Vasopressin early may have benefit. More to come in the future. No current evidence that Calcium and Epi work together either. Only use Calcium if underlying condition indicates use. 4) Hands on defib - Questionable safety. Do it with gloves only. 5) STEMI - 1 in 5 prehospital STEMIs resolve on the ECG before arrival at ER. All still had MIs confirmed in cath lab. Message: do not derail from going to cath lab because ER 12-lead is now clear. Base it off the 12-lead that shows STEMI. Additional note: people who exercise by running adds 3 years on the average to lifespan regardless of underlying condition. Slovis/Nashville
NDMS teams number over 6000 personnel in 80+ teams (DMAT, DMORT and NVDT) for disaster deployment. All are intermittent federal employees. Train about 1000 people per year. Intense training program at the Center for Domestic Preparedness. They use simulation and train as they work. Mobilization occurs within 6 hours instead of the standard three day window for disaster response. Team centered responses and focused. Team commander has federal authority. They respond internationally. Garrett/NDMS
Stay, Stay, Stay, Stay, Stay... Just A Little Bit Longer... Raising the limits on on-scene termination of resuscitation: When should we stop CPR? What is futile? Right now we do not know. What is clear is there is no validity to the common "25 minute" rule. At 25 minutes, in VF/VT you still have a 31% chance of survival neurologically intact. 90% of neuro intact survivors had ROSC after 40 minutes of resuscitation. Even the ETCO2 of 10 to 20 is based on limited evidence. It may be a combination of arrest rhythm and ETCO2. If ETCO2 is rising, you should probably keep going. They are correlating data now and the call point may be ETCO2 less than 15-19 at the 30 minute point and 60 minutes for all arrests. More data next year. Co-morbidity may come into play as well. Age is not enough to base decision on, but co-morbidity may be. Myers/Raleigh
Ultrasound in prehospital cardiac resuscitation: Is it useful? When polled in the room, less than 1% of ground EMS have ultrasound capability. WORK ARRESTS WHERE YOU FINDTHEM! PERIOD! "You do not want to arrest in the emergency room lobby. You want to code in front of rescue." Most common use of arrest ultrasound is checking PEA for flow or no-flow. Positive cardiac motion was suggestive of survival. Simple view technology to see if there is cardiac motion during the arrest. Ultrasound usage in EMS should START WITH CARDIAC ARREST not trauma. Watch for publication of the Reason 1 trial in the future. Harrell/Albuquerque
Transesophageal Echocardiography (TEE) currently not cost effective for prehospital. Probe alone is $30,000, but cheaper, portable technology may be on the horizon. VERY clear cardiac function pictures from device shows clearly what rhythm the heart is actually in cases such as apparent Asystole which may actually be VF. The rate of misclassification of VF is unknown. AED study shows AEDs miss 16% of VF cases and do not shock. Case covered where VF determined by ultrasound was shocked and eventually went on to ROSC. PEA is a very dangerous rhythm to terminate arrest on. Multiple causes that may be correctable. Pulse check accuracy is only 15% when performed for 10 second duration as supported by AHA. Patients continue to wake up in the morgue every year. Fact not fiction. It comes down to: do you want to terminate on a victim that has any type of cardiac motion? Not much clinical evidence for standard hand position in CPR. Current hand position may occlude aortic outflow. TEE can help make rhythm decisions and indicate actual cause of arrest in PEA. Youngquist/Salt Lake City
Bispectral Index Monitoring (BIS) in Determining Futility: "We don't know when dead guys are dead anymore." Case covered where patient communicated with EMS crew while LUCAS compressions were underway by blinking his eyes. Cardiologists should state that recurrent VF is the equivalent of STEMI. This patient had an occlusion found on table after over two hours of LUCAS CPR and lived and is back to work neurologically intact. Most patients do not have external expression of neuro status like this patient had, but it may be indicative of need for longer working of arrest to ultimate, focused intervention. What if we knew the condition of the brain? BIS has been called the poor mans EEG. Used for monitoring unconscious patients in many healthcare settings. Highly validated in accepted usage, but not yet for EMS. Study has been started for EMS. Delivers number between 0-100 indicating brain function. Will tell us brain function when incapable of external expression of neuro status. "We need to know when a dead guy is dead and when we think a guy is dead isn't." Frascone/St. Paul
Termination of traumatic arrest efforts in children: "We all love kids... but not as patients." Hard to call a peds arrest on scene (family chaos, do everything response). There are no good guidelines for terminating pediatric arrest. Adult trauma arrest has some pretty solid termination of arrest guidelines, but not peds. Children are specifically excluded from the EB guidelines. Literature review may support using the 30 minutes guideline for TOR in peds (traumatic arrest) where arrest was witnessed and CPR was started within 5 minutes. If CPR was started as stated, peds patient should be transported with continued CPR. Surveys show no standardized guidelines available and this needs work. Self help options need to be available for EMS personnel working peds arrest cases. Training coming online on coping for EMS dealing with PEDS arrest. training will be free. Express sorrow to the family and offer them help by asking what they need. Never underplay or trivialize the death of a child. Taillac/NASEMSO
Re-focusing on the providers who terminate the efforts: Chicago working to improve the TOR process for EMS personnel. Train on death notification. ICS for cardiac arrest: IC language, team concept. How do we feel? 2309 surveys completed in the system. Average number of years on job in survey: 16. 70% very experienced in taking care of OHCA. 56% had performed fewer than 5 TOR in their career. 60%
Survey of paramedics regarding end of life care: "We will witness or be part of the care for a relative who has wishes regarding end of life care." 100% response rate on their paramedic survey on EOL care. New medics (less than 4 years) vs. experienced medics on knowledge of EOL care. Training can occur combined regardless of cert/license level of provider. All reported experience on this issue. What hey found hard: documentation (DNR type paperwork being present and available), interpersonal communication with families, interpersonal communication with healthcare professionals, need for formal education on the subject and emotional distress toll on provider from these issues (My note... like no facility of any kind wanting to accept the patient who dies on the way to a hospice facility? Creates far more stress for EMS and family than it should.) Yancey/Atlanta
Other feeds available for Eagles: @EaglesGather #GatheringEagles15 and www.gatherinofeagles.us
30,000 people currently following this conference.
PowerPoints available on the website in about one week.
