This has turned out to be an annual pilgrimage to the site of all that is evidence-based EMS medicine in its rawest form: very short, concise, data packed presentations from locales in various places which even included Auckland, New Zealand this year.These are once again my notes from this wonderful event. Please remember that they are notes, therefore they are my interpretations of what was presented. I just cannot say that there are not any small errors in the translation. This is the most massive note set I have taken to date, so I am not even sure that the spelling and grammar will be 100% checked and correct. Again, these are notes.
Without further delay, here it is... Eagles XVIII the 2016 Lee's notes version. I hope you find the information useful. I have inserted links wherever I can to more information and there is a link at the end to take you to the actual PowerPoint sets on the Eagle's website.
And so it begins... WARNING! These ideas could be highly toxic to outmoded practices! Put on your reading glasses and let's dive in...
Slovis/Nashville - Most Important EMS articles: 1) Valsalva
maneuver only works only 5-10% of the time. Still needs to be done. New way to
do the Valsalva. Bear down for 15 seconds, then lay them back and raise legs
for 15 seconds. Return to sitting position. Maximize pressure by having them
blow into a 10cc syringe to move plunger. Improves success in converting stable
PSVT to 47%. 2) ACLS: Hyperoxia is dangerous. Go by pulse ox. When bagging no
more than 10 breaths per minute. Lidocaine and Amiodarone now equal. There is a
randomized Epi vs. no Epi trial in progress. 3) There is software available to
alert cell phones when CPR is needed in your vicinity. Alert generated by 911
system. Bystander CPR start improved by 14% with cell phone alert. 4) NTG is
safe for Inferior MI (forget what you have been told here). 1,466 STEMI
patients in study. No difference in location of MI and hypotension in STEMI.
Bottom line, be prepared for hypotension any time you give NTG to any STEMI. 5)
Decompressing Tension Pneumothorax: 2nd ICS will be missed frequently with a
high failure rate. ICS Anterior Axial Line may be better with a 5cm angiocath.
Augustine/Eagle's Librarian - Urban Legends from 2015: One
of the points of existence for the Eagle's is how do they provide better care
and how do they provide better medical direction for EMS? Ask quick questions
and collect quick answers from peers. 70 Eagle's discussions last year via
email. Important topics this year were: Managing patients with defib vests,
removing athletic equipment, resistant infection, the use of AEDs in trauma
arrests, managing cardiac arrest in near-gravida females and pediatric
intubation and back up airways. There seems to be no agreement on the
definition of "pediatric." This definition is all over the board. On
medications, they discussed Narcan, Ketamine, Hydroxycobalamin and Glucagon.
Large discussion on eliminating Glucagon due to cost vs. benefit. They also
discussed Quality Improvement, checklists, performance measures, texting to 911
and staffing. Strongly believed that paramedic units should have two
paramedics. Other topics were hospital diversion, PHI in hospital
transmissions, tourniquets, CPR devices, CPAP, BVMs for pediatrics, pelvic
immobilization, needle decompression, restraint and end-tidal CO2. Extended to
tactical EMS, violence against EMS and major incident management. Active
shooter changes are needed as demographics have changed in the last year.
Essentially the goal of the Eagle's is sharing best practices.
Antevy/GBEMDA - What I am and am not using from the new PALS
Guidelines and a brief update on community hemorrhage control: The science is
not clear. 2015 recommendations are based on reviews starting in 2011. There
were only 18 questions asked in the PALS arena. A lot of the data is weak.
Review of the studies on fluid prior to shock in septic children showed only
one study saying it caused harm. Routine use of atropine in intubation not
supported, but evidence does support it. Stopping CPR in children is supported
when prolonged CPR and under one year of age in a non-shockable rhythm. No
vasopressor in pediatric arrest was not supported by PALS but is supported in
at least two references. As far as hypothermia goes for post-arrest goes there
was no difference in four studies. One study showed improvement. The guidelines
hedged on this and gave options. Speaker is still using hypothermia.
COMPRESSION ONLY CPR IN KIDS HAS WORSE OUTCOMES. Use standard CPR in kids with
ventilations.
Schrank/Miami - Prehospital Pregnant Pauses That Defy
Gravity, Managing Cardiac Arrest in Those with Child: This is a difficult,
scary topic. These runs are rare and heartbreaking. Massive cardiopulmonary
changes in pregnancy with very little reserve. Recognize Aorto-Caval
compression. You must have blood return for effective CPR. Hypotension will
most likely occur in a normal 3rd trimester mom if placed on her bank. Always
turned to the left. So the patient must also be turned during CPR which is not
possible. Perform manual left uterine displacement. Push hard, push fast, but
have a set of hands pushing the uterus over to the left to get pressure off the
vena cava. Even the lay pubic can perform this maneuver. Perform by pushing
upward and to the left. No mechanical CPR in pregnant women. Use BVM in
pregnancy, no passive oxygenation. Supraglottic airways are fine. No changes in
defib for pregnant women, but be sure and use escalation protocol. There are no
recommendations regarding field termination of arrest on pregnant females.
Peri-mortem C-section is a class one recommendation, start procedure at four
minutes into arrest (in ER) with baby out at five minute mark. There is a
survival benefit FOR MOM and INFANT when peri-mortem C-section. No push toward
field C-section at this time, but should be done on arrival at ER if in arrest.
Speaker states the skill set needed would be akin to "field dressing a
deer." The treatment in these is rapid transport. Infant may need
aggressive resuscitation. EBM shows fluid early in PEA in gravida females.
There is also much risk of arrest up to three weeks post-delivery as well.
Transports in normal pregnant female should be made in the left lateral
position. Alert prior to arrival. GREAT LECTURE.
Goodloe/Tulsa-OKC and Holley/Memphis - Taking the Guessing
out of Decompressing the Pressing, ACD and ITD CPR: Even with the best science,
cardiac arrest survival is dismal. The real difference in this process is in
the decompression stage. More negative pressure means more venous return. Blood
flow to the left ventricle and the brain is improved with ACD ITD CPR. Almost a
3% improvement in one trial. This device can cause pneumothorax (ACD). One and
done does not work for continuing education on this device. Rate with the ACD
device is 80 not 100-110. Outcomes must be tracked. Body motion is not the same
as normal CPR. 80 is not a normal rate for EMS so a prompt must be used. The
ACD optimizes chest recoil. Use less lift if cup dislodges. Not a good device
to be used during transport as there is strong risk of provider fall/injury.
ACD cannot be used with recent sternotomy. May have issues if chest is wet or
extremely hairy. Even correct use of device or normal CPR may cause tension
pneumothorax. Decompress and keep going. Let depth be the guide, not the force.
ROSC has been higher since implementation. Neuro intact discharge has been
good. This is early data. They are still analyzing cases. Good training is
essential to use of these devices. It is all about saving the heart and brain
post arrest.
Frascone/St. Paul - 2020 Foresight, Emerging Roles of
Intrathoracic Pressure regulation: There is no complication of mechanical CPR
that has not occurred with regular CPR. Two theories on CPR... Cardiac pump
theory compresses heart and moves blood. Thoracic Pump theory is negative
pressure pulling blood to the heart. The negative pressure is seems to be
important making regular CPR inadequate. ACD CPR is easier to maintain quality
CPR than high quality manual compressions. Lucas is NOT ACD, it only brings
chest back to neutral, not negative pressure. Lucas is a good device but NOT
ACD (stressed strongly). The ITD (Impedance Threshold Device) when combined
with ACD CPR seems to be the best mix. 53% increase in survival with this
combination. The FDA saw this as irrefutable evidence. 25 animal studies and 5
human studies support this. In standard CPR the ITD does not provide any
different outcome, but with ACD CPR it maximizes the potential outcome. There
is no question on this in the opinion of the speaker. The FDA statement on ACD
ITD combination is that it improves likelihood of survival in adult patients of
non-cardiac arrest. This is a stronger recommendation that what defibrillators
have today. Speaker states ACD ITD on scene, and only use Lucas if CPR is
needed during movement/transport. This was not in new ACLS guidelines and
speaker believes this is scandalous as it was sent to them.
