Faith, Family, Forests and the Field: February 2017

The every year pilgrimage to Dallas...

Once again, it is time...

This last weekend, I had the opportunity to once again attend visit the one conference that seems to mesmerize all who attend into a belief that they have just experienced a sip from the Holy Grail of EMS. I am of course speaking if the EMS State of the Sciences meeting held each year in Dallas, Texas. I count attending this meeting each year as one of the biggest infusions of renewal for my career in EMS. Learning what others are doing, seeing their data and hearing their stories is priceless. I also find a lot of affirmation to what we have preached for years in my own EMS system.

This year was no exception. This conference never disappoints.

910 in attendance this year

The location makes it even more fun as Dallas sports some of the best food in our great nation.

So, here it is in all of its barely edited format, not devoid of spelling and grammar errors... my notes:

Eagles (USCOMMD) is made up of medical directors from some of the largest EMS jurisdictions in the US and the world. This is 19th Eagles meeting since 1998. Dr. Paul Pepe leads the group.

USCOMMD: Medical Directors are the FDMs (final decision makers) for clinical EMS. EMS is seeing an increased level of sophistication and the same is true for the medical directors involved. Eagles is not an austere organization; its members are members of many other organizations, like NAEMSP. The motto is ESSE QUAM VIDERI... "To be, rather than to seem."

USCOMMD: Slovis/Nashville: The Five Most Important Papers of the Last Year: 1) Best antiarrythmic for VF - 3026 patients, 10 sites (ROC). Amiodarone vs. Lidocane vs. placebo. Adults only. Amiodarone slightly better across the board, but not statistically significant. Then looked at six other studies. No strong evidence that any antiarrythmic does any good in VF. 2) Improving survival in cardiac arrest - Almost everything measured shows no improvement in outcomes. Article has ...a ton of various measurements. Minimize CPR interruptions, provide high quality CPR and review arrests. Take an attitude of ever increasing excellence. 3) Epinephrine in cardiac arrest - 2974 VF/VT patients, 1510 with Epi after 1st shock. Do not give Epi before 2nd shock. Far worse outcome if given before 2nd shock. 4) Nitroglycerine 10308 patients from Montreal. Incidence of hypotension with normal heart rate was 2.9%. If tachycardic, 3.9% saw hypotension. Be careful with NTG in tachycardia. Beware borderline BPs. 5) When to stop an arrest - If, not witnesses, non-shockable rhythm with no ROSC after two doses of Epi = 0% survival. 2799 patients. Paris TOR criteria. Lastly... an article was covered that said all arrest patients should be transported to the hospital. The article has too many flaws to believe and it does not jive with many other research article. Take homes... antiarrythmics do not matter. Do not interrupt CPR. Do not give Epi early. TOR rules really rock.

USCOMMD: Goodloe/OKC-Tulsa: Better Scene Coordination: How many of you came here hoping to make work life better in EMS? Better for your patient? Zero impact on Budget? People matter. Those here are committed to patient care. But no one takes care of the caregiver. OKC/Tulsa elongated response times intentionally. No clinical detriment. People are still tired and depressed and there is still attrition. Missing home life. If nothing changes, nothing changes. Applied LEAN Six Sigma principles to time on task on scene like was done on response times. Field supervisors seen as negative. Management does not acknowledge brutal facts. No scene time measurements. Clinical care continued to be excellent. Focus groups created and employees empowered to make a difference. Looked at total mission times. Assigned everyone to teams. Areas saw decreases in mission time. Small changes add up. By decrease 3 minutes on each call, OKC saved 14 hours a day of ambulance availability a day... 19710 hours of availability saved a year. Translates to more EMS down time and getting off on time. Essentially the equivalent of adding 2.5 ambulances to the system. Do not cut staffing if you want to move the needle.

USCOMMD: Dunne/Detroit and Cabanas/Raleigh: Verbal Judo and Protecting Personnel: Detroit - Audio played of crew being assaulted. Crew was clearly attacked. Both injured. Survived on a low priority call and attacked by a bystander. Crew hit assailant with a step stool to get away. One crew member almost bleed out. Partner held direct pressure on partner while driving to hospital. Verbal Judo was trained. Reviewed pharmacologics for combative patients. Used DT4EMS curricula for staff. DT4EMS is like a seatbelt and needs to be used. Ballistic vests looked at and not an option at this time. Staging protocols can be way to firm and lead to poor patient care. They need to be realistic. Raleigh - How do you know your crews are ready for violence? Four stages of patient: Calm, Irritable, Verbal, Physical. Used high fidelity simulation and recorded the scenarios. Showed a video of the scenarios. Crews have role confusion when attacked. Proper response must be trained and practiced. Training must be ongoing. The challenge of violence is not a single solution issue.