Mechanical CPR: Humans perform CPR poorly... just a fact. Machines perform CPR within guidelines. That sums up what we know... other than some details. You will hear "Comparable to human CPR" a lot. Almost all arrests start with human CPR prior to machine CPR which jades comparison. Most do not show a benefit to patient survival with machine CPR at 30 days post arrest. The most successful intervention seems to be simple: Measure what you are doing and improve. Look at data and use it to improve. Look at quality of compressions and pause management (MICPR). Peri-shock pauses in compressions correlate to less survival. This may be the benefit of mechanical CPR. Remember also that transition from human CPR to mechanical CPR causes a pause. Decrease the time of the pause. Is mechanical better than world class human CPR? No. Does it provide a solution for CPR and safe crew transport? Yes. Get the right tool for the right job and use it correctly. Levy/Anchorage
Tennessee two-step: Memphis' advice on the Lucas Device: 125,000 emergency runs a year. About 1500 cardiac arrests over 3 years. AVG arrest age of 60. Males with ROSC 25%, Females was 31%. ROSC rates improve with age of patient. ROSC with Lucas: 30%. ROSC rate with human CPR: 21%. Believes that mechanical is not better at CPR... just better at managing pauses and does not get tired. Holley/Memphis
Analyzing cardiac arrest performance: Credits good data and outcomes to his prehospital EMS workers to start presentation. 1271 resuscitations in last year. 68% are cardiac. "Fundamentals always matter." Little details are vital! When not compressing, perfusion pressure rapidly drops. "If you don't have VF an AED can be a health hazard." (speaking on delays in compressions). Must decrease pre and post shock pauses. Rate matters. 90% of providers compressing without a metronome are compressing at 130 and above rather than 100-110. Do not hyperventilate. PEA is a hazard as it distracts from compressions. P4 in the PIT crew (scene management) is crucial. Should never touch the patient and manage the cardiac arrest. Praise the fundamental performance as well as the outcome. The fundamentals improve the outcomes. Review CPR analytics ASAP and provide feedback (QI needs to be as close to real time as possible). Minimize pauses. Slow compressions using metronomes. Decrease distraction caused by PEA. Fundamentals always matter. The silver bullet does not exist. Work hard in arrests. Goodloe/Tulsa and OKC
Gravity assisted CPR: Looked at whether raising or elevating head affects cerebral perfusion in CPR. Potential flaw of supine CPR: Simultaneously increases venous and arterial pressures in the brain. Duo, high intensity pressure waves hammering the brain with each compression. By elevating head could we decrease ICP and improve blood flow in the brain? ICP was decreased with head elevated 30 degrees. Cerebral perfusion was improved. In head down cases, ICP increased even more than supine and perfusion went down. Pressure was improved but what about flow? Yes with head elevated. Worse with head down. This was done with ITD and Lucas. In past studies, ITD alone does not improve outcomes. No outcome studies on head elevation yet. What is the optimum angle? Unknown... only tested at 30 degrees. They have only been working on this for six months. Pepe/Course Director
AED firing in the awake patient: Nine year old. School nurse put him on AED for stomach ache and a rapid heart rate. AED had a SVT discrimination function. Manufacturer (as all do) states never put an AED on a conscious patient. Short of it... nurse pushed the button on a conscious 9 year old, BUT... it converted the SVT from undiagnosed WPW SVT to NSR. They did however change the verbal belief that the AED should be put on for just the heart rate! Keseg/Columbus
STEMI right into the lab: Do it! D2B as low as 11 minutes. Enough said?Asaeda/New York
Mobile Stroke Unit: Time frame of treatment still very important in stroke outcomes. Huston has mobile stroke unit. Has improved time to TPA. 42% treated within 60 minutes of symptom onset. No word on outcomes yet. Perrse/Huston
ILCOR Draft Guidelines: Sneak peek - We do not know what temperature is good after arrest but we know hot is bad. Mechanical CPR should be used for safety in transport. No large volumes of fluid post ROSC. Recommend against ITD use. Comments close February 28th. Myers/Raleigh
Eagles Lightning Round #1: ILCOR this time has recommendations that are stronger in areas where there is not necessarily proven benefit but where there certainly is no harm. Just because there is a new technology out there does not mean we need to be using it unless demonstrated benefit. Money must be directed to where benefit is demonstrated. General belief of the medical directors that AHA guidelines usually fall short and are behind the science (my note... AHA always seems to be catch up and vague in my opinion). It was noted from the audience that we depend on the medical directors to keep us improving during the five years between AHA changes. Minnesota has a resuscitation consortium to roll out science quicker than the AHA. It was noted that AHA is considering incremental updates instead of an every five year change. We do know CPR in the back of an ambulance is "crappy" and unsafe for EMS crews. Work on scene and stop vehicle if re-arrest occurs so adequate, safe CPR can be performed (unless mechanical in place). The question is how many EMTs, Paramedics and firefighters are we going to lose in crashes doing CPR standing up in an ambulance versus lives saved? Again, work it on scene. All medical directors on stage (Eagles).
Eagles Lightning Round #1: Push toward diminishing use of late Epi and switching to Vasopressin in late arrest (my note... too bad that we stopped being able to get Vasopressin last week. Drug shortages strike again!). Not a lot of data on this yet. Will Vasopressin come back into availability?
Eagles Lightning Round 1: Do not use the term "stay and play," use "stay and save."
Annual Ron J Anderson Public Service Award presented to Fionna Moore, MD Director of the City of London Ambulance Service (formerly the Medical Director)... My note: WELL DESERVED.
