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These are the notes from the sessions I attended as in the afternoons there were multiple sessions from which to choose. My notes are... well... my notes. They are what I took away from the speakers presentation. I must apologize in advance if I get anything slightly incorrect, but there was a lot to write down.
So here we go...
- NAEMSP President's
Address and Welcome (Brice): Apparently the DEA implemented regulations
this past year negating the ability for EMS to give narcotics on standing
orders. The NAEMSP has introduced federal legislation to reverse this. I
think we all need more info on this and need to get behind NAEMSP in this
effort so our patients can continue to get adequate and safe pain
management.
- Identifying Human
Trafficking in America (Bender): Human Trafficking looks much different
in the US than it does in third world countries. Most falls into four
categories: Family, Survival, Gang or Pimp. Most are women are taken from
their family by an older boyfriend after being targeted and moved into
prostitution. Trafficking occurs frequently in rural communities. Familial
trafficking comes in the form of trading services of the child for food or
rent. Trafficking for services is very frequent in the homeless
environment also (survival). Gang and Pimp control trafficking is more
urban. Gang control trafficking is becoming very prevalent. Predators take
advantage of human trafficking. The process of taking a target into human
trafficking is a slow process. If it was obvious, people would not be
easily taken into it. Targets are groomed. EMS and emergency departments
will see many victims of Human Trafficking without knowing it. Traffickers
are attractive, take interest in targets children, give attention and get
very close. They are good at getting inside the targets defenses.
Traffickers use fraud and coercion. It progresses to violence if the
target becomes non-compliant to the handlers wishes. Those being
trafficked are kept scared to be controlled. Those being trafficked are
trapped and turn to drugs and alcohol as coping mechanisms. Those being
trafficked are frequently sold between traffickers. Sometimes those
trafficked are kept in "stables," which are sometimes homes in
gated communities or well hidden. It is very hard to plan an escape from a
trafficker. The handler makes them feel like they are being watched at all
times, appearing out of nowhere. They use children of those being handled
as bargaining chips. "Make the lie big, make it simple, keep saying
it, and eventually they will believe it." - Adolf Hitler. Age 25 is
the full development of cognitive reasoning. It is easier to conform to
control under age 25. Those being trafficked start to see their situation
as normal. It happens in every big and small town in America. Search:
"Boise sex trafficking" on YouTube for a video example of the
problem. Those being trafficked are arrested, injured and touch the system
a lot without being given a route out of trafficking. EMS and EDs have the
ability to intervene. Even when liberated from trafficking, victims often
get federal level charges for what they have been forced to do, including
huge fines from the IRS for failure to report income. Traffickers brand
their victims with tattoos that can be noticed, sometimes inside the
mouth. Indicators: Patient may not be seen alone and have someone staying
very close, looks down when talking, consistent miscarriages, no payer
source, has older boyfriend, signs of domestic violence with
hyper-sexuality, patient can be defiant. They can be as scared of the
repercussions as much as they are of their handlers. Faith based
organizations can be of assistance in recovery. 888-373-7888 National
Human Trafficking Hotline, correlates data and can give assistance.
- Strategies to
Improve Cardiac Arrest Survival (Bobrow): A Time to Act. Primary goal of
lecture is to get us to read the IOM report. Bentley Bobrow, MD. This is a
consensus type report. We have to eliminate "system
malfunctions" where cardiac arrest is concerned. Cardiac arrest
REQUIRES a system response. Speed and quality of care matter. Leadership
matters. OHCA survival is about 6% nationally. Imperfect data hinders
ability to improve and move forward. All current cardiac arrest databases
are incomplete. A national cardiac arrest registry is needed (example:
CARES is voluntary participation). It is sad that there can be huge
variances in survivability between cities. Benchmark cities and systems
show that survivability can be improved dramatically. Any CPR or
defibrillation by the public is better than no care. 911 activation is
crucial. Time too first compressions and defib is crucial. Response time
to cardiac arrest clearly matters. Actions of the public are pivotal to
success. Bystander CPR and AED are very effective. Only 1-2% of arrest
victims get a public AED applied. If a community measures OHCA performance
they get better. Appropriate leadership must be generated at all levels to
improve outcomes. Better therapies are needed for non-shockable rhythms
which are the majority of what is seen (my note: this is the first time I
have ever heard anyone admit that VF VT is not what we see most, but is I
always see in the data). There is a lack of research on OHCA. "EMS is
at the center of all of this." Establish a national cardiac arrest
registry. We do not have good data. Cardiac arrest needs direct
surveillance as a disease process. Foster a culture of action through
public awareness and training. Enhance the capabilities and performance of
EMS systems. Dispatch assisted CPR is a huge component. High performance
CPR is crucial. There must be a leadership culture of excellence. There
must be accountability. Data must be utilized. The enhanced chain of
survival must be used. QI must be a component. Accelerate research. Create
a national cardiac arrest collaborative. A national responsibility to
significantly improve the likelihood of survival and favorable
neurological outcomes exists. The IOM report is a call to action.