USCOMMD: Isaacs/Dallas and Antevy/GBEMDA: RENEW and Pediatric Resuscitation: ISAACS - Primary goal of RENEW is to decrease PTSD and substance abuse/addiction in response personnel. Growing concern regarding mental health in response personnel. Highlighted after Dallas police shooting. Cumulative effects of stress must be acknowledged. Doctors are not immune. Alcohol abuse is rampant. Most departments fire or suspend employees over alcohol or substance abuse. It is a symptom of the deeper problem. RENEW is an effort to change that. Designed to educate, treat and monitor. It protects caregivers and patients. It is confidential. It is being designed in Dallas. Employee wellness and education is paramount. Educate from rookie on. Self-referral is key and confidentiality is important. Medical professionals involved with PTSD and addiction specialists and peers. Grant funding will be sought. One to five year monitoring. Uses the 12-step program. Using specific training for response personnel. Starting a steering committee to drive this program. Looking for best practices. We do not throw our brothers and sisters away. Antevy - Stress after pediatric calls. CISM will prevent the development of PTSD? False. Told story of a two year old drowning and misrouting to the hospital. Driver under tremendous stress. The emotion and reaction is different when in route to a 65 year old arrest than a 5 year old arrest. Must have debrief and closure on emotional issues. We need a mindset change. We must treat kids emotionally as we do adults. Stop running fast with kids. Do the same care we would do with adults. Do the job. Calm down while in route. Treat patients with the same level of emotions. Covered the last Facebook post of a medic who committed suicide and showed pictures of his family.

USCOMMD: Locasto/Cincinnati: Point of care testing: Point of care testing for HIV and Hep C exposures. Survey of 2664 paramedics. 0.3% chance of HIV and 1.8% with HCV of contracting with a contaminated needle stick. Less from mucous membrane exposure. Source patient should be tested as soon as possible. Starting post exposure prophylaxis is TIME DEPENDENT. We need quick test and turn around on results. This is an emergency. The hospital takes over at this point and the massive delays and barriers start. Suddenly no one knows what to do, who pays for it or if it is legal. Even when solved it continues to occur the next time. There is an oral quick test for HIV. About 99% accurate. Cincinnati is using this internally instead of waiting for the hospital. One HIV patient was diagnosed due to this testing. When patient is with you it is easier to get test than when they leave your presence. Psychological benefit of knowing sooner with your personnel. In Ohio, the patient cannot refuse the test and can be done without consent (my note: YES!). All positives are followed up serologically. Negatives are not followed up. The oral test is $25.

USCOMMD: Perrse/Houston: Zika: Update on Zika. 48 states have reported cases, most from travel. Florida and Texas have reported local cases. It is going to become endemic. 1394 of 5001 cases are pregnant. 6% chance of microcephaly in the infant (1 in 20). 13% if infected in 1st trimester. Guillain-Barre with Zika 1003 in 100,000. There are definitely neurologic effects. Humans are the reservoir. Mosquitos are the carrier.

USCOMMD: Yeh/San Francisco: Canaries on the frontline, EMS in emerging threat surveillance. We need to detect things earlier and take action. Bio surveillance is key. CAD and computer generated records are key to the data needed. Fusion centers must be a part of the process. Not only for novel outbreaks or bioterrorism but is useful for opioid outbreaks as well.

USCOMMD: Kidd/Acadian Texas: HCID Response Unit: A statewide infectious disease unit. Spring 2009 and fall of 2014. H1N1 and Ebola. There was great stress in EMS leaders on how to protect responders. Backlog and backorder of PPE. It just was not available. The public and responders needed to be reassured. Teams and plans were needed. Adequate amounts of PPE, properly trained teams and properly outfitted vehicles with trained paramedics were needed. Used Texas regional emergency medical task force regions. Tried and true teams with response experience. Also included DMORT teams. Established caches of equipment and PPE. 4.7 million dollars over 5 years to equip, maintain and train. An advisory committee was established with experts on infectious diseases. Membership was just not Texas but from across the nation including Emory University in Atlanta. What is a HCID (high consequence infectious disease)? A HCID poses an immediate threat, is very contagious and creates a high threat of public exposure and death. There are multiple 24 and 72 hour caches established and one 10 day support cache. Lion apparel and Viroguard created specific coveralls as PPE for Texas and will sell to others. A biocontainment system was also developed for use during transport as the Isopods were considered to be poor in actual application. Fitness requirements for PPE were also developed.