Location! Location! Location! When Dispatch Knows where the AEDs are: 88% of OHCA occurs at home which makes public access defib not very beneficial to those patients. Can we link data so that we know where the closest AED is? Hard to determine where they all are. Firefighter block checks, websites and crowdsourcing can be used to locate AEDs. Used crowd sourcing with contests fro pictures of located AEDs in Philadelphia. Over two month span they gave a $10k of grant money to those who found the most AEDs for their charity. Picture, description, address and GPS coordinates were part of the collection criteria. They found 1429 AEDs in Philadelphia in initial contest in 2012. They have now logged nearly 4000 AEDs. Shapefile is used to superimpose AED locations on map so callers can be told when an AED is close to their location. Challenges: Will owner allow AED to exit property? What if there is no access? What if it gets moved after location is logged? Great potential but has issues. AED drones may be preferable. Mechum/Philadelphia
Acute Astuteness, Focus on Dispatch Metrics: Sending everything hot is not the best answer. We need to send the appropriate resource under the appropriate response status. Not everything needs first response. FR was going on 62% of EMS calls in Austin. Ranged from 23% to 100% of calls in systems across the nation. Using EMD, There is a dramatic drop in acuity between Echo and Charlie level calls. They also implemented a near unit protocol. If ambulance was closer than FR, FR not dispatched on Charlie level calls. Projection is that nearly 10,000 FR calls would be eliminated by no first response on Charlie calls. Over 40,000 calls would be eliminated by the near unit exception. Problem is that it does not save any money as the engine is still there and must be for fire coverage. Cost is not the reason to do this. The value is in reducing the risk to firefighters and community by unneeded lights and siren responses. Hinchey/Austin
Trend-breaking Decision-making in call taking: Switching to a criteria-based dispatching system: When Levy became medical director, dispatch cards (old algorithms) were found under the desk and not used. Noted that dispatchers needed more flexibility in application instead of just moving through the script. Received training in the new system. Using the eCBD system. Started process by streamlining cardiac arrest for DA-CPR. Goal was to decrease time to DA-CPR. They now ask for the phone to go to the patient and make part of the determination based on whether the patient can talk to the dispatcher and what they hear on the caller end of the line. 32 hours training for each dispatcher including A&P and sick/not sick. Percentage of recognition and application of DA-CPR improved dramatically. Listened to tape of one of their calls. Very rapid application of DA-CPR. Empowers dispatch to be flexible. Levy/Anchorage
Back to Basics - Are Tiered Deployment Systems Resurging?: Is there a volume-outcome relationship in EMS? Speaker will argue that we need tiered response and a core group of mobile intensive care paramedics. Response time average in Seattle for BLS is 4.1 minutes and 7.6 minutes for ALS. CPR is the cornerstone of resuscitation... it is a BLS skill. Cardiac arrest is a primarily BLS disease. Do not mess up the BLS to provide the ALS. Volume-outcome relationships matter. You do not get to play in the Super Bowl if you only play one game a year. Decreasing number of ALS units is essential to improve ALS skills. BLS to provide BLS, ALS to provide ALS. Melbourne, Australia uses same type of system but as a three tiered model. Melbourne model has 9 MICP for every 100,000 in population. Cardiac arrest needs a second tier expert response. Is there an optimal number of MICP? Unclear.
Running an Ambulance Service without Staff: London, England: LAS has had worker strikes. Issue escalated from 4 hour strikes to 24 hour strikes. Planned ahead. Staff that did come to work had broader responsibilities. Military used to back fill and allowed to use their skill sets and language (they were not forced to use standard processes). Police used for assistance and first response as well as manning ambulances. Training was ran for 30 minutes (on ambulance) and seven days in classroom. 2500 people were trained. Support staff was trained in MPDS incase dispatch controllers failed to come to work. NHS England (National Health Services Trust) required reports on the planning. Vehicles were pulled off station to four muster points so that there were vehicles available to man if someone did not show up on station. Stored additional uniforming (28 pallets) so that replacement workers were properly identified. 80% of frontline staff did not report to work. Some late calls. No harm. Took an additional four hours for system to return to normal after a 4 hour strike. 24 hour strike has been avoided due to a pay offer on the table. The issue was a decision not to implement a 1% pay increase based on a pay scale review. Planning when these things are imminent is a full time job. Must plan for any contingency that makes staff unavailable. Not over yet... another strike potential looms in March 2015. Moore/City of London
EMT-N's! BLS Small Dose Narcan: Nationwide increase in opiate OD. More people die in Massachusetts from opiate OD than car accidents. Do we know the right dose? Boston has been giving BLS Naloxone since 2006. RR<8 on adults only is criteria. Single BLS 2mg dose intranasal. It was effective in 95% of 742 patients. 8.8% of patients required further dosing in the hospital. Dyer/Boston
When Blue Bloods Treat Blue Blood - Experience with police administering Narcan: 467 Philadelphia intoxication deaths in 2013 with Heroin being the chief culprit. They are also seeing Fentanyl laced Heroin. The Kensington area is where much of this occurs. Rough and tumble area. Sadly, lots of death. Police and FF now allowed to give Narcan. The law provides immunity from liability. Must have an agreement with transport EMS. Must take a state approved training course as well. Police must be certified in First Aid and CPR before being allowed to give Narcan by Pennsylvania law. 2mg intranasal dose. First aid required following Narcan. one to two administrations a week. $60,000 in initial cost of drug.Naloxone price now going up. Not sure how to continue funding this. Discussion regarding whether ventilating patient till EMS arrival would not be better. Mechum/Philadelphia
Pre-arrival Revival - Experience with Bystanders using Narcan: Large number of social issue groups supporting public administration of Naloxone. Studies in Massachusetts have shown decreases in death from narcotics where lay administration has been allowed. Narcan auto injectors cost $630 each. Single dose. Syringe has a chip and gives voice instructions to the person giving the drug. Easy to identify areas of geo clustering where this could be utilized. Geographic small areas where EMS give Narcan are also areas where bystanders may be beneficial with the drug as well. You must develop refusal policies for patients who are refusing service after administration. Yeh/San Francisco
Eagle's Lightning Round #2 - Short discussion on double sequential defibrillation. Not enough data. Seems to do well with producing ROSC, but not a lot of outcome data available. Myers states that we do not know what the best way to do this is, but changing the energy vector may be the answer. Move the pads if defib not effective in terminating VF.
Eagle's Lightning Round #2 - Good move! All EMS fellows (new board certification program in EMS for physicians) invited to join Eagle's on stage. I cannot stress enough the importance of this board certification process to the future of EMS and EBM.
Eagles Lightning Round #2 - In light of drug shortages, write protocols based on classes of drugs, not specific drugs. Allows for agility in changing when shortages occur.