Report at: http://www.iom.edu/cardiacarrest
- An update on the EMS
Subspecialty Board Certification Exam (Marianne Gausche-Hill, MD): In 2015
332 physicians took the exam. 223 passed - 67%. Fellowship pathway success
was 76%. Practice-only pathway pass rate was 64%. There are now 459 EMS
certified physicians total.
- PECJ (Menegazzi):
Prehospital Emergency Care Journal is now bi-monthly!
- Oral Abstract:
Hypotension dramatically increases mortality in head injury. It is
significantly higher than though. Hypotension doubles mortality.
Hypotension doubles cost of care per episode. Most studies look at mean
arterial pressure (MAP). This study looks at systolic BP vs. MAP. This is
the EPIC study. Uses the Arizona State Trauma Study. Study incudes head
injuries age 10 and above. 10-fold cross validation was used for the
study. Three models of analysis were used. 8627 patients met inclusion in
the study. Study shows that SBP is nearly identical to MAP in measuring
hypotension. SBP far more convenient a measure in an ambulance than MAP
(my note: for those of us that think NIBP in the prehospital environment
is accurate, this is great news). Study shows that SBP is as good as MAP
for determining mortality in head injuries.
- Oral Abstract:
Prehospital Intubation in the Pediatric Patient Across North Carolina:
Christopher Higgins, DO. Potentially lifesaving. Part of standard
curricula for medics. Studies have shown no difference between PETI and
bag valve mask ventilation. Study to determine success rates of PETI in North
Carolina. Retrospective database review. Children less than 18 who
received transport and required PETI. Transfer patients excluded. 364
patients identified. 189 excluded. 175 were reviewed. 95% confidence
interval. PETI occurs 1.5 times more frequently for rural populations.
Overall success, rural 65%, urban 74%. 1st time success was 58% rural, 52%
urban. Increased number of attempts increases mortality. Severity of
illness and time to definitive care requiring PETI seems to be higher in
rural environment. Reasons for lower success rates seems to be related to
exposure to PETI.
- Lightning oral
presentations: CPR FEEDBACK (Milwaukee County): retrospective data before
and after CPR data feedback to crews. 275 encounters, 158 before and117
after implementation of feedback. Results: compression rate improved
slightly. Perishock pause decreased from 21 to 14 seconds average. This
was a non-randomized. Feedback alone caused improvement. TEMPORAL TRENDS
IN OHCA (Ontario): Uses a regional Canadian Arrest Database. 40,000
arrests annually in Canada. Survival at about 10% but on the rise. Data
from 2006-2014. 2006 - 5.1%, 2014 - 9.3%. CPR quality was improved during
this time. Hypothermia WAS utilized. Could not exclude Hawthorne affect
being credited with improvement as well. Improvements made in bystander
CPR and AED use. More hospital interventions as well. ELEVATED INITIAL
TRAUMA CENTER TEMPERATURES DECREASED OUTCOME IN TBI: High body
temperatures most likely due to environment. Having a high body
temperature after brain injury is rare. Hospital stay longer if
temperature is elevated. Hospital charges are higher if brain injury in
context with elevated temp. If they arrive with higher temps, longer stay,
more cost. Crux of study: There is significant risk if we try to correct
this in the field. MAINTAINING HIGH QUALITY CPR INTEGRATING MANUAL/MECHANICAL
CPR DEVICES (Zoll): Used Zoll Autopulse. Manual compressions used until
mechanical could be initiated. 71 patients. 39 received manual only. 32
received manual and mechanical compressions. Compression fraction between
manual and mechanical was 87% 91.7%. Study advocates placing the device at
the ready after ROSC in case of re-arrest. There were NO statistical tests
on this data (wow...?). STRESS AMONG EMS PROFESSIONALS (NREMT): Stress has
been associated with PTSD. 3.8% of EMTs and 8.2% of paramedics report
being stressed. 4,238 newly certified NR EMTs and Medics recruited for a
10 year study. Self-reporting in seven areas generating a composite score.
For three years, medic stress increased by year from 18% to over 30%.
Incidence of stress was nearly 3 times greater for medics over EMTs.
Currently three years into study. Self-reporting may be dropping off as
stress increases. Stressors on medics are increasing. Stress reducing
tactics needed. EFFECT OF EVENT LOCATION ON DROWNING OHCA SURVIVAL (Korea):
Location determines whether there are lifeguards and rescue tools. Used
Korean national arrest data. 170,064 patients. 381 excluded due to
suicide. Most cases were unsupervised areas. EMS response time shorter in
supervised incidents. Lifeguard supervised public areas had highest
survival rate. Bottom line, do not swim without a lifeguard. ACCURACY OF
MEDICATION INFUSIONS BY EMS PROVIDERS (Roanoke): There are calculation and
administration errors. Consistency of errors points to more of an equipment
issue than a human error issue. Errors are higher if using gravity flow
than if an IV pump was used. ERRANT SHOCK DELIVERY IN OHCA (Pittsburgh):
Defibrillation may be lethal if not a shockable rhythm. IRB approved
study. Defibrillation download files utilized for the review. 1,377 shocks
analyzed. 131 shocks were errant over 91 cases. 9.5% were errantly
shocked. All cases were ALS with AED cases included. PUBLIC CARDIAC ARREST
IN ENCLOSED PEDESTRIAN NETWORKS (Toronto): These are areas where vehicles
cannot get to easily that have only pedestrian access. Used PATH
underground network in Toronto. All arrests analyzed were atraumatic. Out
of 2621 arrests, 50 were in the PATH area. Arrest density much higher but
have no demographic differences from other arrests. Bystander CPR and AED
were greatly higher in the PATH. Response time to patient side was NOT
increased by the environment. PARAMEDIC AND PATIENT POSITIONING FOR
INTUBATION (Pittsburgh): Suboptimal positioning complicates intubation
attempts. Six positioning scenarios with choice of laryngoscope blades.