USCOMMD: Dunford/San Diego: Awake, Alert and Orient, targeting healthcare hotspots: High tech hot spotting. Frequent flyers define the issue. Used time elapsed heat mapping to show spice epidemic hot spot in downtown San Diego (my note: again... use of data!). San Diego has a bi-directional information exchange system. There are five paramedics that are part of a team that rolls out to solve community health problems. Frequent callers are targeted using EPCR data. Can be sorted by homeless, behavioral or substance abuse patterns. Individuals are profiled and the information is available as well as their reported needs and medical history. A cost screen is created to show the impact this individual is having on the EMS and hospital systems. Uses probabilistic matching to the profile and it is immediately known so the community paramedic can call the medic on scene to impact care and direction of the individual. Data entry is real time rather than after the fact. Directing care has impacted direction of care and allocation of system resources dramatically. The outcomes have been amazing. Cost was impacted to the tune of a 2.6 million dollar savings and over 50% reduction in responses. Appropriate care is directed and utilized. Alerting process are needed for an array of patients to direct care from contact. A 211 call service is also integrated for social issues. Soon, medics will be able to see all past medical history, meds and allergies on all patients contacted. EMS is where the rubber meets the road in healthcare.

USCOMMD: Yancey/Atlanta and Antevy/GBEMDA: Mobile Integrated Health (MIH) after Discharge. Keeping the Discharged at Large: Yancey: Decreasing 911 usage and decrease hospital admissions is the primary goal. MIH using prescription assessment based on diagnosis, Istat testing and mobile x-rays. They are performing med reconciliation, reviewing hospital discharge instructions, battery changes for medical devices and connecting with community resources including churches. Team is a paramedic and an advanced practice provider. Using EPIC for charting. Medic is also responsible for scene safety and mobile data. The team also coordinates non-emergent transportation for appointments. The team draws routine labs for Istat testing on scene. 2016 saw 322 visits. 53 visits were paramedic only. Only 3 visits resulted in transport by ambulance to an ER. Only 4.08% percent were readmitted (11 patients). The team also discards expired/unused medications. Helps decompress front and back door overloading of the ER. Long stay patients can be moved to home care with MIH management. Antevy: In his system, Istat and ECG is used in MIH and they carry antibiotics, antihypertensives and insulin as well. 506 patients seen many acutely ill. Only 2% transported to ED. At 18 months they have seen over 1800 patients. They also use wearable devices monitored by a call center.

USCOMMD: Bronsky/Colorado Springs and Isaacs/Dallas: EMS Police Health Specialist Response Model: Bronsky - Police/EMS Mental Health Response Team. Team has a police officer, paramedic and a social worker. Uses serum samples and Chem 8. Urinalysis as well. Prior to implementation 98% went to ED. Now 52.3 people are treated in place and only 13% go to ED. 50% of EMS units now do not transport from these mental health scenes. Pediatrics are included. Isaacs - Eagles steal from each other. They are duplicating it in Dallas under the RIGHT Care project. Trying to eliminate long waits for metal care and bed availability. Funding is an issue. Dallas funding through a non-profit granting 1.5 million in funding. It will not be self-sustaining. Care direction and employee morale is better but it is cost neutral at best.

USCOMMD: Mechum/Philadelphia, Keseg/Columbus and Scheppke/West Palm Beach: REACT-ing Well to Addiction, recruiting and managing the patient with Opioid addiction: Not just giving Naloxone (Narcan) but managing them after (my note: Exactly!). Mechum - Massive increase in Opioids. They look at Narcan usage daily by zip code. Most use is in an area of North Philadelphia that is called the "badlands." Keseg - Read the book "Dreamland." He believes Columbus is ground zero and has seen Carfentanil laced Heroin. They have a recovery outreach program for patients that get a second dose of Narcan in one year. They are offered help that includes home visits. It includes a home Narcan kit and social resources. They actually reversed a 72 year old with a thirty year Heroin addiction with the program. Drop your notions on this issue. Offering the help does make an impact. Responds to both Opioid addiction and mental health issues of the patient. Scheppke - The revolving door of Opioid abuse needs to stop. As Oxycontin availability went down, Heroin came up. 3600% increase in death rate from injectable narcotic use. This is a national health issue. Hep C and HIV are making a comeback due to this epidemic. Palm Beach County spent $500,000 on Narcan last year. Current status was a revolving door... OD, Narcan, ED, released home. All other chronic illnesses get treatment. Abstinence works for a small percentage of people. Treatment model: Must control withdrawal symptoms to work. The abuser will do anything to avoid withdrawal. Buprenorphine/Naloxone treatment eliminates the withdrawal without the high. Lack of insurance or no room in the program are barriers. New process is while in ER, post Narcan they start the Buprenorphine in the ER and local EMS/Fire visits patient every day for the next week and gives the Bupremorphine. After that a team takes over care.