Pepe/Eagle's Coordinator - Elevating the science on gravity
assisted resuscitation, it takes more than tilt to effect head up CPR: Supine
patient chest compressions are inadequate. It sends pressure waves to the brain
that increases ICP which is already ischemic from arrest. The hypothesis was to
elevate the head during CPR and provide better circulation, decreasing ICP and
improving brain flow. With head elevated 30 degrees, arterial pressure remains
the same but ICP comes down. If we lower the head ICP goes way up. Tracked
blood flow to brain with radioactive isotope and found better blood flow with
head up CPR. This was true in all areas of the brain. This may be how to save
the brain during CPR. So the question for this year, what is the optimal angle?
At 40% the arterial pressure decreases so that is too far. Do we elevate the
upper body or just the head or neck? Study subjects are swine. 30% seems to be
optimal. Palm Beach Fire has been using the concept (see pictures in comments).
They have had improved survival since implementing this after Eagle's meeting
last year. Does head up CPR work without ITD and ACD CPR? It works better than
supine CPR without ITD and ACD, but works far better if ITD and ACD. Angle best
if upper body is elevated and then head tilted forward even a bit more.
Lowering ICP pressure needs to be a key focus.
Miramontes/San Antonio - Managing Strokes with Great
Dispatch!: San Antonio uses only paramedics in the dispatch center. They use
the MPDS Stroke Tool prior to ambulance rolling. The progression allows for
crews to be attuned to stroke center needs before unit even roles. They
retrained the stroke tool so that it would be used as it was intended. They
focused on performance using the tool. Stroke care today is still time
dependent. Best results in under three hours with some benefit within a couple
of hours after that time frame. Nothing has changed here. Most ERs have a
target of 60 minutes from door to TPA. Crews need to focus on a target 10
minute on scene time. Dispatchers use the FAST Stroke Assessment on the fine
with a slight modification to make it telephone friendly. If the stroke score
is greater than 2, dispatch alerts the crew to a positive stroke score. O2 only
if SPO2 is lower than 94%. Serum Glucose is checked. Plan for rapid extrication
from the home using fire department is part of the protocol. All care other
than serum glucose check is done in route to hospital. Hospital is alerted.
"The only treatment the stroke patient needs is diesel fuel." From
the dispatch perspective, there were only 4 in the last period of measurement
that turned out to be false for stroke. 76 were correct. Fire Department starts
moving patient out of house prior to ambulance arrival.
Gilmore/St. Louis - Brain Docs Making House Calls: 63 square
miles in St. Louis. 330,000 to 550,000 population between day and night. Time
is brain. For every minute a stroke patient goes untreated they lose almost two
synapses and seven miles of neural fibers. The system has to be sequential. You
must use a stroke chain of survival. They placed stroke cards with the
glucometer. The card has a family member on scene call directly to a
neurologist. Allowing the neurologist to interrogate the family member has
helped drop door to treatment lower than 30 minutes and in some cases even
lower. Biggest issue is talking to a neurologist at one facility when
transporting to a different facility. Cards were produced through grant funding.
McMullen/Cincinnati - Different Strokes for Different Folks:
If any one item fails in the Cincinnati stroke scale the chance of a stroke is
72%. A Comprehensive Stroke Center can care for all types of strokes. They are
few and far between. In Cincinnati, there is one CSC and four primary stroke
centers. A stroke system requires prehospital triage. Over triage must be
balanced with under triage. Four triage scales are being evaluated. None are
ready for prime time use. We need a dashboard of stroke performance
measurements with hospital outcomes provided to EMS. Prevalence of disease,
Drive times, door to needle times need to be measured. We need to move
1,600,000 neurons a minute faster as that is how many a stroke patient loses in
60 seconds without treatment. Put the patient first, competing centers MUST
work together.
Antevy/ Broward Florida - ELVO has entered the building!
Facilitating Cerebral Embolectomy for Large Vessel Occlusion: Stroke evolves as
time passes. TPA works, but... large vessel occlusion is not as affected by TPA
use. TPA effectiveness on large vessel clots can be as low as 6%. Clot
retrieval had less than favorable use in the literature. The Mr. Clean trial
only looked at large vessel occlusion. Seven trials now show clot retrieval to
provide better outcomes with ELVO patients. RACE score is an extended
Cincinnati scale. If you are above a score of 5, ELVO is likely. Clot retrieval
is in cath lab. Can be activated prehospital if score is higher than 5 with
ambulance bypassing ER and going to lab. Using Pulsara app to activate stroke
response in facility. They are showing amazing times in clot retrieval. EMS is
the gatekeeper for stroke patients.
Hunter/Orlando - A Fractious Practice or Stroke of Genius -
What are the Outcomes for Comprehensive Stroke Care Triaging?: Benefits of
Comprehensive Stroke Centers... interventional procedures provide benefits to
large vessel occlusion patients, focus is on strokes of all types. TPA is still
the bread and butter of stroke. Time to CT is critical. All EMS suspected
stroke patients go direct to CT, not the ER. Stroke patients are six times more
likely to get TPA at a CSC than at a PSC. All times to care were decreased when
they switched from a PSC to a CSC. Speaker believes all strokes should go to
CSCs.
Persse/Houston - Street 'em and Treat 'em, Experience with a
Mobile Care Stroke Unit and Its Impact: Biggest issue with TPA is that door to
needle is far too slow. Target is less than 60 minutes. Door to CT target is 25
minutes. Solution, take the ED door to the patient and keep the stroke process
simple. A full time medical director and project manager are a must. There have
to be collaborative agreements with all stakeholders in the process. $1.8
million was DONATED to make this happen. There is now a Houston Mobile Stroke
Unit Coalition. This was complicated due to number of PSCs in Houston area.
Cost of unit was $1,465,000 with the CT scanner. Payback takes seven years. Use
of unit: 42% were treated in under 60 minutes. 37% were treated in 61-80 minutes.
Outcomes are being analyzed. Prehospital triage and treatment will be the next
quantum leap in this area. A stroke has to be considered to be a reversible
gunshot wound to the brain.
Eagle's Lightning Round #1 (all medical directors on stage):
1) Thoughts on transport destinations regarding stroke: Definitions of PSC and
CSC vary by state. They suggest doing collaborative regional systems. EMS can
identify patients at risk who can benefit from a certified center approach. We
have a duty in EMS to search out the hospitals data so that we know they can do
what they say they can do. Just because they say they are does not mean they
are achieving the goals. Look at the data. EMS is a practice of medicine and we
have to look at facts. Make destination decisions on what really happens at
that destination. Specialty care destination decisions is a huge issue. 2)
Duration of resuscitation: We do not know where the end point is for stopping
resuscitation in arrest. It seems to be longer than previously believed. It is
unsafe to do CPR in the back of a moving ambulance, so resuscitate on scene.
Manual CPR in the back of an ambulance must go away. Incredibly dangerous.