Two in ambulance, four outside ambulance. Worst success was patient supine
in ambulance with medic sitting. Bottom line: Patient on floor with medic
prone was best with 93% first pass success. Success in general was far
better outside of the ambulance.
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The USS Theodore Roosevelt and the USS Carl Vinson at dock, viewed from the concierge lounge of the Grand Hyatt Manchester in San Diego. |
- EMS MYTH BUSTERS
(Minneapolis/Wichita): 1) Trendelenburg position, does it help shock? Dr.
Walter Canon introduced this into practice and later reversed his opinion
after WW one. Actually only causes a short term increase of circulating
volume of 1.8% that goes away quickly. Increases ICP. Decreases cardiac
output. NO BENEFIT... Passive Leg Raise is about the same but might help
identify patients that could benefit from a fluid bolus. Head up 30
degrees may actually help increase cerebral perfusion even in CPR. Head
down/feet up busted. 2) Injecting a medication in the high port of IV
tubing will dilute the medication before it reaches the patient. Some meds
may benefit by dilution. They ran an experiment to check this thinking of
passive dilution through port use. Does not significantly dilute the
medication. Busted. However, if we use slow push with a slow drip rate, it
might offer a more controlled administration. 3) You are not dead
until you are warm and dead. How cold is to cold to code? HT Level 4 has
no vitals. Vitals must be checked for a full 60 seconds. Which came first,
hypoxia or hypothermia? Better survival if you get cold before you stop
breathing. Do not withhold resuscitation and do not withhold ACLS. Full
neurological recovery is possible especially if ECMO is available at
receiving facility. Myth plausible if hypothermic before hypoxic.
4) To adequately give Adenosine you must use a rapid administration
sequence with a stop cock valve to get it to the patient before half-life
is over. Adenosine does have a short half-life. EMS loves a good flashy
procedure too. Saline behind the bolus DOES NOT dilute the med (good).
Rapid infusion works well at keeping the bolus together. Using a stop cock
valve actually separates the administration (not good). Myth busted. No
stop cock valve needed. Give it through a rapidly flowing line.
5) EMS should always try to transport pregnant patients on their left
side to prevent occlusion of inferior vena cava. Is there really anatomic
compression of the IVC? YES. In the supine position it significantly does
compress, BUT few show symptoms. Placing on side does help but unsure as
to what degree of side tilt. Only 8 to 15% of third trimester patients
actually show symptoms related to this. It takes about 30 degrees tilt to
improve flow. This means the right shoulder may need 10" elevation of
the right side. How can this be accomplished safely for transport? This
myth is plausible if the patient is reporting symptoms or is unconscious
and unable to report. 6) EMS should never administer more than 3
sublingual nitroglycerine (my note: are we really still doing this
anywhere?). If we believe this we have to accept that continuous nitro
must be evil and we know better. Busted.
- Resuscitation
Outcomes Consortium Successes and Impact (Daya): ROC focuses on very early
interventions by EMS. $114 million dollars of investment in ROC studies.
264 EMS agencies and 287 hospitals involved. Over than 100 IRBs involved.
60 peer reviewed publications. Greater than 70 abstracts. 1,500 citations.
Major impact on AHA 2010 and 2015 guidelines. ROC has gotten EMS providers
involved as authors. ROC proved futility of the ITD. ROC also showed fluid
limitation provided lower mortality in shock from trauma. There is an
Amiodarone-Lidocaine-Placebo study coming out in March (my note: cannot
wait to see this!). It has 3,025 patients in the study. ROC is currently
looking at TXA in hemorrhagic trauma (randomized-placebo). They are also
looking at optimal airway control for OHCA (3,000 patients). ROC mandates
collection of data from the cardiac monitor (very positive). ROC
communities have varied oversight, EMS performance and populations. EMS
engagement in research is crucial. "We need a culture of paying
attention to the details." CPR quality is essential to all cardiac
arrest trials. All communities involved in ROC have showed outcome
improvement over their involvement span. "One size does not fit
all." - referring to practice and involvement (my note: I cannot
agree more...). https://roc.uwctc.org/tiki/tiki-index.php?page=roc-public-home
- I just have to
inject this Facebook post I made at the end of Day one, just love spending
time with Larry Miller: Having a drink with the man who brought us the
EZIO... Larry Miller. Always an immense pleasure.
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A seagull attempting to steal my breakfast on day two. |
- Promoting Innovation
in EMS: Driven by DHS, NHTSA and HHS. Does your state foster innovation or
stand in the way? Do your protocols take into account for variances in
individual practice? Prehospital EMS is uniquely positioned to take care
of 15% of the lowest acuity EMS calls WITHOUT transport. This would
provide solid care and save Medicare 600 million dollars each year. The
problem is with the barriers. The federal government is funding the
innovations in EMS project. Another issue is that people hate change.
