NAEMSP 2016 - My Notes

This will be another "Lee's Notes" blog entry. I normally just do this for the EMS State of the Sciences Conference. This year I moved up in the world and took an Android tablet with me so that I could take notes, post to social media and still not have to lug a notebook computer around with me. Even though this meeting moves at a much slower pace than the State of the Sciences Conference does, and the sessions are much longer, this meeting is the hardcore science of EMS. You will see NNT (Number Needed to Treat) and research process in many of the presentations.

I had not been to San Diego since 2006 and was kind of looking forward to the trip. It was made even more enjoyable because we flew from twenty degree weather to a sixty degree tropical arrival. I even got to take my loving wife along on this trip.

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.



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.

 

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).

 

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.

 

Another trip completed... one more little trinket placed in the stone bowl of memories from places visited and things experienced... maybe I should write about that sometime too. Hope these notes are helpful.

 

Till next time... God bless.