USCOMMD: Yeh/San Francisco and Levy/Anchorage: Sobering Facts for 911 Providers: Alcohol impacted patients has been and continues to be an EMS issue. Yeh - EMS is doing more and more complicated and in-depth things. Different tools are needed. San Francisco use of sobering centers. US costs per CDC 2010 -$223.5 Billion. Alcohol accounts for 11% of healthcare expenditures. The answer is multifactorial within a community. A sobering center is primary care for an intoxicating subject. Sobering centers are expanding across the country. Staffing is a combination of a lay person, an EMT and an RN. Adults only. Publicly funded. Receive patients from police van or ambulance. They have cots, laundry and restroom/shower facilities. Food is provided after sober. In the absence of a sobering center, the sobering center is the hallway of the ER. The hallway does not mentally equate to good care in the mind of anyone. Sobering center requires GCS of 13 or above, stable vitals and lack of violent behavioral history. It is not a final destination but provides safe monitoring during sobering and provides resources post incident. 1-2% of total patients qualified for the sobering center over ER.EMS brings the most patients to the sobering center. 119 of 208 did not bounce back to the ED. Only about 4% go from the sobering center to the ER (unrelated complaint, fall, etc.). Robust protocols in place. 66% of clients only come in one time. The connection to social services is crucial. Levy - There is a lot of alcohol intoxication in Alaska in general. The sobering center transport time is busier than EMS in Anchorage. Unit is called the Anchorage Safety Patrol. Drunks outside become human popsicles in Alaska. Lots used to die of hypothermia. The Safety Patrol and Sobering center cost about $2 million a year. Many homeless camps in and around anchorage and they drink a lot. Candidates must be declared "title 47," BRAC >350 and repeated every 30 minutes. There a few Super users. 1% of the users take up 30% of the resources. Availability of the service has decreased non-sobering center deaths. Specialized vehicle for transport to the sobering center. Sobering van has been stolen. Vans have cameras. Clearly define admission criteria and there will be bumps in the road.

USCOMMD: Bronsky/Colorado Springs: Marijuana in Colorado: Children admitted for lung inflammation from Marijuana intake was 21% in 2015 (still think it’s safe?). Cannaboid abuse hyperemesis episodes are occurring. Those smoking Marijuana have an exacerbation of mental health issues. 21% of motor vehicle fatalities now test positive for Marijuana usage involvement. The hyperemesis issue has been very common. Edibles are a real problem. With smoking, when you can't lift your hand you stop. With edibles it is all in before effect. There are a lot of cannaboid overdoses in laced gummy bears in kids. Positive tox screens are on the rise. Very prevalent in child suicide (based on positive test). Rise in younger homelessness. Gas stations now providing Marijuana. The Planned Parenthood shooter tested positive for Marijuana. It is simply a huge negative impact.

USCOMMD: Lightning Round, Medical Directors take the Stage: 1) If a city manager wants to combine communications, who should run it? Police or Fire? Denver made it independent and they think it works well. Equal influence. New York City goes to police first and they distribute. They are civilian police dispatcher. About 60% say it is governed by police. There were none for fire led dispatch centers. Louisville was designed to be integrated. Integrated 911 is extremely important to outcomes. 2) How many systems still intubate before ROSC? About 65%. How many have TOR in place? 100%. 3) How many use Narcan in arrest? About 55%. Respiratory support during arrest alleviates the need for Narcan. Other side of coin: May be helpful in false PEA due to hypotension. Concentrate on working the arrest, not Narcan. Some statement of futility of medications in arrest period. Some have noted an increase in Opioid related arrests. Some discord between those on stage. We know what a drug abuser looks like and they look like everyone else. One community had a family complain on an arrest that Narcan was not given (family had already given a home kit). 4) Video Laryngoscopy? Any real successes? Minneapolis: Younger medics tend to use the VL and they have better success rates than the older medics. Most on stage want VL but cost is the issue. There is a trial between SGA and ETI in progress. Wait on VL until that data comes out. No issues with cleaning. Some finding that success rate increase with VL linked to quality of training. Most value of VL is the ability to record so you can retrain. 5) What drug is best for the violent patient? Ketamine for the most part. Some using for airway control. Benzos and alcohol tend to lead to desaturation. They can deteriorate rapidly. Ketamine and alcohol tends to get intubated as well. 6) Bypassing to comprehensive stroke centers? About 50%. 7) Mechanical devices in CPR? Answer coming this afternoon!