First Backboards, Now C-Collars: C-collar use was never based on data and may be harmful. C-collars increase ICP and decrease cerebral blood flow. They limit motion as they are supposed to but is that needed in all cases. The patient that has been walking prior to arrival... lets eliminate c-collars there first. Lets talk about not applying c-collars to the elderly with spine curvature. Just like backboards, c-collars would not pass a first level FDA review for approval today. Colwell/Denver
Do ALS interventions in penetrating trauma decrease mortality? PIPT - Philadelphia Immediate Transport in Penetrating Trauma Trial is starting soon. Inclusion criteria will be central core gunshot ad stab wounds proximal to the elbows and knees. Goal 780 patients in three years. Mechum/Philadelphia
Intraosseous monitoring: IO can be used for monitoring blood pressure and is far less dangerous than a central line. One trial in progress. Yes there is an IO pressure and it can be monitored with a good waveform. Frascone/St. Paul
Prehospital Infusion of Plasma: Current therapy is sodium solutions for blood loss. Permissive hypertension is the right thing to do when dealing with Saline. Polyheme showed no improvement in outcomes. Now going to try Plasma. This is the COMBAT study. Over 18, with hemorrhagic injury SBP less than 90 and HR >108. The test field will be Plasma prior to blood administration with little or no saline. Requires FFP in a cooler and Permatherm water bath warming system in the ambulance. It is essentially the start of a massive infusion protocol while still in the field and over 20 minutes out. The study has an exclusion from informed consent. Patients can opt out by wearing a wrist band only in the Denver area. Study started in May 2014. 36 patients so far. So far, data looks good. Results will be out next year. Colwell/Denver
Compensatory Reserve Index Use in Trauma: Hemorrhagic shock is still responsible for 40% of civilian deaths in trauma. Huge issue in combat casualties as well. Initial vitals are relatively the same in patients who lived and those who died in hemorrhagic trauma. We need a predictive model of when shock will occur. We need early signals of hypovolemia. What we see today is too far down along the shock continuum. Heart rate and shock indexes are associated with tolerance to low blood volume. What should we measure? Arterial pulse waveform can lead us to measurement of a compensatory reserve index which can predict when shock will occur. The machine can calculate this from as small an amount of data as 30 heart beats. Classifies as green, yellow or red based on amount of compensation left before shock. Showed video of results tracking CRI into shock. Test shows to be specific to shock and accurate. Provides time to act on immanent shock. Manifold/ACEP
EMS Use of Tempus Pro Technology: War is where we learn about EMS and what works. The primary military focus is to stop bleeding. 4th century BC gave us the tourniquet. They are now common along with hemostatic agents. TXA is used some in EMS. Permissive hypotension should now be common. Tempus Pro monitors blood pressure, SPO2, ETCO2, ECG with 12-lead and 4 channels of invasive lines... AND VIDEO LAYRNGOSCOPY! It also does video conferencing (physician consult? Community Paramedicine?). It is ultrasound capable as well (not yet deployed). May be placing an ePCR on the device. Does not defib or pace though. It does continuous streaming of vital signs to the ER. Cincinnati just deployed four of the devices and are looking at usefulness. Transmits photos of car wrecks and video can be used for complicated refusals. Capable of photo documentation (airway!). Locasto/Cincinnati
Is Stocking Glucagon worth it? Starts lecture by stating this is the only conference where attendees stay every day to the bitter end (very true). Recognizes military veterans in the room. Typical inability to give Dextrose scenario presented. NEMSIS data shows Glucagon use at 1.2/1000 calls. Eagles range 1.2 - 2.3/1000. Utah was 0.9/1000 runs. Not commonly used but not rare either. Glucagon is thrown away 3x more than what it is used. Many now giving D50/D10 via IO instead. D50 might be toxic to marrow so D10 is better choice (my note... go figure!). D50 via NG may be at risk for aspiration. States that D10 is probably the best drug all around (again, go figure!). Rectal administration did not work (good!). Conclusion... Still worth carrying due to aversion to IO for this when IM Glucagon is available. Intranasal Glucagon may soon be available... and cheaper. Taillac/NASEMSO
Do we really need supplemental Oxygen? Are there conditions where Oxygen is harmful? Studies as early as 1900 (not a typo) show decrease in pain due to hypoxia. Today we know that too much oxygen decreases cardiac output without benefit. Multiple studies since 1965 show Oxygen may be harmful if high flow. High flow O2 induces decreased coronary blood flow in the micro circulation in patients with three vessel disease in as little as six minutes. Risk is better on room air in cardiac. CHF patients getting high flow O2 decreases cardiac output also. CPAP devices that flow 100% O2 need to be replaced. In COPD we should be using compressed air for Nebs. Same issue for Asthma. High flow O2 decreases cerebral blood flow up to 33% in stroke. O2 shows no benefit in clinical stroke outcome scales. We do need to protect against hypoxia. Hyperoxia decreases oxygen consumption in Sepsis... again bad. Oxygen does not improve survival in trauma. There is a proper sweet spot, but it is not high flow. High flow is not helping at the cellular level. Avoid hyperoxia. Avoid hypoxia. Gilmore/St. Louis
Throwing Away the Radio: "Are MD and RNs on the radio a real threat or just a menace? Can we stop them before they kill again?" (interesting start to a lecture BY an ER physician...). Most systems cannot afford full-time medical direction which defaults medical control to whoever is on duty at the ER. Inter-physician differences on radio call ins may cause confusion and variable standards of care. Some physicians are excellent but there is a high degree of variance in application of care and physician desires. Speaker advocates medical authority NOT be attached to the hospital. States we should reduce the need for radio communications. Guidelines should be used, not protocols or algorithms. Guidelines allow for variance that simply needs to be explained, not disciplined. There is a lot of confusion regarding need to know versus nice to know in the relaying of information. Software called EMResource can allow prehospital query of diversion status and hospital availability. Also allows for a data burst prior to patient arrival that can give ER needed info without calling. Works well in Tucson. Also saves data to note "alert time" for facilities. Valenzuela/Tucson
That is it for today... will be back at it tomorrow. Now Cafe Pacific for dinner and prepare for day number two of massive note taking.
DAY 2
Standby for breaking comments from the 2015 EMS State of the Sciences Conference in Dallas... controversial comments all day from Day 2 till the end....
Esse Quam Videri... look it up. Good motto for EMS. This is the motto of the “Eagle’s” group.