Maine had to pass a law to allow community paramedicine. Places trying to
innovate are reporting that it is hard. NHTSA does not think it should be
hard. Remove the barriers. NHTSA is trying to rewrite the EMS Agenda for
the Future which is 20 years old this year. Innovation is not an option.
If you are not innovating you have missed the train. Learn the new
healthcare system and adopt its incentives. Part of this is like reading
tea leaves and trying to look into the future. Care is better in home
environments than in nursing homes. By 2018 90% of fee for service will be
linked to quality, and 50% of the total will be paid by alternative
models. The outcomes will be based on population health and not the
individual. There will be performance metrics from the National Quality
Forum. Socials variables underpin the healthcare costs. No one knows these
variables better than a paramedic. The EMS Compass is where we are heading
simply to get funded. California now has a Core Quality Measures project
to identify metrics. San Diego has a HIE, Health Information Exchange and
EMS is a part of it. It is a bi-directional information exchange. There is
EMS surveillance and alerting producing a registry of patients that
surpasses super users and sends community paramedics to care for them
appropriately. The medics develop the care plans. Data tracking also
tracks finances and therefore they know the savings. It has even helped
with homelessness. They are on the innovation exchange so that you can
simply adopt the program idea. The CIE, Community Information Exchange
links the program with Senior Care, Meals On Wheels, faith based
organizations and other agencies. Medics can refer people (with info) to
multiple other agencies and programs using a global consent process once
entered into the system. EMS super users were identified through cross
matching data as being at nutritional risk so that it could be solved.
Innovation is trying to translate an idea or invention into a good or
service for which customers will pay. Successful companies have a culture
of innovation. EMS has to adopt this culture. Question existing
structures. We have trouble moving the needle. We have trouble convincing
the stakeholders. Empower the workforce to be entrepreneurial. Reward the
pursuit and sharing of knowledge. Ultrasounds, sepsis pathways, blood
cultures, lactate levels and telemedicine are already out there on
ambulances. Referral programs are becoming more common. There is an EMS
organization monitoring TB patients. The biggest barriers are financial,
legal and workforce buy-in. State EMS statutes in most states do not
reflect what EMS is currently doing or needs to do go forward. There are
complex inter-relationships... legal, financial, training, information,
etc... The barriers being removed must be the focus at the ground level.
Statute and regulation must support innovation not hinder it.
www.emsinnovations.org has draft recommendations. Flexible scopes of
practice are needed. States MUST be silent on practice settings (ability
to function in any environment). Base on NHTSA practitioner levels but be
able to customize beyond it. We need to demand longitudinal record keeping
rather than single incident reporting. Data MUST be shared. Two entities
cannot be working on the same patient and be unaware of each other. EMS
leaders in state government MUST be involved in reform initiatives within
Medicaid and other areas. Local medical directors cannot have limited
authority. Medical directors need support to innovate. Medical directors
cannot have conflicts of interest with their duties to the EMS providers.
Innovation approach must be interdisciplinary. Evidence based medicine
consensus guidelines and best practices should be incorporated into EMS
protocols establishing minimum standards of care appropriate for that
locale. EMS physicians must be trained in population health (my note:
probably paramedics also). www.emsinnovations.org
- More oral abstracts: EVALUATING COST AND UTILITY OF EPI AUTO-INJECTORS: Schools encouraged to have Epinephrine capability for asthma and anaphylaxis. 69% increase in epi pens from 2003 to 2010. State of Michigan mandates that all schools stock two Epi auto-injectors at all times. No literature available on time dependent nature of Epi effect on mortality or morbidity. No data on frequency of need in schools. This is a retrospective cohort study. What is the frequency of need in schools and what is the cost? Manual review. Source of Epi also a component. IRB approved. Response times of EMS were also assessed. Training costs not assessed by study. 18 public school cases. Most Epi belonged to the patient. Only 2 received Epi from the school. Allergens were mainly food and insect. Cost was vast compared to those who received benefit. ALS response time was rapid. Study suggests that lack of use does not warrant cost. Some schools at a distance from EMS may need Epi, but not all schools. IMPLEMENTATION OF A DISPATCH CPR SYSTEM WITH GOOD NEURO OUTCOME FROM OHCA (Taiwan): Bystander CPR rate improves OHCA survival. Impact of dispatch CPR is unknown. Study performed in Taipei, Taiwan. One dispatch center. Nurses utilized in dispatch. Nurses give prearrival instructions. The nurse’s purpose is solely to give instructions, not dispatching. 1.9% improvement in survival to discharge. 2.1% improvement in neurological outcome. Limitations: No knowledge of prior CPR training of given bystanders given instructions. PREDICTING SECOND SHOCK SUCCESS (Zoll): Amplitude Spectrum Area is a predictor of successful defibrillation. Retrospectively assess changes in AMSA with CPR. 609 patients. 448 patients failed to convert on 1st shock. 193 patients received 2nd shock. 2-3 minutes between shocks. AMSA measured at first shock and before second shock. Used multivariable logistic regression. Patients who had increased AMSA responded better to second shock success (my note: not so sure this is related to CPR as we already know defibrillation decreases threshold for subsequent successful defibs). Admits CPR quality was not measured also TOURNIQUET APPLICATION (Nova Scotia): Tourniquets have been used for 2,000 years. Indicated whenever direct pressure fails to stem blood flow from external limb bleeding. Is there a difference in outcome between standard hemorrhage control and tourniquet? Observational studies were reviewed as well. Review shows a lack of controlled studies. Lack of info on pediatrics and the elderly. Believed that tourniquet instructions could be given by dispatch. Tourniquets effectively control bleeding but it is unclear at what level it affects mortality. There is an obvious LOWER complication rate if a tourniquet is used versus no tourniquet used (historical viewpoint debunked).