USCOMMD: Eckstein/Los Angeles: EMS and Darwin: The Evolution of EMS as a Public Health Entity: EMS has been not transport, no reimbursement. This has not changed. CMS must pay for treatment where no transport is required (my note: we need tort liability reform as well). Majority of EMS calls are not time critical. Very low number of true emergencies. Recently, LA saw a 7% increase in homelessness and acuity. They have seen a drastic increase in super users as well. Super user...s are the low hanging fruit to target for alternative health management. Emergency Department = $2800, EMS Treat and Refer = $279. EMS needs to look different. EMS needs to be in prevention and community-based care that reduces hospital admissions without losing our high performance emergency edge. 90% of LA fire responses are EMS, not fire. The MIH program is for mental health, chronic inebriates and underserved areas of the community. There is no such thing as inappropriate request but there is certainly inappropriate response. Fee for service must be expanded to include treat and refer, treat and release and alternative destinations other than ERs. They also have a Nurse Practitioner response unit as well. This is for low acuity patients. Istat heavily used. Catheter changes are utilized. Antibiotics are carried. Just received funding for a sobering unit to go with the new sobering center. They are putting advanced providers in dispatch for consultation on responses and scene needs. Whether we like it or not we are in the public health business. You call, we haul is no longer sustainable.

USCOMMD: Mechum/Philadelphia and Dunne/Detroit: Community Responses to Epidemic Opioid Crises. Mechum - Philadelphia had 700 OD deaths in 2015, 840 for 2016. Cheapest Heroin on the east coast and have seen carfentanil. State has increased funding for treatment centers. Physicians can now see online controlled substances prescribed to each patient. There is now a task force to work on decreasing the number of overdoses. Many organizations involved. What more can EMS do? Deploy... more units during OD spikes? Community paramedicine? Refer to treatment centers? Having issues with response times now, what happens if scene times increase? Dunne - Michigan passed a public act requiring BLS and FR personnel to have protocols for Naloxone and required the drug to be exchanged at hospital cost. Michigan has a lot of unfunded mandates (per speaker). Rural communities fought against urban on the law. State data was not up to date on the issue due to two versions of NEMSIS. Thousands of narcotic ODs occurring. 2016 had 2038 administrations of Narcan in 2016 in Detroit. Using data to plan. Used nasal atomizers anyway during the recall (no issue). Opioid issue is complex. Finding solutions will require an integrated approach. EMS may play a larger role. We must be clear...what is the aim? What does success look like? Again, we are the first line of public health.

USCOMMD: Harrell/Albuquerque and Schrank/Miami: Strength, Epidemiology and Safety Threats of Carfentanil: Harrell - Carfentanil causes overdose spikes. Louisville had 151 in 4 days. There is an exposure hazard for responders. Carfentanil has been found shipped into the country in printer cartridges. We are not talking about diversion of Fentanyl. Precursors and Carfentanil. Product is all coming from China. Carfentanil can be 500 to 100,000 times more powerful than morphine. O...ne seizure of drugs had individual dosage of 1.8mg in what appeared to be an Oxycodone tablet. 2mg is fatal. Processes have to be in place to protect responders from exposures. 24mg of Narcan is sometimes used if Carfentanil is suspected. BUT... never forget that the bag valve mask is the most useful treatment. Schrank - Each OD is not just another OD. OD patients can have other issues. High Potassium can be a problem, Rhabdo, Plexopathy, renal failure can occur. Compartment syndrome can be seen due to positioning during the OD before found.

USCOMMD: Weber/Chicago: Fire, EMS and Police Cooperative Training for Windy City Shootings: Program has made frontline officers capable of saving lives. Has brought police and fire/EMS together and increased public trust. Violence is largely gang on gang and those caught in the crossfire. Bloody 2016 was the highest for almost 20 years. 2017 is already at a higher rate than 2016. A very stressful environment. Law enforcement medical and rescue training was implemented TCCC training was utilized as the concepts. TCCC was coupled with high fidelity training to reinforce the care. Didactic training was limited and was made experiential. Sealing dressings, trauma gauze, pressure dressings and tourniquets are taught. Police, fire and EMS were trained side by side. Showed video on how mush officers thought the training was excellent. There has been multiple positive outcomes from the police care.