Scene times must be longer for resuscitation. Some anecdotal information is
showing success with Lucas all the way to cath lab and balloon with positive
neurological outcome. Slovis states that we have to look at the patient before
advocating long resuscitation times, advocates for watching for and calling
arrest based on low ETCO2 levels. 3) What labs are being used pre-TPA in
stroke? Consensus was it needs to be limited. Draw for many but do not delay
administration. 4) Is air medical recommended for stroke transport in rural
settings? Consensus is ground is more appropriate out to about a 45 minute
transport time (no evidence was stated except for "our experience").
5) What about interfacility stroke transport? Goodloe advised there is a very
strict protocol for this and is considered emergent if going to a stroke
facility.
Copass Award for Excellence and Contributions to EMS: Craig
Manifold (ACEP and NREMT).
Slovis Award for Educational Excellence: Sophia Dyer
(Boston).
Persse/Houston - How 1115 Permitted Legalized ETHANized in
Houston, Early Results of a 911 Based Telemedicine Program: ETHAN is the
telemedicine system. Need for ER diversion strategies. Goal was to redirect
patients to appropriate destinations. Between 300 and 400 EMS transports daily
in Houston. Houston engines staff with four EMTs. Every EMS Toughpad is capable
of telemedicine. There is a loose protocol so that if the EMS contacts feel
that the patient might need diverted to care other than ER they can invoke a
telemedicine consult. Some patients are diverted to clinic by taxi or even POV.
Home care instructions can even be given. 911 does not equate automatically to
a transport to ER. The ER physician can deny transport to ER but not access to
healthcare. 82% agreement rate between EMT/Medics and ER Docs on transport to
be utilized. Flat fee for cab usage in program of $35. Estimated 95% savings
when patient is diverted to appropriate care other than ER. They feel this
program is the answer to ER overuse.
Eckstein/LA and Moore/London - While LA May relay the Repeat
Play, London's Calling for Falling Dispatching Specialized Nursing Staff in LA
and the UK: LA using nurse practitioner response unit for treat and release to
reduce utilization. Idea is to treat and release lower acuity patients. Uses
experienced nurse practitioners from ER. Specialized response unit. They use
iStat for labs. They can replace G-tubes, prescribe meds and close wounds.
About six responses per day. Has been up and running for a month. 21 to 24
minute response times. 51% of patients seen are diverted from ER. They have
field ultrasound and telemedicine. They have also launched a patient liaison
program. They plan to put NPs in dispatch in July 2016. The NPs are independent
practitioners. London Ambulance Service now has a "Falls Car." Being
used in northeast London. Designed to improve care of frail, elderly fallers,
manage patients at home, save money and decrease unneeded admissions. 34% of
patients being transported were over age 75. A significant portion were falls.
Uses a community treatment team as part of LAS. Paramedic and community nurse
led. Multidisciplinary planning. Another gal was to reduce pressure on
ambulance availability and improve patient satisfaction. Serves others than
just falls including those with infections. 29 minute average response times.
If deemed to be acute, response time is 8 minutes. Also addresses patients who
might be considered lift assist that are still on floor. 65% of patients are
kept at home. Patient feedback has been very positive and included award
nominations. Large cost savings to system.
Yancey/Atlanta - Not a Fulton Folly, It's a Peach of an
Idea, Bringing Primary Care Docs to the Streets of Atlanta: This is a component
of Grady EMS Mobile Integrated Healthcare. Includes frequent callers which are
considered to be more than five calls in a month. Lowest levels of EMD acuity
are also included in this response program as well as patients at risk of
readmission. Frequent user evaluations are performed including environmental
temperature, fall risks, physiological issues and activities of daily living.
Behavioral is also part of the assessment along with substance abuse. 41% have
behavioral issues and 38% have drug or alcohol abuse problems. Attempts are
made to manage ability to stay at home. Out of 9,000 calls in a month almost
1200 were MIH eligible. EMD codes 26-A-1 and 26-A-8 where the predominant EMD
codes indicating MIH. Grady EMS provides a medic and SUV with iStat and
physician exam equipment. Home Physician LLC provides the physician. If you are
following up on a CHF patient, assessment time is at least 30 minutes.
Asaeda/NYC - A New Version of Gentle Coercion Using
Diversion Inversion, Re-directing Ambulances Away From Parking Facilities:
Nationally there has been a 3% to 12% increase in EMS call volume over 2015.
1.4 million responses a year in NYC. Nearly 1 million transports. About 4000
calls a day. EMS will honor ER diversions if they can. Diversions are only
allowed for 2 to 4 hours at a time. Once one hospital goes on diversion it causes
a chain reaction until they all are on diversion which cancels all diversions.
Hospital redirection now occurs if there are 3 or more ambulances at the
hospital for more than 30 minutes. EMS then puts the hospital on redirection
and suddenly beds start to clear up as they stop getting patients. This is
still a "Band-Aid." So how do we deal with Emergency Department
overcrowding? Increased call volume causes increased turnaround times as being
at the ER is a safe haven for a few moments.
Moore/London - Finding a Way to Layaway the Day-to-day
On-scene Stay Delay, Decreasing Job Cycle Times in the LAS: By 6pm most days,
at least 120 calls are being held on scene awaiting an ambulance. Many things
affect job cycle time. Staff is being run ragged which affects turnaround
times. EMS crews have a responsibility not only to the patient in hand but also
to those who are waiting. There must be recognition that this is everyone's
problem. High level work is required with hospitals and organizations. Long
term EMS cultural change must occur. Measurements must occur on all aspects of
time frames so that everyone gets served. EMS colleagues must compare their
performance against their peers. They are being dispatched over a 35 mile wide
area with long responses and multiple hospitals, not just in one district.
Trying to decrease need for transport and do more treat and release. If the EMS
workers performance is outside the average they are made aware and it is
discussed and analyzed for issues affecting the job cycle time. Scene time is
not part of this, but all other times are looked at. The goal is to streamline
getting to patients and available, NOT managing the time with the patient.
Project is actually decreasing job cycle times. 5% improvement so far. Turn
around at hospital is still the biggest outlier outside of EMS control and may
have a value of hundreds of hours.
Eckstein/LA - A Faster Ignition for Arrest Recognition,
Making Dispatch Modifications to Save More Lives: Tiered dispatch system is
being utilized. All dispatchers are now EMTs or Paramedics with EMD
certification. Focus is now on time critical incidents. Cardiac arrests were
being missed two out of three times. They visited other cities looking for
dispatch best practices. Goals were to decrease call processing times on
critical emergencies and improve recognition of cardiac arrests. Designed their
own system to fit their needs. Another goal was to decrease time to CPR start.
New philosophy of No-No-Go! Bad trauma, cardiac arrest, etc, gets immediate dispatch.
They consider it appropriate if CPR is started and not needed, but a maximal
failure if an opportunity to provide CPR is missed. Lack of bystander CPR is
indicative of death. No longer allowed to ask if the patient is breathing. They
must ask if the patient is breathing NORMALLY. Agonal breathing is highly
indicative of a shockable rhythm. They have increased number of recognized
arrest and CPR instructions provided. 8% increase in survival in witnessed
arrest with shockable rhythm. 5% increase in bystander witnessed but not
shockable.