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View from our hotel room |
- TXA and Hemorrhage
control in TBI (Jui, Oregon): TXA costs about $100. Speaking on TXA in
trauma and TBI. Hemorrhage causes 90% of traumatic deaths. TXA in surgery
decreases risk of transfusion by a third without much complication. CRASH
2 study was conducted on 4 continents and was shown to decrease mortality
on each. TXA inhibits plasmin and reduces clot breakdown. 20,211 patients
randomly allocated to TXA or placebo. Males are predisposed to trauma more
so than females. CRASH 2 has a great cross section of patients. If using
TXA, quick administration is best. If not going to give within three hours
do not give it. No increases noted in thrombosis. DVT was same in both TXA
and placebo groups. NNT is 67. MATTERS 1 trial was at Camp Bastion trauma
setting in Afghanistan. 896 combat casualties. TXA group was more severe
AND had better outcomes. TXA group had decreased mortality in spite of
worse ISS scores. Immediate causal relationship noted between
hypocoagulopathy and mortality was noted. NNT was 7. There was an increase
in DVT and PE in this study, but may be from the combat injuries. MATTERS
2 looked at effect on TXA and Cryoprecipitate. TXA and Cryo had best
outcomes. PED-TRAX study was on Peds and TXA (also military theater).
Showed decreased mortality once again. No significant complications. TXA
group showed better neuro at discharge. CRASH 2 data also showed no
difference in survival of isolated TBI but did show less hemorrhage. Only
one retrospective study (VALLE 2014) shows worse outcomes with TXA and in
that study it was based on physician individual choices rather than a
designed trial. A UK trauma system study on civilians showed decreased
mortality as well. Use in first hour has best outcomes in summary.
- Bariatric Patients in
EMS (Clarke): Training for a Growing Problem (Akron): Bariatric patients
have higher incidence of diabetes, hypertension and many other disease
processes. Biggest issue was training sensitivity toward the issues. The
number of physical barriers is staggering even with EMS equipment. Do not
make jokes. Do not make a public display of the need for larger equipment.
Bariatric patients commonly have decreased mobility. Schedule needed
equipment in advance. There may be prolonged extrications from buildings.
Air transport may not be feasible in some cases due to airway and weight
issues. Bariatric patients have a very low threshold for intubation need.
Can you get to where you need to be to perform procedures on the patient
in an aircraft? Clear plans and manpower are needed to insure crew and
patient safety. The training was designed to be three hours. It is a
mobile program. Combination of didactic, skills and scenarios. Skills
stations are airway and miscellaneous skills. Uses IO, IV models, airway
trainers, bariatric cot and bariatric tarp. Bariatrics have increased
chest wall resistance and greater abdominal pressure on the diaphragm.
Bariatrics desaturate more quickly. Traditional BVM ventilation is
difficult and may require a two-person technique. Most are very difficult
intubations. Sniffing position is best. Alternative airways may not work.
Surgical airways are difficult. Try and keep bariatric patients upright.
They also have an increased risk of aspiration. They built a bariatric
intubation simulator. It may be difficult to obtain blood pressure and
cuff size is crucial. Venous access is problematic. Even splinting may not
be easy to accomplish. Bariatrics get hypothermic more quickly. Needle
decompression may need longer needle. There is a bariatric water suit
available for rescue manikins to bring manikin weight to 500 lbs. Lifting
techniques must be defined and practiced.
- Everest Basecamp MCI
(Zafren): Speaker was there when earthquake happened. 7.8 earthquake.
April 2015. Killed 9,000 people. Injured 22,000. Everest base camp had 19
dead. Nepal is the least developed country. No roads. Existing roads are
rough and slow. No formal SAR. Military handles incidents. Most rescue is
by companions or other expeditions. No ALS ambulances in Nepal. Prior to
this earthquake, last major one was an 8.0 in 1934. The earthquake was
somewhat expected at some point. There were many aftershocks. Hundreds of
thousands were left homeless. Deaths were decreased by time of day and day
of week as children were not in school. Base camp is at 17,598 feet
elevation. Accessible only by foot or helicopter. Most deaths at base camp
were from avalanche blast force. Most deaths were immediate due to head
injury. 17 died right away. 80 injured included extremity fractures,
pelvic fractures and soft tissue injury. Three doctors at the makeshift
base camp ER. The ER tent was destroyed and one physician died. A second
doctor was injured, leaving one uninjured doctor. Communications were
limited initially... meaning NONE. No helicopters had night vision or IFR
capability. Closest hospital is a 15 hour walk. The two remaining doctors
were busy overnight with poor conditions forecasted for the next several
days. Weather actually cleared overnight and the first helicopter arrived
unannounced. Each helicopter took two critical and one walking per trip.