USCOMMD: Multiple PMDs from Anchorage, Raleigh, Colorado Springs, Albuquerque, Houston and NYC: Severe falls, hemorrhage and multiple calls: 1) Video shown of a 10 story jumper. 10 stories and he survived. Landed on roof of car. "Lucky." 2) Nursing home calls... study regarding limiting transport of falls in nursing facilities. A clinical decision rule with an advanced practitioner talking with the patient’s primary care provider. 65% not transported! 3) Handheld Infrared scanner shown for the detection of intracranial bleeds. Two minutes to perform scan. It will find 3.5cm bleeds within 3.5cm of the surface. It is being deployed in a prehospital trial. 4) TXA and Ketamine in the Grand Canyon. Transport by ground out of the Grand Canyon is one hour and twenty six minutes from the rim to ER in Flagstaff. TXA used for hemorrhage and Ketamine for long term pain control. Fairly liberal TXA criteria for usage. Most usage is in wilderness and not near roads. 5) Ground EMS Blood Products: Not a new concept. Blood products must be taken care of during storage for use. Inclusion criteria includes FAST ultrasound scan. 6) MCI. FDNY many specialty vehicles for MCI management. One unit can transport four gurney patients. There is a unit that can give oxygen to 32 persons at once. A large MCI vehicle can take 24 supine patients plus 10 wheelchair bound. There are hazardous material specific ambulances. Logistical support units are used as well. Six lectures in six minutes!

USCOMMD: Ellis/Auckland and Slovis/Nashville: Managing Anaphylaxis Down Under and in the Music City: Ellis - Anaphylaxis is a resuscitive emergency. There is confusion sometimes on giving Epinephrine that delays administration. Anaphylaxis does not always have urticaria. Reaction can be skin, respiratory or GI, but two of the three need to be there for diagnosis. 10-20% of life threatening anaphylaxis have no rash. Isolated hypotension could possibly be anaphylaxis. In respiratory, is it asthma or anaphylaxis? Sometimes misdiagnosed. The treatment is Epi and fluids and more Epi and fluids. Steroids and antihistamines common as well. No evidence that H2 antihistamines reduce mortality. No evidence for routine use of steroids (my note: I need to see the numbers on this). Fluid administration could be up to 3000ml. Link of anaphylaxis with asthma not fully understood. Do not be scared of IV Epinephrine. Use caution but do not be scared. If hypotensive, IV Epi is needed. Statement: "If you follow ACLS guidelines on anaphylaxis you may kill your patient." Some discussion regarding arrest and Epi plus fluids. Slovis - The number one cause of death in anaphylaxis is failure to give Epi by people all the way through the spectrum of care... the patient, the family, EMS, the nurse and the physician. Give the Epi! The elderly can safely have Epi in anaphylaxis. Use the two of three model stated above to define anaphylaxis. 0.3mg IM 1:1,000 (up to 0.5mg if a giant). On IV dosing, use a wide open IV and piggyback another IV with 1.0mg in the bag.

USCOMMD: Schrank/Miami: The Phenomenon of Thunder Asthma: There truly is Thunderstorm Asthma. Four killed in Australia in an MCI Thunder Asthma incident. 8500 patients treated in under 24 hours. A 911 call every 4.5 seconds in Melbourne during event. Many worldwide cases from 1983 on. Caused by perennial rye grass and pollen ruptures that travel deep into the airway when water logged. It is an allergic reaction.

USCOMMD: Conterato/Minneapolis: What is the best SGA? Covered history of non-visualized and newer SGA airways. Good SGAs are disposable, have a short time frame to use, ability to sustain airway pressures, provide for gastric decompression, wide age range, compatibility to intubate with device and price. It is also used as a rescue airway for failed ETI. Cuffed and non-cuffed SGAs discussed. Cuffed SGAs can compress cervical vessels and affect blood flow to the brain. I-gel discussed. This system compared the King airway to the I-gel. Insertion success improved with I-gel by nearly 5%. I-gel also increased use of SGA. Your SGA must be reliable and have a low complication rate. Different, ranged I-gel sizing permits one airway for all sizes and an excellent pass rate. It minimizes vessel compression as well (My note: I-gel strikes again. I still think this is the best airway on the market and our experience in Evansville has been excellent).