Levy/Anchorage - Hatching New Matching for Cardiac Arrest
Dispatching, The Anchorage Move to Criteria-based 911 Call-taking: Is your
medical dispatch system an emperor without clothes? Have you empowered your
dispatchers and responders to actually rescue? The first 30 seconds of CPR is
most important and needs to be started as early into the call as possible. Jump
straight to what is needed and start CPR. Empower dispatchers to go straight to
CPR when indicated. Medical directors must be at the top of the chain of
command for the dispatch center. Every dispatcher initiated CPR needs to be
reviewed and have a hot wash evaluation. “No-No-Go!” is the concept here also. www.anchoragesurvivors.com
Eagle's Bullet Rounds - 1) Taillac (Utah) - Auto Dispatch,
Advanced Crash Notification Becoming a Standard Feature at 911: AACN is coming
to dispatch centers. On-Star started this. System is activated by crash sensor
and GPS. On-Star calls the car, if no answer they activate 911. On-Star
operators are EMD certified. Sensors predict severity of crash. Vehicle
telemetry data is part of the CDC Trauma Triage guideline. 2) Levy (Anchorage)
- ALS Care is NOT Dangerous: Recent article/study shows ALS has a higher
mortality rate than BLS care. This issue has been discussed for many years.
Speaker states that ICUs are more dangerous than ALS. Interventional data needs
to be looked at rather than billing codes (like in the article). 3) Jui (Portland)
- Vasopressin, Ramifications of a drug shortage: Vasopressin is not out.
Multnomah County showed better ROSC with Vasopressin in non-shockable rhythms,
and lower ROSC in shockable rhythms with Vaspopressin. Maybe institute for
non-shockable only? 4) Miramontes (San Antonio) - 30 Seconds for EMS to always
give report. On patient arrival, nurse calls an EMS Timeout for the report.
They use the MIST style report for the verbal report. EMS satisfaction rate is
high. Bridges the communication gap. www.strac.org contains info.
Dunne/Detroit - The Motown Blues Morphing Into a Rock n'
Roll Rhythm, How the Detroit EMS System Began to Rev Up Its Engines: What
happens when your city goes broke? Not all of Detroit is abandoned. Some nice
areas. When broke, you beg, borrow and steal. Labor challenges. In 2011 they
were down to 6 to 10 Ems units each day and broken fire apparatus. Response
times were vague, believed to be 20-25 minutes. $78 million in FEMA grants were
awarded. Public Safety Headquarters moved to a Casino. Joined CARES. Penske
donated 23 ambulances. Penske had been trying to do this for years and was
politically stonewalled. Fire now doing first response. May hired LEAN process
people to improve public safety. Fire coverage is now up to 75% of what is
needed and improving. They have enough medics but not enough equipment.
Privates are now helping cover 911 during peak times. CARES survival overall
was 5.4% which is the best they have ever had to date. Self Defense training
implemented for all EMS. Trying for EMD accreditation now. EMS leaders are now
attending resuscitation academies. Lessons: This is a team sport, break down
walls and don't take NO for an answer.
Eagle's Lightning Round #2 (all medical directors on stage
plus any EMS Fellows in the audience) - 1) Are Community Paramedicine programs
integrating ER staffs and social workers into the program? Case managers are a
key component in many programs. One area reports that case managers are a paid
part of their CP program. 2) Relaxing the patient load... are there any active
programs to train people when to call 911? Most report that if you try to do
this education, it actually results in more calls. It backfires often. Some
areas, STEMI and Stroke do not call EMS enough. 50-60% still come by private
vehicle. 3) Is anyone using more AEMTs? Only one area reported that the see a
role for this and are using the AEMT level for 911. 4) How many areas are doing
active shooter training? Almost all areas are (my note: if you are not, you
should be). 5) Should we be using Transesophageal Echo to assure we are
compressing the left ventricle? Complex question. It might be better to look
for a best placement for ACD than use TEE. 6) In one word, what is the biggest
challenge for EMS in the next five years? Staffing! (my note: Agreed!).
Professionalism was also mentioned. Transport or not to transport. Education
and retention of rural EMS. Workload Distribution. Alternate destinations.
"The ACA." Competency of personnel. Leadership. Apathy. Funding.
Value. Funding. Efficiency. Quality. Geriatrics. Expectations. Data. Funding
(repeated a lot). Meaningful outcomes. 7) Are EMS Fellows getting any training
on how to deal with unions and CBAs? Only experiential observation. Reported to
be a painful experience. 8) What over triage rates are acceptable for STEMI? Do
not call it over triage... call it activation without intervention. Still do
the right thing. Dallas allows for 15%. Others report 15% as well is allowed.
Actual is around 7-8%. Bigger concern is when the interventionist cancels the
alert. NEVER call it a false positive. It is a positive without intervention.
Do not deter calling alerts.
Isaacs/Dallas - Interpreting Interpolated Interruptions vs.
Compression Non-secession, Analyzing the Results of the ROC Clinical Trial of
CCC vs. 30:2: Which is better, continuous compressions or a 30:2 ratio? Old
studies that were observational supported continuous compressions. Now there is
a randomized trial with available results. Well matched sample across the
board. Outcome: No difference in survival between application of CCC vs. 30:2.
It is felt the AHA should reconsider its recommendation for CCC. Maybe if there
is no difference, and CCC is easier to teach and perform, it may indeed have
value in application but not outcome.
Youngquist/Salt Lake City - Fiber-Optical Illusions, Can
Video Laryngoscopy Offset Interruption of Compressions?: Over half the room had
video layrngoscopy available on medic units. Video is the preferred method of
intubation in Salt Lake. Medics preferred video in study. Does it offset
interruptions in compressions: Not in a system where CPR quality is monitored.
Richmond/Ft. Worth - A Quantum Leap in Qualifying for
Quantitative Quality Improvement, Two Easy Pieces to Save Lives: We have been
chasing the Holy Grail of EMS performance measurement for a long time. NEMSIS
data dictionary had 400 elements in 2003. We need to keep it simple. Answer one
to two questions a year with data. What happens when you use Mechanical CPR or
Supraglottic airways? CPR is hard to do well. Studies show no benefit to
outcomes with mechanical CPR but they do enhance provider safety. Goal is to
decrease frequency and length of pauses. Pausing is a really bad idea by the
data. Do not stop compressions wile defibrillator is charging. Case studies
presented showing pauses caused by placement of mechanical CPR while device is
being placed. This pause must be decreased. Sometimes 40 seconds. This was
focused upon and cut to about 8 seconds with training. Now 71% are placed in
under 10 seconds. Supraglottic airways: Literature says up to 25% percent of
intubations have unrecognized esophageal intubation (without ETCO2 monitoring and
recognition of ETCO2 data). Data shows from this presentation that the King
airways were misplaced 19.4% of the time. (my note: another reason I prefer the
I-Gel, seals the entire glottic opening and the securing strap decreases
movement. No cuffs to deal with). Misplacement was a combination of placement
and cuff inflation.
Schrank/Miami - How to Know Low (or even No) To and Fro
Flow, Not Missing an Obstructed Airway with SGAs: She has developed a concern
regarding missing airway obstructions with the emphasis on chest compressions.
ABC is now CAB but A and B are not gone! Multiple valid choices for managing
airway and breathing. We do airway control in the middle of an uncontrolled
mess. Case studies presented. If patient is not ventilating (chest rise, ETCO2,
etc...) check for airway obstruction. Obstructions are rare but real. If found
in arrest you do not know if they choked first. If you do not use BVM
ventilation (such as passive oxygenation), you may not know the airway is
obstructed. Go back to A. Check the airway. Confirm SGAs with ETCO2 as well.
Holley/Memphis - It's Humanly Possible To Now Demonstrate
Obstructed Arteries with SGAs: This is incredibly preliminary data, so do not
change practice yet. A cadaver model for CPR measurement has been achieved. It
can also show airway and artery pressures. Researchers are encouraged by the
creation of this model. SGAs can maintain airway pressures during CPR. I-Gel
and Endotracheal Intubation showed the same for NOT obstructing arteries. The
King Airway however did occlude the arteries. I-Gel was closest to ETI in NOT
obstructing arterial flow (my note: more to love about the I-Gel).