16 patients staged from Everest at Pheriche. White tape with text was used
for triage. Mattresses were used to carry people to and from helicopters.
Patients went from Everest base camp to Pheriche and then to Lukla and
then to Kathmandu. Definitely an austere environment. Kathmandu had less
damage than expected. It is impossible to plan for every wilderness
disaster. It is hard to be a victim and a rescuer at the same time. There
were many depression issues.
- Prehospital care for
the spinal injured athlete (Hudson): Athletic Trainers are first line of
defense and understand the equipment and mechanisms of injury. team
physician training varies greatly. Most are family medicine and only 4%
are emergency physicians. NFL now has "airway" docs. NHL now has
emergency physicians. EMS may be on standby or dispatched. Read "Prehospital
Care of the Spine Injured Athlete." More mounting arguments about
long spine boards being used. There are decision trees that should be used
to determine when spinal stabilization is used. There are about 10,000
spinal injuries a year and about 10% are from sports... all small numbers.
ACEP states backboards should not be used as a therapeutic device. Sports
still indicating use. Axial load is the most common injury. Three times
more likely to occur during a game than practice. Sports is an austere
environment. Football equipment is designed to maintain neutral alignment.
Not true for hockey. Most helmets do not accommodate a c-collar. C-collars
may even be debated. Airway control after face guard removal is not a
challenge but speaker recommends a non-visualized airway over intubation.
LIFT, don't roll onto devices. Keep stretchers ow to avoid tips (EMS needs
to learn this for ALL patients, period). If you respond to hockey, MANDATE
Yak-tracks for crew and patient safety when on ice. Everyone needs to know
each other. Athletic trainers, physicians and EMS should work together.
Avoid conflict. Use LSB to extricate and then get them off the board to
the cot. LSB should be removed before transport.
- Just looked at a
poster study confirming our local use of steroids in respiratory patients.
Good to know our local long-term thoughts are confirmed
regarding Solu-Medrol usage. Good stuff in realtion to reducing length of
stay.
- Electronic Dance
Music, Designer Drugs and Teen Death (Fitzgibbon, Lawner, Levy, Seaman):
Designer drugs including Molly are a lethal threat to teens and adults.
Electronic music dance festivals produce unprecedented patient numbers
related to this issue. Patient numbers start as soon as the Rave begins
and escalate during the event. Some of these events draw large crowds.
Drugs are used to enhance the music experience. Fastest growing genre of
music and attracting as young as 14 year olds. One chemist designed 179
different designer drugs. Finding the exact drug used is almost impossible.
Care is supportive to hydrate, stop seizures, prevent hyperthermia and use
benzos to decrease agitation. Prevention efforts are needed. Best
practices need to be identified and shared. Six deaths were attributed to
drug usage at three different festivals (all had multiple patients). One
best practice is to deny access to event for unescorted minors. One event
had 21 transported patients with two cardiac arrests. Friends may abandon
victim when patient becomes unresponsive which may prolong recognition of
emergency. Reviewed major patient case studies from one event. Benzos may
have limited effect. Mass gathering prediction models are overwhelmed and
inaccurate for these festivals. Parents must teach children about these
drugs as well as those commonly mentioned. Excited delirium has been seen
in these cases. There must be pre-event intelligence looking at what
happened in the cities they were at before. Deny concert permits if prior
issues. People who are on Molly do not respect boundaries. Station EMS and
first aid at a distance from the spectators so that they are not
immediately overwhelmed and have to determine first aid versus real
issues. Form medical action plans. Get support from poison control
centers. Have a separate command center from treatment areas. Starting to
not allow liquids to be brought in and using controlled water supplies.
Some are using paramedic treatment areas with physician presence. Have
lots of benzos and tubs to cool down hyperthermia and excited delirium.
Treatment areas and tents must be designed for patient flow and
segregation by type of patient. Ketamine on site may be needed.
- Top Innovations for
2016 (Brent Meyers): 1) Active assailants have become a big issue.
Everything we have done to prepare for active shooters is based on data
from 2000-2013. Most incidents involved a single shooter. Most were male.
Most were caught. It also showed that law enforcement engaged and about
25% of the time an officer was injured. The shooters almost always
committed suicide or were taken out by LE. During that time only a few
used IEDs. We thought we could plan a response for this based on the
numbers. We are going to have to be prepared for five or more critical
patients and understand and operate in the austere environment. 2015 negated
all of the previous data because there were multiple incidents with large
numbers with multiple shooters, sometimes in a single day in multiple
cities. He showed 12 slides of tables with just 2015 data. When does an
MCI become a disaster? Stress and debrief are going to be an issue. 2)
Healthcare reform is for real. Reimbursement changes are coming. Three to
five year VERY substantial changes. Value-based payment is becoming a
reality. By the end of 2017, 80% of payment will be based on value per
government sources. Payment will be based on doing things correctly. We
will move from volume based Fee for service to value based for population.