USCOMMD: Levy/Anchorage, Scheppke/West Palm Beach and Holley/Memphis: Mechanical CPR: Levy - Great ideas from the bench do not always translate to the field. Four trials with 12,000 patients. No difference in outcomes. No better but no worse. If it fits into your needs it is at least as good as manual compressions. Some evaluations show worse outcomes. Infrequent use shows worse outcomes. If you are a frequent user your outcomes will equal manual compressions. Time off the chest is crucial. Average time to apply is 36 seconds. This is a long time to not be doing CPR. Pauses are a determinant of poor outcomes. Anchorage uses mechanical CPR about 75% of the time and they match what the trials report. Practice can decrease the application time. Scheppke - Bundling therapies. If you delay PPV, raise head and use mechanical CPR what do you get? Increased ROSC. Holley - In Memphis, 1445 arrests. 919 got mechanical CPR. ROSC rates static. Pauses are a problem in device application. They compared to the ACD with ITD as a comparison. ACD and ITD showed an astounding increase over mechanical CPR with Lucas. 47.1% of resuscitated arrests were neurologically intact in this group.

USCOMMD: Gilmore/St. Louis and Schrank/Miami: Managing LVAD and Defibrillation Vest Devices: Gilmore - 159 LVAD implementation centers across the US. Kids have them too. The stuff you have to bring with the patient... batteries. Chargers... etc. No KED use with LVAD. No trauma shear use with LVADs. No pulse at all is normal. ETCO2 the best way to judge perfusion. Listen with a stethoscope for device function. CPR... probably not and only if necessary (how do you define necessary?). EMS guides are available. Schrank - LVAD and Defib vests: Even with a complex device, the common things are most common. Don't forget that LVAD patients can still be hypoglycemic and have normal emergencies. Assess the patient. One LVAD patient died of an unrelated GI bleed. Teamwork is key. Airway and breathing support quickly when indicated. IV access quickly. Get family calmed down and involved as they have the information on LVAD function. Listen for LVAD device operational sounds. Do not confuse "life vest" defib vests for an LVAD. This has happened. Do not cut off a life vest, they are $45,000 each. If you take it off, place defib electrodes. Just in time info resources are needed.

USCOMMD: Gallagher/Phoenix and Manifold/NAEMT: Public Access AED and Gloves on Defibrillation: Gallagher - Phoenix has 700 plus arrests each year. 300 AEDs have been placed for public access. City employees were trained for AED and CPR. 85 AEDs are in the airport. Each AED is within a 2 minute walk in the airport. AED holders are alarmed to show location of use. 1,000 aviation employees trained in AED and CPR. 59 VF arrests at the airport since 2001. All witnessed. 100% bystander CPR. Defib is within 4 minutes. 46 out of 59 discharged neurologically intact! Before the program, survivability at the airport from OHCA was 0%. Bike EMTs with AEDs are used at the airport as well. Teamwork through the entire system is key. Manifold - "Hands on defibrillation is not for sissies." Some ability to feel through gloves. Minimized transfer of energy in a cadaver model. Should you try this at home? Yet to be seen. Not yet for prime time. 0.2 micro amps were measured in the person doing compressions. Pepe actually tried this about 25 years ago (He said he was never depressed again). Not sure if cadaver models transfer the same amount of energy.

USCOMMD: Sayre/Seattle: Nitrates, the Hot Dog Study: Sodium Nitrate for OH Cardiac Arrest. Half of those who have ROSC die before discharge from hospital due to damage to the brain. What do we have to work on the metabolic component? Nothing. Mitochondria do not work well after arrest as they need nitrates. Nitric Oxide is a possibility. So is Sodium Nitroprusside. Not affordable at $881 a vial. What about Sodium Nitrate? In hypoxia can get restoration of flow to the brain. Safety data is being collected. They are increasing the dose. Phase two will be an OHCA trial. Measuring for improved outcomes.

USCOMMD: Holley/Memphis: New Angles on Head Up CPR: Lessons from the dead. Looking at ACD plus ITD, head up CPR, c-collars and mechanical CPR plus ITD with head up CPR. ACD plus ITD shows a drastic difference in airway pressures and cerebral perfusion pressure. Hopefully this will lead to better outcomes. Head down CPR ICP goes up and cerebral perfusion goes down. Not good. The opposite happens with head up CPR and this is what is desired. Best improvement was a bend elevating the waist and another slightly elevating the head at the neck. All reproduced in cadaveric and animal models. C-collars negatively affect cerebral flow and increase ICP in cadaveric models. Chest wall recoil is incredibly important in manual CPR. Venous return is decreased if no full recoil. What makes research possible is those who donate bodies to science for research.

USCOMMD: Jui/Portland: New Observations in double sequential Defibrillation: Using 5th or 6th hock. 48 total occurrences in their system. 31% had ROSC. Most of those after two shocks. Five survivors in five years from that group. Most that survived were young and did not have CAD upon cath. If no ROSC after 2nd DS defib, transport to cath lab.