Dyer/Boston - Knowing Ur "Rights" When Ur Under
(Respiratory Arrest), Apneic Oxygenation and the Best Metrics for Success: All
providers fear for degradation of ETI skills with more SGA use. Most want to
keep ETI as a non-cardiac arrest airway skill, but with more SGA use, frequency
of skill is dropping. We want it, but we want it safe. Are we worried about
number of attempts or oxygenation of the patient? Apneic oxygenation requires
two oxygen tanks, one flowing a nasal cannula at 10-15 liters per minute. The
other for the ventilatory device. Desaturation occurs faster if no continuous
O2. Keep CHF patients totally upright and on CPAP until the moment of
intubation. "Amateurs talk strategy, Professionals talk logistics." -
Omar Bradley.
End of Eagle's Day 1! More tomorrow... now for some great
Dallas food! Cafe Pacific.
Myers/NAEMSP - Expert Explanations of Extraordinary
Excerpts, Exigent Exports from January's Exceptional NAEMSP Meeting: 1) Every
EMS system needs to be able to take care of five shooting victims at a moment’s
notice. This means going in on active shooter incidents. 2) Reform is real. By
the end of 2017 80% of Medicare will be value-based payments. This will be
value-based by population. EMS is starting to get paid for community
paramedicine. What was the outcome and how much did you spend? EMS will be
integral to the reform. 3) Drug abuse is a growing problem. Overdose death
rates are on the rise. The notion that every time we use Narcan it saves a life
gets us in trouble. This is an epidemic. We have to have proper statistics. 4)
Advocacy is not a bad word. We must be advocates for EMS. We must change the
DEA. The narcotic issue has to be fixed. House Bill 4365 must have immediate
support. Multiple EMS entities support this bill. This is a white hat issue. It
is a common sense, easy solution. 5) Medical director courses by the NAEMSP are
being taught internationally. These are the top five things to learn from the
NAEMSP Annual Meeting.
Reich/Kansas City - Their Pet Threat That They Most Regret,
The Top Safety Concerns of EMS Crews: 1) Safety Culture. Establishing a Just
Culture environment is crucial to safety. We must know about every incident and
near miss to be able to fix things. 2) Device Failures: If we rely too much on
technology we cannot function when it fails. Technology can be used wrong and
also have power failures. Reliance is a huge issue. 3) Med Errors: Stay with
the five rights! Slow down and double check what you do. We function in stressful
situations. Use engineering controls. 4) Airway Management: Confirmation of
airway placement is huge. Must have backups. Waveform Capnography MUST be 100%
available. Have Bougies available. 5) Transition of care: There must be good
information exchange face to face. We cannot miss things. Providers must talk
to each other at transition. 6) Crashes: Ambulances are unsafe. Fatigue is an
issue. Speed is an issue. Seatbelts must be used in the patient compartment.
Use driver feedback systems. They work. 7) Pediatrics: These are the most
challenging and they are different from all other calls with adults. Do not
memorize and do not calculate. Use a reference. 8) Behavioral patients: Less
resources available and more patients being seen. Situations deteriorate
quickly into assault on EMS crews. We need situational awareness and
de-escalation training. 9) We do not need to be the second victim due to
stress. We must take care f ourselves. EMS must require things that decrease
accumulated stress. 10) Mobile Integrated Health is a safety concern. If we do
it we must be good at it. It is a new environment to learn in... and it is a
bit of an unknown.
Levy/Anchorage - Wow! This Thing Is Way Too Spicy! The Drug
Epidemic Becomes an MCI in the Last Frontier State: Synthetic Cannabinoids are
an EMS operational challenge. Alaska has a problem with Spice. It is causing
drug abuse multiple casualty incidents. It is easy to get and distribute. It is
demoralizing the workforce. Synthesized THC effects. The recipes are online and
it can be made easily. It is made as a spray and is sprayed on leaves for
smoking or used in vaping. Agitated delirium with hypertension and fighting.
Sometimes bradycardia is seen. Coma is common. Coma lasts several hours. It is
huge in the homeless population. 10,581 Transports, 1,187 were synthetic
Cannabinoids. They can see the same person twice in one shift. Ketamine used to
manage acute delirium. Not uncommon to see multiple patients at once. Copious
vomiting is common. These patients overload the system. Eleven patients
accounted for 169 transports. There are a lot of chemical variants in play in
this community. Spice users tend to be a bit older than average abusers. This
issue needs interdiction, sobering centers and focus. No current parameters to
send a spice patient to a sobering center.
Weber/Chicago - An Overdose of 911 Drug Responses in the
Windy City, The Impact of Fentanyl-Laced Heroin in Chicago: Medics recognized
epidemic before other healthcare providers. Opiate overdose deaths are way up.
Largest number of deaths is synthetic Fentanyl-laced Heroin. They cut with
Fetanyl to expand quantity of Heroin. In October of 2015, medics noted a huge
spike in OD patients and asked for a data review. This found a big spike in OD
numbers. In 72 hours they responded to 90 calls. It was recognized in the first
day. Chicago PD saturated the area of town and found the distributors. Huge
spike in deaths in September-October 2015. They usually see an increase in the summer,
not the Fall. EMS OD responses have doubled in three years. The US is in the
middle of an Opioid crisis. EMS is on the front line of this battle. Use data
and realize EMS has a role in syndrome surveillance.
Conterato/Minneapolis - NMAS Says No Mas! Reported Violence
and Abuse Against EMS: Prehospital provider violence is a problem. EMS has been
shot at. Fire has been shot at. A firefighter was maced. Providers are being
hit. Even stabbings have occurred. Paramedics are 14 times more likely to be
assaulted than firefighters. How do we protect prehospital providers? A survey
was performed with responses from every state. 700 respondents to the survey.
Represented 5,000 years of EMS experience. 72% said they had not had enough
training in violence prevention. 75% percent said no safety training at all.
73% said job is becoming more unsafe. 75% had been physically assaulted on an
EMS call. 90% received verbal threats against them and their families. 10%
received written threats. 60% said narcotics were involved. 70% reported having
to use chemical restraint. 17% have had patients get out of restraint. 35% feel
they are NOT SUPPORTED by their organizations they work for and their
directors. What do they feel they need? Only 15% wear tactical vests on duty.
15% carry unauthorized offensive weapons while on duty. The prehospital
environment is becoming more unsafe. Period. Providers are finding their own
way to deal with it in a vacuum. We must evaluate this issue and adapt. What
cannot be measured, cannot be changed. Every incident must be reported and
addressed. We cannot keep up with the intoxicants and their effects. Write
policies on law enforcement interaction. Penalties against those assaulting
responders must be high (my note: many are misdemeanors, at least Indiana is a
felony). Use the Verbal Judo course as a starting point for training. GREAT
PRESENTATION.
Harrell/Albuquerque - Analytically Annotating Anecdotes
About Antidotes, B-12 at Fire Scenes and Law Enforcement Use of Naloxone: Are
these fiscally sustainable? If Cyanide is involved in an arrest, the chance of
survival is low if you resuscitate using normal means. Hydroxocobalamin via the
Cyanokit is the antidote for Cyanide poisoning in victims and firefighters at
fire scenes. The biggest obstacle associated with this drug is the very high
cost. Most are carried on supervisor units and not on the ambulances.