We have to decouple "transportation" from what we do in the
prehospital environment. We have to get states to stop saying what
environments a paramedic can and cannot function in. Bundled payments for
quality improvement are coming. EMS can do both simple and sophisticated
things to assist the patient and the hospital in this environment.
Prehospital clearance of chest pain has been studied and is viable IF done
correctly and objectively using patient scoring, 12-lead and on scene
Troponin assay. 3) Narcotic dependence and overdose: 700% increase in
narcotic dependence in Vermont over last decade. NYC CVS soon to sell Narcan
OTC. It now only costs $6 for an overnight high. Parents have been caught
overdosing while at hospitals visiting admitted children. As the price of
Heroin dropped and prescription opioids increased, Heroin took over. Note
that 350 million prescriptions for narcotics were written last year.
Narcotic overdose is now the biggest issue in the United States. Public
access Narcan is here to stay. We need to account for public access Narcan
in our cardiac arrest survival data. This is a true epidemic. 4) Advocacy:
We have an obligation to stand up for what we believe. We also have an
obligation to stand up for our patients. NAEMMSP is moving forward with
the DEA bil to advocate for pain relief in our patient. The DEA has no
sense of humor. Every local DEA representative has a different
interpretation of EMS and narcotics. Advocate for this Bill with your
legislators. 5) International outreach: NAEMSP held three medical director
courses outside of North America this year (Havana, Mexico City and
Taipei).
- I have to start
carrying WHAT on my ambulance? (Cooley, San Antonio): Speaker has
Congenital Adrenal Hyperplasia (CAH). Cortisol deficiency. Some have
Aldosterone deficiency. Androgen excess. There is a lot of variability n
patient presentation. Some have salt wasting and are more severe. May have
hypertension. Cortisol increases contractility and cardiac output.
Patients present with virilization, early puberty, short stature, acne,
infertility and depression. What we are worried about from an EMS
perspective is adrenal crisis. Triggers are stressors: Trauma, fever,
dehydration, surgery and extreme exercise. Emotional and mental stress are
not a stressor for induction of adrenal crisis. Weakness, fatigue, fever,
vomiting, diarrhea, abdominal pain, lethargic, AMS, tachycardia,
tachypnea, metabolic acidosis and hypotension. Receptors do not work so
Epi may be non-effective. They may have elevated potassium. They are
diagnosed at birth or later in life due to crisis. Initial episode may
take 10-14 days to develop. Use Hydrocortisone, 0.9% NS for IV, potassium
may need to be managed in ER. Unknown as to whether Dexamethasone works or
not. ERs and EMS may be education deficient on this topic. Communication
and retrieval of information are key to success. Patients and families may
have Hydrocortisone with them for injection. You can make a known CAH
protocol or just a protocol allowing medics to administer patient carried
medications. Speaker makes note that he went to Philmont as a boy scout
and got his injections in the backcountry of New Mexico. Solu-medrol can
be used if hydrocortisone is not carried or available. The disease is not
common but the care is lifesaving. He feels that medics should always have
the ability to utilize patient's medications.
- The EMS Compass Initiative (Garza): Is EMS accepted as a medical practice within the house of medicine? It should be. You have to know the WHY before you can show the HOW. How do you define quality from the aspect of value? Alice's conversation with the Cheshire cat rings true here... where do you want to go? Healthcare costs are the highest in the US without providing great outcomes. EMS is only mentioned in the ACA seven times. The IHI Triple Aim should guide us. We must forge a stronger link between quality and payment. The most valuable commodity is information. Show the data or you will not be believed. It is not enough to do your best; you must know what to do and then do your best (Deming). The National Quality Forum and Hospital Compare are great websites to look at basic metric use. How does EMS show value? EMS Compass is the HOW. EMS Compass is not punitive. Measures are being designed and tested. "Amateurs talk strategy. Professionals talk logistics." - Omar Bradley. The effort must be continued post-compass development. Improvement equals quality. Quality equals better patient care. Better patient care equals value. www.emscompass.org
- TEMS Response to
Civil Unrest (Ferguson) (Dr. Tan): Intel was used utilizing social media.
Decontamination was improvised from fire departments in case biological
fluids or chemicals were used. Specific kits were put together for
supplies. Stress issues were addressed using buddy checks. Use unified
command. Run table top exercises before events occur. Know what
destinations will be used. Know the capabilities and staffing of your
destinations. Look at quantities. Do you have 100 tourniquets? Do you even
have 50 tourniquets? Be very specific on kit design. Pneumo kit needles
need to be 3-3.25 inches in length. Learn tactical priorities of care.
Protocols must allow for austere environments. Do your protocols have
chemical munitions exposure care? Do you have eye wash? TEMS should
coordinate with local EMS. Be crystal clear regarding security plans for
your personnel. Clarify with command staff as to expectations and
responsibilities. Who is defined as the patient? EMS is caught in the
middle in these incidents. Incidents must be studied to learn how to
respond. Stage and wait is not practical. If that is your plan today, work
with other agencies to change it.