Description of the Eagle's group: Most of the medical directors for the 40 top populous cities in the US and key federal agencies. "To be an Eagle you must be a FDM (Final Decision Maker) for your system and your city must be visible from space at night." The Eagle's name was pinned on the group by a media report regarding an early State of the Sciences Conferences. All presentations are limited to 10 minutes with 5 minutes for rapid questions. Question answers are limited to 20 seconds. Pepe/Course Director
Tales and Emails from the Eagle's Archive: How can we improve care? How can we make the lives of our personnel better? Quick questions, short answers. Conduct industrial tourism (go visit other EMS operations). But... much can be asked, answered and shared via email. Who does lift assists? 50% send ALS and an engine on every lift assist. Most do not charge for lift assists. Most use CDC guidelines for trauma transport decisions. A "major embarrassment" in healthcare is that the majority of ERs receiving patients with ETCO2 monitoring do not have ETCO2 monitoring capability. This needs to change. 60% of EMS systems use Fentanyl for primary pain control while only 6% use Dilaudid. Another important issue at hand is working with Law Enforcement. We must integrate and have effective relationships with LE. If we work better with LE we can better care for serial inebriates. Very few transporting directly to psych facilities. Everyone working on familiar face patients. Everyone needs to make substitution lists for the ongoing drug shortages. Plan ahead. Versed is commonly used across US. The job of the Eagle's is to monitor what is going on and duplicate best practices. Augustine/Eagle's Librarian
Trauma Activation Fees: Do you know what the trauma center alert fee costs your patient at each hospital you transport to? Does it affect your transport decision or will it in the future? EMS must be patient advocacy. We must concentrate on quality of care and responsibility to the patient. Level II trauma centers in Florida historically closed because trauma was a money loser. Florida trauma centers in the media for charging "outrageous fees." HCA Trauma Activation fee is $32,000 before any care is given. Medicare allowable is $1,000. Part of this is that if $32,000 is charged and $2,000 is paid, this generates a $30,000 loss that can be booked to offset profit. Only those who can pay do pay or get sent to collections. Fees are still climbing. Best advice: Do not alert. Call in data and let ED make the call to alert (my note: this is common in my area... we call in the patient report and let the ED decide to alert or not). This was expected to lead to legislative change in Florida but has not as of yet. Medics do not need to be stuck in the middle. It is common for patients to refuse transport to TC in Florida if they are aware of charges (media). Schrank/Miami
The EMS Issue of Freestanding Emergency Centers: Two types, hospital outpatient ER and Independent. The hospital one is recognized by CMS for payment. The other is not. Texas has enacted code to regulate requiring 24 hour operation and staffing requirements. They are required to participate in the EMS system and have diagnostic services. ACEP only states that freestanding ERs should abide by EMTALA and offer correct services. Billing for transport between freestanding and hospital can be complicated depending on hospital code numbers and patient status of admission. STEMI patients in urban environments need to go to ER with a cath lab. In rural settings the freestanding might work for TPA in STEMI. (my note: the commensurate care issue under COBRA could be big between a freestanding ED and a hospital with a critical patient). San Antonio initiated an application process for freestanding EDs to participate in the local EMS system. San Antonio did not allow freestanding EDs to opt out of psych and/or inebriated patients from EMS. Kidd/San Antonio
NYC Turn Around Time Project: NYC AVG 3,700 calls a day. 4,000 a day common. 1 million transports a year. 4,000 EMTs and Medics. 60% ALS. 11,000 FF first responders. Out of 11,000 FF only 24 are female. 15 trauma centers, 4 burn centers, 61 receiving EDs. Goal was 25 minute TAT. Was not possible. Trying now for 40 minute TAT at ED. Running about 43. Ideal would be 10 minutes. More hospitals? More ambulances? Those would take more MONEY. Need to fast track those who are not essentially ALS. TAT needs a "greeter nurse" to direct to drop off location. Out of over 800 patients only 12 removed from fast track and given to main ER. No bad outcomes. TAT in study dropped to 21 minute average. Buy in from both EMS and hospitals has been hard. They are going to continue pilot but they are starting to get inquiries from hospitals asking if EMS would consider transport to urgent care centers to alleviate load and improve TAT. For every 45 shifts added to the EMS schedule, cost is 11 million dollars. Asaeda/NYC
Early Results of a Fire Service Community Paramedicine Program: DFR has 41 years of caring for unscheduled emergency needs. CP programs can bridge gaps between EMS and hospitals. Parts of the ACA lend toward the development of CP programs. DFR concentrating on high frequency patients and readmission reduction as its two chief foci. The readmission component is phase two and is just starting. They will be the highest risk patients. Algorithm controlled interventions to direct the patient to proper care or even in home treatment. They are finding that medication reconciliation and education is the number one issue impacting patients. They are using I-Stat devices for labs in home. Meetings every Monday morning in the "war room" to tweak program. Program is finding out things about the patient that their primary healthcare provider would never find out otherwise. On the other issue, High frequency patients have went from an average of 2.4 calls per these patients each month to nearly zero. Reimbursement is still nebulous. Dedicated personnel. I-Stat pictured below. Isaacs/Dallas
High-Teching the Home Visit with ETHAN: Emergency Tele Health And Navigation. Can telemedicine be used to redirect patients? Google Texas 1115 Waiver as to how rules were designed. Nurse 911 call screening for redirection did not work because they were not ER nurses and the protocol wastoo conservative. ETHAN uses in field, tough tablet with telemedicine to communicate with physician and redirect patient safely and accurately. Doctors do not need an algorithm as they practice medicine. They make medical decisions. ETHAN work station on physician end shows video of patient and data about patient including closest alternative care available that is appropriate to the patient. They can even schedule appointments and transportation from ETHAN. Physician CAN refuse transport if not needed. All get follow up calls and are made sure to stick to the care plan through outcome. Partnered with multiple healthcare agencies to make this work. Persse/Houston
Increases in 911 Calls After Establishing Homeless Shelters: Do you know what percentage of your calls are to homeless shelters and have you met with their leaders to determine alternative care options? A large shelter housing almost 500 opened in Columbus and it immediately became a primary 911 caller. Mainly calling late in the evening and hammering the closest 911 ambulance. There was a rule at the shelter that they could not leave after curfew and hold their bed UNLESS they were transported to an ER by EMS. This was gamed to get transport to ER, leave the ER and do what they wanted to do, then go back to their held bed. A simple change occurred. Now have to have ED discharge paperwork to get bed back. Many of remaining runs were BLS. Shelter already had two new exam rooms that were not being used. EMS helped open a free clinic in the exam room with a faith-based organization to deliver care in the shelter, further reducing unnecessary EMS calls. Important lesson? Work with the shelter! Keseg/Columbus