Albuquerque has had several good outcomes with the Cyanokit. Rare to use, but
essential. Naloxone by law enforcement: New Mexico has a high number of drug
abuse deaths. Higher than national average. Narcan use has been successful with
the exception of those down from multiple drug ingestion. One was a cardiac
arrest reversal post Narcan. Cost is an issue on both drugs. Cyanokits are
about $800 dollars with a 30 month shelf life. The Narcan project was about
$7500 for the entire department but was grant funded and will be an ongoing
cost.
Mechem/Philadelphia - Blue Bloods Treating Blue Blood, Part
Dos (or is it Over-Dos?), One Year's Experience with Law Enforcement Naloxone:
Is it beneficial for officers to give Nalaxone? What is the cost? Pennsylvania
leads nation in OD deaths in ages 19-23. 43% increase in OD deaths. 45%
increase in OD deaths where Heroin is involved. Implemented Law Enforcement
Narcan in January 2015. Kits have 4mg of Narcan and a nasal atomizer. 121
administrations. Cost has been around $100,000. The program works but it is
very expensive. Currently funded by grant money. When will the grant money dry
up? Pricing will impact sustainability.
Reich/Kansas City - Getting Psyched-Up with a Show-Me-State
of Mind Approach, Laws Empowering EMS in Behavioral Emergencies: What kind of
laws effect you as a provider? How do we protect our own? Do you have immunity
protections when using restraint? Mandated transport? Patients exit moving
ambulances a lot apparently. Many cases of patients getting away from EMS that
may be unstable. Many issues occur with behavioral patients. What are the gaps
in your state's laws? Many issues occur during transfers. Law Enforcement
support is not always available at the time of need. Use of restraints is a big
legal issue. The biggest issue is how do we protect the provider and caregiver
from suit? How do we keep patient from fleeing from EMS. The Center for Patient
Safety Data on this issue is a very small sample and lacking on reporting any
crew injury. Missouri wrote Senate Bill 895 which is sailing through giving
protections. It gives EMS authorization to hold. It has training requirements
as well. Must have a protocol for hold. Patient needs to have the likelihood of
causing harm or be significantly incapacitated by drugs or alcohol to invoke
hold. Harm may defined as suicidal nature as well. The harm can be defined as
environmental as well (food, shelter). Verbal de-escalation training (Verbal
Judo) will be mandated (or equivalent). There must be collaboration with law
enforcement for this to work. The bill requires hospitals and nursing homes to
give advance notification if the patient has a history of violence or eloping.
The bill gives EMS specific immunity on this issue. It also addresses the
physician hold issue as well. It does not affect the duration of the existing
psychiatric hold status. Crisis Intervention team (CIT) involvement is needed.
Basic and advanced verbal skill development and training is a must. There
appear to be no barriers to passing in Missouri... except for the trial lawyers
who do not like the word "immunity."
Manifold/ACEP and Mechem/Philadelphia - Remedy for Extremity
Disamenity, Re-visiting Field Amputations and Response Paradigms: Case study on
a field amputation during a train accident. It actually was deemed to have
saved the life. Luckily, there was a physician response team for this. Before
this recent call the last response had been in 1990. Rare use. There was no
institutional memory on how to do it. Is there a better way? Some things are
considered last resort and we wait too long... surgical airway, peri-mortem
C-Section and Pericardiocentesis are good examples. Amputation is a low
frequency, high risk procedure. It must have a defined process with skill
maintenance. More EMS physicians are responding to the field with the advent of
EMS Fellows. There must be an immediate life threat and the only means to
release the patient from entrapment. Amputation, disarticulation and
dismemberment are the three processes. Proximal hemorrhage control must be
addressed. There has to be a degree of urgency to justify an amputation.
Ketamine and Etomidate are options for sedation. These are unusual events and
can be a resiliency issue. Need a trauma/orthopedic surgeon, an EMS physician
and a prehospital provider to make a good field amputation team. USAR and
military experience are beneficial. The challenge is sustaining the skills.
Best incorporated through a trauma center. Team must be ready for environmental
issues as well. Notification and transportation with equipment must be
addressed ahead of time. Who makes the decision? Define decision maker.
Destination decisions need to be addressed ahead of time as well. Personnel
changes over time. Fill vacancies. Multiple tourniquets needed. Multiple
medical saws are needed with extra blades. Non-sparking blades are preferred.
Less vibration is better for later outcomes. manifold@uthscsa.edu for
questions.
Taillac/NASEMSO - How to Heed, Read and Succeed with a
Deep-Seeded Bleed, 2016 Ways to Use Hemostatic Gauze Properly: There are
numerous YouTube videos on this issue. Hemostatic gauze must be applied with
direct pressure. Must be pushed into the wound to be effective. Essentially
packing the wound. 1) Direct pressure, HARD. If this can be done with a regular
dressing, fast, do it. 2) Put your finger or hand in the wound and push hard.
3) Pack the hemostatic dressing in the wound. Keep packing it in until no more
can go in and then put more. 4) Apply firm pressure for three minutes. 5) Is it
still bleeding? Splinting can help keep bleeding from restarting. If still
bleeding, pack more. Continue to use direct pressure. Do not forget that this
is for areas not accessible by a tourniquet. Some studies show that Kerlix may
work just as well if packed in tightly. Wound packing is being added to the
medic curricula.
Mechem/Philadelphia - Prepping for the Papal Visit: Very
large number of pedestrians. They had no way to estimate how many would come to
see the Pope. No clue how many patients. Pope has had masses for up to six
million people at once. They were working with constantly changing attendance
estimates and budgets. They started calling it Pope-ageddon. Pope attended a
concert while he was in town. Stayed the night at a seminary. Moved around the
area a lot. Parkways were lined with people just to see him pass. 800,000
attended mass. 423 associated responses with 129 transports. Planning ended up
being a bit overkill. Planning took almost a year. Credentialing personnel was
difficult due to Secret Service time frames.
Ellis/Auckland - Annihilation Contemplation, Incorporating
Armageddon into Risk Management Fiscal Plans: This is EMS at the Apocalypse.
Plan for the absolute worst case scenario. 4.5 million people in coverage area.
Big disasters are common place. How long does a disaster last? How long is each
phase? They started with an assumption of an escalating response depending on
severity. How long can you work without resupply? Food? Water? Medical
supplies? Lodging? Be careful when someone shoulder taps you and asks if you
want a job. You end up planning for the worst. Took the job, but had to sign a
three page confidentiality agreement. Had to write a plan for broad spectrum
continuity of government and business in a massive disaster. These are
"Black Swan" events. Probability low and impact very high. These
include volcanoes, societal collapse, pandemics, massive weather events and
nuclear war. It is a fundamentally selfish process as it is about survival and
continuity of life. Many multinational companies involved. They are very
focused on protection of families. People do not come to work in disaster
situations unless their families are safe. States and governments will not
openly spend money on this but businesses will. 72 hour self-sufficiency
waiting for help is considered insufficient by business but is the standard for
government. It is more than just operational supplies... it is about food,
water and warmth. A global apocalypse is more likely to affect you than winning
the lottery. GREAT LECTURE.
Elder/New Orleans - Taking a New Defensive Striving Course
in the Crescent City, Enhanced Preparations for Chemical Disasters N'Awlins
Style: Biggest fear for this speaker is a chemical incident. New Orleans is a
port and a rail hub. All of the hazmat danger is near population. The issue is
not just terrorism related, it is accident related as well. New Orleans is part
of a national project on responding to a massive chemical incident. Huge
incidents are not so simple. The healthcare infrastructure can be annihilated
quickly if exposed. Two major incidents have been practiced as drills. One was
an organophosphate release near the French Quarter.. Another was near the
convention center. Public information releases are defined. Interoperability is
now well embedded since Hurricane Katrina. Still needs to be practiced. How do
we take care of the patients? What will we need? Mass decontamination and
moving people must be planned.