- DEA Update (Sahni): HB 4365 needs to pass to make our current EMS operations legal. Most DEA rules for EMS are made up by the local DEA contact as there are no EMS rules. EMS has asked the DEA for rules for many years. The CSA says no standing orders for narcotics. Must have a name and DOB for narcotic administration. Must be audited. Please write your congressional representative to support 4365 which fixes the issue. Supported by the American Ambulance Association and the IAFF. If 4365 passes, the agencies will register as opposed to the medical director. Do this quickly. Letter template, info and tool kit at www.naemsp.org
- The 2015 AHA
Guidelines: Not Carved In Stone (Sayre): This guideline cycle has significant
changes, but it is a focused update to the 2010 guidelines. There are two
chains of survival, IHCA and OHCA. Training materials will differ. Cath
lab is now a link in OHCA (Good!). The AHA now encourages adoption based
upon your environment. The AHA now expects you to figure out what works
for your system and community. No impact on outcomes with ITDs (blinded
study with sham ITDs). However, ITCD plus ACD CPR (not blinded) did show
approximately 2% improvement in outcome (NNT was 45). ITD not recommended
alone, but ITD with ACD CPR may be reasonable. Mechanical CPR: Four
studies, none showing improvement in outcomes. Manual chest compressions
remain the standard for care BUT may be useful in areas of decreased
manpower or safety of personnel. Vasopressors: Nothing showing standard
dose Epi improves outcomes. Same with high dose Epi. However, time to Epi
may matter. IHCA data shows much better outcomes if Epi is given in the
first few minutes of arrest. Standard dose Epi may be reasonable but is
now a class IIb LOE recommendation. HD Epi is not to be used. Nothing
wrong with Vasopressin but it is no longer in the algorithm but it can
still be used. It was removed to streamline teaching. Failure to achieve
ETCO2 greater than 10mmHg after 20 minutes is associated with poor
outcomes. Insufficient evidence to recommend ECMO unless there is a known
reversible etiology. Cath lab should be used emergently if there is a
STEMI. Hypothermia: Prehospital cooling with saline no longer recommended.
No differences in outcome.
- Articles that may
change your practice (Bigham, Millin, Rittenberger): 1) Older injured
adults are often under triaged against the CDC trauma criteria. Using AIS
instead of ISS to score patients. Mapped to ICD 9 codes. 33,000 patients
with most common injury being extremity injury. 80% were falls. Turns out
that CDC guideline with any positive worked well. But by using the
criteria they increased over triage by 164%. Under triage was however
reduced. Poor specificity in study. Instead of using the exact criteria,
simply use a higher level of interest in assessing and triaging this
population. Lactate measurements may help determine if a trauma center is
needed. 2) Ischemic stroke treatment: Discussing IA therapy. Demographics
of included patients similar to other studies. Possibly better functional
outcome with IA therapy if under 6 hours from onset. Not without risk. CT
scanners in ambulances? Are there adequate numbers to support this? Are
there other ways to operationalize this? TPA early may be better. Looking
for patients that benefit from IA may be like looking for a needle in a
hay stack. 3) STEMI: Is bypassing local hospitals to go to PCI centers
supported? Can BLS crews safely triage to more distant PCI centers safely
(many BLS units have 12-lead in Canada). 12% had events on way to the PCI
center. Many required ALS intervention by ALS intercept. Closest hospital
increases time to PCI by 47 minutes. ALS intercept only increased time to
PCI by 1 minute. The entire 12% received ALS by intercept. Conclusion, BLS
transport to PCI at a distance decreases time to PCI and is safe even if
ALS intercept needed (my note: this data would finally support 12-lead for
BLS). Limitation: Distance to PCI capable hospital was only an additional
12-15 minutes. 4) Pediatric airway: This study used experienced medics.
All medics had OR experience INCLUDING pediatrics. Used peds bougies and
Succinylcholine as part of tool kit. 66% first pass success with 97%
overall success. There were no unrecognized esophageal intubations. If you
design your airway training well, pediatric intubation may be safer (my
note: but does it affect outcome?). 5) Continuous or Interrupted chest
compressions in cardiac arrest?: AHA says 60% CCF. This study showed 77%
was really good at producing better outcomes. MICPR obviously better than
continuous compressions. Speaker states that perhaps the greatest
intervention is passion and enthusiasm. ROC studies are driving
improvement... period.
So therein lies a summary
of my notes from the 2016 NAEMSP Annual Meeting. Again, as those who have read
my notes from these type meetings before well know, if you attend EMS
conferences, please assure that the NAMESP Meeting and the EMS State of the
Sciences Meeting are the two at the top of your list. These two meetings are at
the top of the mountain for evidence-based medicine in our EMS world.
Back in Evansville, in my little corner of the
world, we can attempt to translate these things to applicable practice to
benefit the outcomes of our patients.
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgByzGCXERg8hugPdwcp4Mm0fPCkp8Na93_XOXnL7kfMZqIazcZ9t-jmvic8kV-LPJUsvx-rrQeKnvwytOFa0ycYxC3biSpEQWB0lwFbwFF3JBdVL9q-VSZqZxwk0I9a4nQ3gCnEg9NWzw/s320/20160121_151151.jpg)
Till next time... God bless.
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