Managing Homeless Through EMS: 2.5 million homeless in USA. Almost 10,000 homeless on the streets of Phoenix on any given night. Many have complex medical issues: TBI, substance abuse and mental illness. Book on the issue at www.robertokinmd.com. Some single incidents for healthcare on a critical homeless individual costs >$500,000 (one case of a dental issue caused bacterial endocarditis which was a 2 week admission). Phoenix has EMS Crisis Response Vans who can direct patients to appropriate care and give referrals through online collaboration with physicians. Van staffed with a social work graduate and one EMT. Over 3,000 responses in a fiscal year. Top frequent EMS user before plan initiation was 35 ED visits at 31 EDs in 169 days. Another person had 192 ED visits with no admissions in seven years. Several million dollars in charges. Proper programs reduce use of EMS and EDs for services that can be better provided by other specific providers. Gallagher/Phoenix
"Come on in my friends to the show that never ends. Come inside, come inside." -Paul Pepe/Course Director
A Toxic Wasteland: Salt Ponds, Gravel Pits and Molly - Realms: All things are poisons, it is only the dose that makes them usable. What are safe options for treating drugs of abuse. Drugs are now highly varied. If you can figure out the drug class, you can treat it. 20% drug use in fatally injured drivers. In 2009, drug abuse accounted for 1.5 million ER visits. CNS stimulant abuse on the rise. Almost all are amphetamines. Present with HTN, Tachycardia, dysrhythmias, hyperthermia and delirium. High mortality. Bath Salts still on the rise. Gravel (alpha-PVP) is a new drug, mainly in Tennessee and Kentucky. Bromo-Dragonfly has 36 hour duration and is an amphetamine with psychedelic affects and comes on blotter paper. Very potent. CNS stimulants cause Bruxism (teeth grinding). Agitated delirium and seizures are common. Hallucinogens are on the rise also. They raise body temp and heart rate. They also cause sweating. Ecstasy was the classic. Now Molly is here and is considered safer on the street but really not. Paranoia is common along with agitation. Narcotics are still big and Heroin is back in force. Acetyl Fentanyl is growing and works so fast that the patient is in arrest on EMS arrival. BHO (butane hash oil) is concentrated THC. Marijuana tortilla chips (the only munchie that gives you the munchies). Marijuana users eat the edibles to sustain high. Paranoia is common along with delirium and agitation (yeah... marijuana is safe, right). Many of these can lead to death in custody. Hydration, Sodium Bicarbonate, Narcan are all considerations. Chemical restraint is also key. Ketamine is still the drug of choice and is growing in use for patient sedation and chemical restraint. Conterato/Minneappolis
When the Combative Trauma Patient is Refusing Transport: How do you decide when you are going to let a patient refuse care? Obtunded patients are not capable of refusing or combating. However, the agitated, angry patient can try and refuse care. Combative patients can have head injuries, hypoglycemia, hypoxic or inebriated. Determining capacity to refuse is hard. The one question that must be answered is does the patient understand the decision to refuse and impact? Alternatives? Distractions affecting the decision? If you have capacity, you have the right to refuse and make bad decisions. When in doubt, you must lean toward not having capacity to protect the patient. Be sure and document why you do not thing they have the capacity to understand. Be ethical. We have a duty to patients and a duty to others. Colwell/Denver
Putting Wonder in Those Toxically Asunder Down Under - New Zealand's Experience with Ketamine for Acute Delirium: Five year experience with Ketamine use in EMS. 1250 ambulance calls per day, serving 4.5 million people. Rural/urban mix. 400 EMS vehicles. Staffing is 60% medic, 15% intensive care medic and 25% EMT. Severe agitation requires us to impose care against the will of the patient for the safety of the patient. "Drug induced bad behavior" is common. Ketamine is part of an escalation spectrum of treatment. 200mg dose is standard. Quite a few patients receiving Ketamine needed airway control but this may be related to condition and not Ketamine. 43% of administrations were at home. After administration, only 14% were still agitated. Of those not affected, several still did not have decreased agitation after a second doe in the ED. There were four respiratory arrests and all were of short duration and managed safely. One use on a 75 year old agitated patient at home with no adverse issues. Doses between 200-400mg appear to be safe in treating severe agitation. Ellis/St. John's New Zealand (Keep in mind that this gentleman flew from New Zealand to deliver a 10 minute presentation… pretty amazing!)
Dissociative Associations in the Land 'o Lakes - >1800 Uses of Ketamine in in the Twin Cities: Ketamine is both a sedative and an analgesic. Analgesic at low doses. It is a PCP derivative. Airway reflexes remain intact. Works at the spinal cord level to block pain. Ketamine has been used to sedate horses. EMS uses Ketamine for pain control and sedation of severe agitation (hypermetabolic state). Onset IV 1-2 minutes, IM 3-8 minutes. Versed is 1-5 minutes IM, so Ketamine may generally be faster. If hypermetabolic, IM Ketamine works even faster, 1-2 minutes. Ketamine dissociates the brain, they can still think, they just cannot act on it. Very good for acute or adjunctive pain management even in peds. For pain control should be given over 3-5 minutes. 4% of those receiving Ketamine still had to be tased by LE. Ketamine VERY effective for induction in RSI with no further sedation required! Only 3 adverse reactions were reported when used for sedation. In pain management 72.3% required no further analgesics in the ED. Only eight patients required intubation. Two deaths reported but neither were Ketamine as causation (one was blunt trauma). Safe and effective. Conterato/Minneapolis
Supporting Ketamine use for Pain Management: In Colorado they can legally put 50mg of THC in a Swedish Fish Candy. A joint is typically 30mg. The problem is they eat too many before they take effect. This is causing higher number of OD seen in the ED.... that was intro to the lecture... Ketamine is the perfect EMS drug. It can be used intranasal but hard to get good concentration. Denver uses 500mg IM for Severe Agitation. Indications for Ketamine prehospital are pain uncontrolled by narcotics OR pain with hypotension (safe). Lower risk of airway problems than MS. For pain 0.2-0.3mg/kg slow, intermittent IV injections. ICP is NOT a concern in Ketamine administration. Conclusion: Ketamine is ideally suited for the prehospital setting. Colwell/Denver
The Eagle's and all attending medical directors on stage for a
Day 2, Eagle's Lightning Round #1: What do you do with a patient that does not have capacity and is on there feet ready to fight? Police must physically restrain and then EMS medicates. It is difficult for LE to intervene if the patient has not yet broken a law. Death in custody cases are making LE more reluctant to help with restraint. If LE does not physically restrain, EMS should not approach if still on feet.