Augustine/Eagle's Librarian - Terminal Illness, EMS Airport
Interfaces Beyond the Runway Mishap: EMS Operations at the World's busiest
airport. EMS is an all hazards workforce in many environments. Atlanta Airport
is the most difficult assignment in the city. It is an all hazards approach.
The airport delivers great emergency medical care. Many resources are applied.
A principle of airport EMS is an extreme culture of safety. There are ten
layers of safety culture. There are a million take offs and landings each year
and no one currently working in public safety at the airport was alive the last
time a crash occurred. Realities: Everyone is going to sue. Documentation skill
must be high. Continuity of operations is an extraordinary driver of scene
operations. The airport cannot just be shut down. Everything has to move around
an ongoing emergency. EMS is hard to graph at the airport as it is affected by
everything including the weather. There are tremendous surges in volume.
Patients at the airport are already stressed (time, TSA, waiting). Most in
cardiac arrest are believed to already have a high level of Adrenalin and are
highly likely to survive. 100 million people travelled through the airport last
year. EMS sees themselves as Ambassadors of Atlanta and the United States.
Death on an aircraft is not uncommon as people try to get to the United States
for medical care. The airport is in the CARES registry. Disposition is hard as
people do not want to go to the hospital, they want to get home. This includes
pilots. There are no removal of civil liberties here. They have to help them
make a good decision on disposition. EMS has to manage patient’s families and
transportation also. Ebola preparation has been an issue. They train for bombs
and active shooters also. Two or three times a day wounded aircraft are
diverted to Atlanta due to resources available. All airport MCI plans are being
revised based on the Asiana crash.
Asaeda/NY and Jui/Portland- Disaster Du Jour Tour, from
Snowmageddon to Aedes Aegypti: NYC: NYC has a disaster a day. Asked to talk
about the Snow Storm Contingency Plan. Readied for January 22, 2016 with winter
storm Jonas. 26.8 inches of snow fell. 0.1 short of the cities record snowfall.
Plan mandates transport to closest facility when implemented. When a disaster
strikes, engine companies can accept refusals and transport when needed. No
hospital diversions allowed. The plan is implemented by the medical director.
Portland: Two viruses out that we need to worry about. Zika is one of them and
is currently in Florida. Zika can be transmitted through blood, saliva and
urine. Contact transmission is possible in females.
Saussy/Past Medical Director for Washington, DC - Standing
ovation from 850 attendees and speakers! We take an oath to do no harm. She
decided to be the medical director as they said they were ready to get high
level help. When the chief cannot discipline the firefighters how could she?
The culture in DC fire and EMS was "toxic." She was placed as an
assistant chief and was hamstrung. She could not change deployments or triage
responses. There were frequent, preventable deaths. A cardiac arrest was
cancelled by the ambulance without making contact with a family doing CPR. She
was asked to validate competency. She could not do this; there was no way to do
so. Units would hide from calls using many excuses rather than doing their
responsibility. As a medical director, you are responsible. What does the
public think when politics gets in the way of lifesaving? She left as she could
get them to change. She hopes the community is not immune to the daily grief.
This brave woman just set a new standard for medical director involvement.
Pepe National Excellence in EMS Award: Drew Dawson and James
Augustine.
Eagle's data: 850 attendees for 2016. Largest group ever.
This is an unadvertised conference. 60 faculty from around the world. 16.25
credit hours of CEU in two days. If my count is correct, 63 presentations (all
in one room, no breakout sessions). They are going to try next year to put the
audio online with the PowerPoints after the conference.
Taillac/NASEMSO - Pointing True North, A Brief Report on the
EMS Compass Project: Performance measures are specific and quantifiable
measuring processes and results. Performance measures are easy. Measure it.
Analyze it. Fix it. EMS Compass uses NEMSIS data to develop performance
measures. Developing 5 to 7 core initial performance measures. You must ask,
what can YOU do with YOUR data? The process is 1) Measure concept, 2) Measure
design and 3) implementation. Looks at structures, processes and outcomes. The
first measures released will be clinical process and effectiveness related. Uses
NEMSIS 3 data elements. Compares apples to apples like CARES does.
Gilmore/St. Louis - It's Virtually a Reality, Simulation as
an Acceptable Surrogate for Credentialing: Simulation has been around for a
long time. Simulation is great for technical skills. Simulation is also great
for teamwork but seldom used. You have to have the right tools for simulation.
Article: Simulation-based Assessment of Paramedics and Performance in in Real
Clinical Contexts. Another article on the rating system left more questions on
how it is applicable. Rating should look at patient safety, responder safety,
comfort and outcome. The most dangerous phrase in the English language is
"We have always done it that way."
Hinchey/NAEMT - Navigating Approval for Removal, Optimizing the
Proper De-credentialing Process: We all make mistakes. 3 to 4% of patients are
harmed by the hospital. It is not the mistake you make but what you do when you
make the mistake that matters. Bad people are not generally the cause of
mistakes. If you focus on the person you miss all the other factors. As a
result we have swung all the way to the far side and only look at the
processes. Sometimes, bad people do bad things. Reckless behaviors must be
addressed. Some behaviors must be unacceptable. Engineering controls and
processes do not work to combat things that start with ill intent.
ACCOUNTABILITY should be important to all of us. Trust, Respect, Value and
Pride must matter. Harder to find good, competent providers. Your caregivers
want another competent provider sitting in the rig next to them. Credibility is
very important when you wish to make progress. Process has to be consistent and
defensible when removing credentials. Clearly define unacceptable behaviors.
Read the book "Whack a Mole." People must be able to come forward and
report mistakes. Punishment does not change behavior. Do not tolerate
unacceptable behavior. At risk behavior is not the same as reckless behavior.
Peer Review or Peer Torture? It should not be the only means of determining a provider's
fate. We eat our own. We are hard on each other. It is brutal and not
productive if not made to work right. Be proud of what you do and who you do it
with. It is the key to success. We must focus on contributing factors but not
to the exclusion of bad behaviors.
Roth/Pittsburgh - It's Not All a Uniform Approach, Tailoring
Sports Equipment Removal to Team Needs: Should helmets and pads be removed on
scene? What is the role of the Long Board in sports injuries? Use STEPP:
Situation, Training, Equipment, People, Pre-plan. Needs to be a group decision
on both topics. No brainers on equipment removal: Airway control and CPR. Long
boards are a good moving tool but not for limiting motion. LSB for movement to
the cot but not for transport.
Jui/Portland - A Double Dog Dare You Shocking Report,
Results of Dual-Sequential Defibrillation Cases: Large number in room have
implemented DS Defibrillation. Refractory and Recurrent Ventricular
Fibrillation are different. DS Defibrillation is for Refractory VF. Use dates
back to 1986. There are at least eight articles on the subject. Most are case
studies. Sequential pulses may apply a larger current density and more even
distribution over fibrillating cardiac tissue. Portland protocol: Must be
refractory after five shocks and 450g of Amiodarone to use DS Defibrillation.
Small numbers but... 46% had electrical success to a perfusing rhythm and ROSC
of 32%. In literature there have been few survivors. Portland actually has
three! Almost all required TWO sets of DS shocks for conversion. May be a
viable option for refractory VF.
Conterato/Minneapolis - Sooner to Ballooner, Going Straight
to the Cath Lab with Persistent Ventricular Fibrillation: This is for
Refractory or Recurrent VF. How do we manage the patient that will not convert
from or keeps going back to VF? What happens with this in the ED after EMS
brings the patient in? There is not a common approach to this issue.