Day 2, Eagle's Lightning Round #1: Much discussion on issues regarding what freestanding ERs can handle and the transport issues and financials surrounding the issue. CMS has ruled that the transport between a freestanding ER and hospital (even if the freestanding ER is owned by the hospital) cannot be provided for free as it would be an incentive for keeping patient in system.
Copass Award for Excellence in Advancement of EMS: Presented to John V. Gallagher/Phoenix
Cory Slovis Award for EMS Education: Presented to Christopher Colwell/Denver (well deserved).
The Secondary Gain from Clinical Trial Implementation: Trials of neuroprotective agents for stroke have mostly been negative results. 49 have been tested, 0 have been approved. This is on Magnesium administration for Stroke. Placebo controlled and double blinded trial. 4GM Magnesium doses. 1700 patients enrolled within 2 hours of onset. 40 EMS agencies, 60 receiving hospitals. Inclusion criteria via a stroke screen, ages 40-95, last known well time within 2 hours. Deficit present at least 15 minutes. Magnesium group and placebo group had no difference. Even though drug failed to help there were positive side effects from the study. Side effect of FAST MAG trial was decrease in time to care and improvement in treatment actually delivered just from being in the trial. Proved paramedics could diagnose stroke 96% of the time. Lead to creation of comprehensive stroke centers. There are collateral advantages to participating in clinical trials. Eckstein/Los Angeles
Standardizing the Standards: National Model EMS Clinical Guidelines are stressed to be guidelines and NOT protocols. They may help you write protocols. Taillac VERY clear to say one size does not fit all and even rigid states with strict protocols should allow variances for local care (my note... GREAT MESSAGE!). They are trying to provide guidelines that cite evidence-based references to assist systems in writing how they will do their prehospital medicine. This is uniformity of approach with tweaking allowed locally. It is to help enhance care by putting forth evidence. "These are not mandatory and not inclusive and not meant to dictate local practice." Several have been published already and the list will be growing. They will be organized by chapters. Quality Improvement key points are a component of each guideline. Cited references in each guideline as well. (If you like this status report, please share it!) www.nasemso.org Taillac/NASEMSO
OLA from NOLA! Late Breaking Reports from NAEMSP Last Month: The Impact of Chest Compression Fraction on Clinical Outcomes from Shockable Cardiac Arrest (no impact! In other words, short pauses at certain places are not bad. The preshock pause is what must be eliminated). Police Narcan (no deaths). More movement on backboards than on cot mattress (my note... get over it. LSB is bad). The day a drug expires is does not turn bad (lose the notion... still does not mean we can use it legally… that decision is state dependent). Active Threat Response testing: Tourniquet was placed correctly 96% of the time. 88% of tourniquets in test were placed by LE (my note... quit griping about cops and tourniquets... they are RIGHT, you are WRONG). Myers/Raleigh
Update on the Medical Response to Active Shooters: 98% are single shooter incidents. Most are conventional firearms, not military weapons. Businesses are 40%, schools are 29%, multiple locations 19%. New mantra is that first arriving officers engage the shooter. On arrival of LE shooter turns focus to LE or kills self. (my note: reference Hartford Consensus). In 2013 there were 5,909 IED incidents in the US including the Boston Marathon. 390 injuries and 31 deaths. More common than people realize. Both active shooters and IEDs can occur in any community. Bystanders will respond and usually be VERY beneficial. Bystanders were motivated and capable and affected outcomes at Boston. Bystanders motivate other bystanders to action. The FBO Office of Medical Services is now determining the role of bystander first responders, specifically hemorrhage control. Hartford Consensus referenced by speaker. Threat roles have been designed and EMS is not in the cold zone. Fabbri/FBI
Public Access to Hemorrhage Control: Is it time to recommend tourniquets to the lay public? Active shooter video showed student doing hemorrhage control in simulated school shooting. Time to train TEACHERS and STUDENTS in hemorrhage control AND TOURNIQUETS (my note... myself and others have been saying this for some time. Those IN THE INCIDENT have to have the ability to stop bleeding).. No one should die from uncontrolled external bleeding. Broward County teach tourniquets to lay public and producing hemorrhage control kits with tourniquets and placing with AEDs. Placed with every city registered AED. Teaching tourniquets to every CPR class. Now Force App allows for finding response packs in a community by bystanders. Awesome lecture as always from Peter Antevy. Antevy/Greater Broward County
Why have we gotten to the point where we are afraid to being an expert? WE ARE EXPERTS. Act like it and accept it. But, stay in your lane. Be an expert where you are one. Take care of yourself so you can take care of others. How we train is how we plan. Know the plan. Texas Division of Emergency Management (I did not catch the gentleman's name but he was excellent and did not use PowerPoint!)
Re-Tooling Decon for Emerging Epidemics: Coming attractions: Ebola, MERS and Bird Flu (again). What lessons can we learn from the Ebola outbreak? Ebola was a US wake up call... North Americans are geographically challenged. Ebola will never go away. Animals are reservoirs for the disease. Direct contact is the mode of transmission along with body fluids. Must enter through a mucous membrane, not skin. Virus does not live long outside of body. 21 days incubation followed by 12 days of progressive symptoms. Day 7-9 headache followed on day 10 by high fever.12th day is peak and when most may go unconscious, followed by death. Earlier access to care dictates survivability. Commonality of survivors are that they were medical personnel who went for medical care EARLY. All EVD therapies are investigational. None are approved. The virus has glycoprotein spikes that turn off interferon. PUI (suspected possible Ebola) patients must go to designated Ebola hospitals. Treatment must be a coordinated effort. Develop relationships. Jui/Portland
Hazmat Response: Covered an incident where an organophosphate exposure was brought to ER without decon. They formed a consortium with hazmat teams and created a hazmat alert protocol. Alert can occur as early as dispatch. Transport ends outside the ER door and is evaluated by the hazmat team representative (not hospital personnel) and they make determination on further decon or direct entry (it is all about communication and using expertise). Detergent suicide becoming common in Orange County which creates a hazmat issue as the dead body can off gas hydrogen sulfide for several hours. Hunter/Orlando
How Ebola Affected Dallas: By three ways we learn wisdom... reflection, imitation and experience. Experience is the most bitter. Dallas was not aware they had transported an Ebola patient until two days after it happened. The vehicle was taken out of service immediately. "Our first response was to set the ambulance on fire and drive it off a cliff... no, not really." Primary focus "was to contact medics, comfort them, love them... then isolate them." EMS was immediately educated on the disease. CDC copied some of their education. Fear vs. fact was media driven. After two nurses attention then turned to physician in NYC. Many things went well including City media plan. Learned many lessons. regional, not just local. Expect politicians to over react. Fowler classifies this as a disaster response because no one knew what was going to happen next. Presbyterian is the "Ritz-Carlton" of hospitals. This incident put public stigma on them that was not warranted. The Dallas patient had the highest Ebola Titer ever recorded. Many details concerning this man and how he came to be in the US. Truly a life of trying to overcome his life status and died after finally making it to the US in search of a better life. The public wanted the ambulance destroyed. "Bleach is a beautiful thing." Within 48 hours jail inmates started stating they had Ebola symptoms to try and get transport out of Jail to EDs. Pepe, Fowler and Isaacs/Dallas
Ebola and the Airports: CDC has quarantine stations, one of which is at Atlanta Airport. Vital sign zero is gaining information before ever touching the patient. If you identify a contagious process through information, do not put in rig until you know how to handle and gain expert medical advice. Ebola was classified as a liquid/chemical hazmat incident by the airports. Augustine/Eagle's Librarian
Ebola and London: LAS NHS developed a risk assessment algorithm so that all agencies used same resources regardless of how the patient would access the system. Implemented health screening at all ports of entry. Viral Hemorrhagic Fever working groups were created for communications, transport, decontamination, etc... Everyone answered to the Director of Operations (LAS). Facial beards became a discussion topic regarding PPE. Several patients were transported by the RAF internationally. Communication was vital. The fact that CPR was judged to be futile in Ebola patents was heartbreaking to crews. Moore/London, England
The 2015 Great Debate Fowler (F) Vs. Valenzuela (V): (F) violence is a huge issue. Should all providers have EMS armor PPE? Military has it right about PPE, what about EMS? Body armor use has not become routine. It should be like eye protection and gloves. Some EMS agencies require employees to opt out if they do not want to wear armor. (V) Body armor not needed by EMS. Fowler needs to be punished more. "lets get real. To what does EMS respond?" 90% medical calls. Sick people, falls, respiratory, chest pain... rarely active shooters. "What is your threat assessment on a geriatric sick patient or a cat in a tree? Perception is reality. Do you want to be perceived as a stormtrooper? Are there threats? Yes. Does EMS need body armor routinely? No." Required gear would be around $1,100 per person. Color of uniform also lends toward perception. EMS knew the job was dangerous when we took it. Deal with it. Audience reaction sided with Valenzuela.
Better Breathing Through QA: Mandated full ECG/waveform capnography upload on calls. Tells the true story of what happens to patients even when the narrative does not. Tells story of whether we were watching, recognizing and treating our patients appropriately. Its about accountability. If ETCO2 says zero, your ET tube is bad. PERIOD. Do not second guess ETCO2. One in three intubations fails at some point in the process. ETCO2 is the only thing that truly confirms initial and ongoing tube placement. Without ETCO2 a misplaced tube can go unrecognized 23-25% of the time. With ETCO2, recognized 100% of the time. Stop trusting any other indicator. Upload the entire continuous waveform to the ePCR. QA must watch the data on every case. It is too important not to do so in every intubated patient. "With great power comes great responsibility." Richmond/Ft. Worth
Getting Patient Safety Organization Buy-in for EMS CQI: We have moved from punitive culture to blame free culture to just culture. Just Culture holds the system and the individual accountable. Accountable does not mean discipline. All barriers to safety incident reporting must be eliminated or safety issue will simply continue. Confidential reporting can be a component. EMS must encourage a culture of safety. Performance feedback is crucial and should only be used to stimulate positive change. Use independent, external experts. Develop best practices and benchmarks. Produce safety alerts and one page informational distributions after every "event" that occurs. Have a working group to review incidents. Same people each time can classify and respond to trends. KCFD had 93 submissions in 2014. It has increased every year (trusted). It has to be used over and over and over again to work and become culture. Fear of discipline must be removed. Reich/Kansas City
Considerations in Pediatric Pain Control: Pain is a primitive teacher but it is cheap and plentiful. Pain is unpleasant by definition. Nociception is the other part of pain... the visual adds to the sensation. Every patient has a right to have their pain assessed and treated. Caregiver perception about how often we treat pain is always higher than reality. Inability to assess pain is reason given for not treating pain in kids 93% of the time. Pain scale not used enough in peds. The earlier the pain in kids is treated the better it is controlled and it sets the tone for further pain control after EMS. AMR nation-wide treated a ped with pain every 15 minutes in 2014. Narcotics given to treat ped pain every 8 hours. 24% of peds calls were for pain. 67% were trauma related. 87% of those that got pain control got it IV. What causes this? Barriers? Hard to assess pain in kids. Fear of adverse events. Availability of intranasal administration. There was not a single incident of Narcan admin to reverse the affects of an administered narcotic since 2010. Adverse reactions are not a reason. Racht/AMR CMO
That is it for the EMS State of the Sciences Conference for 2015.
If you should ever decide to go, it is usually about $175 for a paramedic to attend for the conference registration. It is usually at a very nice hotel and they negotiate the room rate down to about $100 a night. Airfare from anywhere in the U. S. to Dallas is usually pretty reasonable. Breakfast, lunch and snacks/drinks each day are included in the conference registration.
If you are a final decision maker, clinician, quality manager or protocol writer... this is the conference for you. Plus, the food in Dallas is absolutely awesome.
Till the next time I get the urge to type... be safe and may God bless you and keep you.
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| Heading home... |
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