Resuscitated VF and VT taken to the cath lab. Over 50% had a coronary artery
lesion. Outcomes were better the sooner they got to cath lab. This leaves a
premise that recurrent/refractory VF may need cath lab to correct underlying
cause. Advocates for those getting three shocks without conversion get loaded
and go direct to cath lab with continuing ACLS. Required to have a presumed
cardiac etiology of arrest. 60 minute window. Some are put on ECMO, others a
balloon pump, then angiography. If no cause found, arrest is terminated if no
ROSC. If positive lesion and corrected with ROSC, then proceed with post
resuscitation pathways. They are wishing to move this to a randomized
controlled trial. Currently activation of the cath lab for recurrent/refractory
VF is an EMS call in Minneapolis. It is time for a new approach. As we continue
to improve resuscitation rates we must try new things.
Youngquist/Salt Lake City - The Extracorporeal Tutorial, How
to Survive to the Cath Lab via ECMO: Many times ACLS fails us. Take the patient
to definitive care or bring the definitive care to the patient in the field.
The bottom line is we find the cause and treat it, many times as part of the
post-resuscitation care... if they have ROSC. Fibrinolytics did not work well
in arrest patients at treating the causal lesion. Intra-arrest PCI with
mechanical CPR still pretty dismal. Enter ECMO... take over the circulation with
ECMO during PCI in the cath lab if still in arrest. ECMO removes blood from the
body, oxygenates it, removes CO2 and puts it back. ECMO is a small device. ECMO
increased survivability during the SARS epidemic. Not for all arrests and
limited to those of cardiac origin that are resuscitation candidates. How early
is too early for Extracorporeal CPR? One study showed 27% survival rate with
ECMO. 20 minutes of ACLS may indicate need for ECMO and PCI if VF/VT. Paris is
using ECMO on scene and is reporting a 35% survival rate. Some risks associated
with ECMO including infections. Disposables alone cost $15,000 for ECMO. You
must have a cardiac interventionist who is willing to take arrest patients to
the cath lab. ECMO is a bridge to PCI. This is a cautiously optimistic therapy.
Note the picture here of ECMO being performed at the Louvre...
Fowler vs. Valenzuela - the 2016 Great Debate! Is
Subspecialty Certification in EMS Practice an Advance or a Step Backwards?
Fowler: Pro. Valenzuela: Con. FOWLER: Are we prepared to say that Board
certification in EMS should be required to be a medical director? Specialty
means one who specializes in something. EMS has a history of excellence. We
have an obligation to be more excellent than what we are today. CARES, ROC and
EMS Compass are all indicative of striving for excellence. Goaded Valenzuela to
read up on the subject. The knowledge required to pass the board test is the
core of emergency medicine and how it applies to EMS. Dealing with thorny
issues like Washington DC is not for those who are not prepared and are not
experts. It is a "freaking" hard test. There are 750 who have taken
it with a 50% pass rate. Data will drive the need for board certified EMS
physicians. "Are we a specialty or are we not?" VALENZUELA:
Disclaimer posted on opinion... Why is Fowler so enthusiastic? Is this a threat
or menace to EMS? "Is Fowler a conniving, bottom feeding, selfish waste of
oxygen?" Why is there a proliferation of subspecialties? Feels that the
purpose is mainly statements of faith not fact. What is the mission? The early
medical directors were there to extend the physician to the field through EMS
caregivers. The mission is not to create a new "cool kids" club. The
mission is not to fragment the system or isolate geriatric medical directors.
Dr. Fowler also recognized that "every good scam required a text."
Then was begat the subspecialty certification. Those that are here now will
continue to be here. Fellows do not cost much and are free labor (wow... he
went there). What do young MDs want? They are dedicated to the mission. Desire
to distinguish themselves uniquely to EMS. The market for these diplomats does
not currently exist. Three job postings on the NAEMSP web site. Gravy hairs
still rule and we do not retire or die. You will have too assassinate us. The
need for improved EMS and firefighter salaries will hurt being able to pay for
EMS Board Certified Medical Directors. "I am part-time as a medical
director." When you are looking for a medical director you look for who
knows "shit from shinola." Valenzuela declared winner by the
audience.
Taillac/NASEMSO - All Dressed Up or Somewhere to Go? The
Pros and Cons of Free-Standing Emergency Centers: The one he works is sees 15
patients a day. Some free standings are urgent cares with CT scanners. Some
have everything except surgery and admissions. Some are in strong financial
demographics indicating that patients will come there for convenience. The
majority actually have emergency physicians. CT and ultrasound are standard and
some have MRI. No specialty docs on site other than emergency medicine. Some
are not open 24-7. EMS needs to try and minimize need for second transport. Do
not bring if there is need for a specialty or admission. Some are extensions of
a base hospital while others are independent. At the speaker’s facility, they
pay EMS if patient is transferred to the base hospital. Many states do not
allow free standing ERs. Free standings cannot accept CMS patients, therefore
they are not under EMTALA. Free standing ERs are big business. There is a
feeling that these could replace critical access hospitals in rural
communities. Only 7% are currently in rural areas due to lack of financial
incentive (currently, but being discussed). Some of these are siphoning off
paying customers from ERs that have to see everyone. ACEP says that they should
act like a regular ED including adherence to EMTALA. There are 400-500
nationwide in 40 states. When attached to a base hospital they decrease ER load
in main hospital but increase overall number of patients seen. There are
guidelines on what you should bring and not bring to a free standing ER
(Journal of Freestanding Emergency Medicine March 2014). Overall take is that
these are pretty good when an extension of a base hospital.
Racht/AMR National CMO - Illud Est Quod Est! It's Time to
Say Goodbye to "ALS" and "BLS": There were once ambulance
drivers and ER docs. What have we done in EMS? EMS is defined by more than
procedures, it is outcomes. We must change what EMS looks like across the
board. Recent article said ALS was bad, but... it was based on Medicare claims
data, not outcomes. We do need to focus on the outcomes, not the meds and not
the procedures. Procedures may not have the impact we want them to have. Some
things create improved outcomes, others do not. A very recent article discusses
the need for a connection between EMS procedures and outcomes. 2011 NEMSIS
data, 40 states, 14 million responses, 7 million data adequate charts... 11
million procedures performed. The article breaks down what impressions received
the most procedures. EMS has four levels of provider doing numerous types of
actions. It is time to remove the terms BLS and ALS. We do care. We need to do
appropriate care at all levels. If is needed and effects outcomes, train it and
do it. This crosses the BLS/ALS definition. Current definitions are outmoded
and obsolete.
Goodloe/Tulsa and OKC - Please Take Time Out, Challenging
the Perennial Obsession with Response Intervals: We must have a relentless
pursuit of optimal out of hospital emergency medical care quality. It must be
done safely and with fiscal responsibility. Quality is more than getting there
fast or is it? EMS Evidence-based System Design White Paper for EMSA (Google
the document). Showed response time data with intentional increase in response
times (my note: same as what we did in Evansville). They looked at lights and
siren returns and relative increases by individual MPDS code. They have not
made a single change as there is no impact of the increased response times
(stated to be between two to three minutes longer). They have cut over 237,000
red light responses! That creates a safer environment without impacting
patients.
So that is it for Eagles XVIII. Hope you enjoy the challenges that these lectures may start in your community. They are not only good challenges... they are great ones!
At the time of blog publication, the PowerPoint presentations were not yet up. At some point, I am sure they will be up at the following link. You can access past year's presentations here as well:
Yes... that is a Twisted Root Burger... Amazing!
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