USCOMMD: Conterato/Minneapolis: Should All VF Cases Go To Cath Lab? STEMI is easy... go to cath lab. Early angiography should have better outcomes. The ACCESS Trial looked at this. Needed to get around the "too sick to go to the cath lab" belief. Broad inclusion criteria. If ROSC and STEMI gets early cath. Trial looks at all resuscitated VF patients going to cath lab regardless of STEMI. Those that went to cath lab had better outcomes. The earlier they went the better cardiac function was and ended in less heart failure. Early access to the cath lab is crucial for resuscitated VF. Survivability is 75% in this group! 40% for those that do not go to cath lab. That is a large difference. This will now be a NIH funded study. Looking for several thousand patients.

USCOMMD: Bronsky/Colorado Springs: PULSARA - Streamlining STEMI and Stroke Activation: Communication streams are essential and fragile. Teams in single silos cause barriers to streamlined communication. Ability to share prehospital data across the silos at the hospital to enhance alert process and save time. Start by making it EMS led (Peter Antevy style). Make the hospitals believe it is their idea as they pay for it. Get all hospitals to go online at the same time. 19 agencies in his jurisdiction went live on the same day. 88% compliance with use initially with STEMIs and quickly went to 100%. Pre-registration at the hospital can occur through Pulsara. Helps facilitate bypassing unneeded care. Decreases time to CT in stroke. Decreases time to cath lab in stroke. Faster and more efficient care. Moving to use with all patient types.

Eagle's is done for Day 1.

Day 2! Standby for EMS research updates and local project reports from the EMS State of the Sciences Conference Day 2 starting in a few minutes...

USCOMMD: Augustine/Eagles Librarian: Nails the Tales from Bales of Eagles Trails of Emails: The Eagles share quick question surveys from across the nation for each year. This is from the 80 discussions that occurred over the last year. How are your EMS staffs doing? They are in danger from fatigue and violent patients, Fatigue management is a poorly managed issue. How are we doing to protect from violence that is on the rise? We need best practices in educating for safety against violence. New stuff? SGAs, digital thermometers need to become standard, Epi in a syringe instead of Epi-pens, higher doses of Narcan, patients with specialized drugs for their needs, IO placement and removal. Ketamine. Ketamine. Ketamine. A lot of discussions on the importance of airway and easier management of the airway. Discussions on MIH and treat/refer and treat/release. As was seen yesterday there is much discussion on sobering centers. How do hospitals clear beds quickly for incoming MCI victims and how does the 911 dispatch center play a role in overall MCI management. Much said about destinations for stroke, arrest and sepsis. On MIH... EVERY COMMUNITY HAS DIFFERENT NEEDS, one size does not fit all. Must be local and specific needs to fill gaps with MIH. Decreasing red lights and siren responses is needed as well. EMS needs a strategic plan looking far, far ahead. The fire service does this every 10 years at Wingspread. What should EMS look like in 2026? EMS and fire is an all-hazards workforce. Sustainability is a huge question and always will be. What is our responsibility? Bomb squads and hazmat units may become joint hazard assessment units. Is MIH the next unit to be added to the vehicle response bay? Areas need to have their own Eagles groups to meet and share ideas and data.

USCOMMD: Eagles Lightning Round: EMS Fellows on stage and charged to answer questions. 1) What is the most important thing you learned during fellowship? Listen to the EMS providers. Their opinion is valuable. "Providers can teach you a lot more than you can teach them." Be patient with the slow process of change. Take care of your providers. You are an advocate for a lot of patients at one time. Listen to your mentors in the ED. Be an advocate for specialties. Eagles is an amazing resource. Advocate for EBM. Measure and improve. 2) How much time is spent in the field by Fellows? Some actually serve as paramedics in orientation as the partner to an experienced paramedic. Denver program has a lengthy field fellowship component. Fellows from Indianapolis, Denver Seattle and others on stage. Some fellowships are on an ambulance, others are in a separate response vehicle. "Essential to be in the paramedics shoes." Most seeing a significant amount of time on the street. 3) What have you walked away from at the two days closed door at Eagle Creek? There are a ton of questions in EMS and a ton of approaches. Use of Narcan in cardiac arrest was an interesting subject and there is an art to the EBM on approaches and two things can be different and still be right. Fundamental EMS issues are the same worldwide including funding. 4) Mental Health and provider safety, what keeps you up at night? Provider safety is huge. We have to be aggressive on integrating with police and have great relationships. Barriers to chemical restraint need to be removed. 5) George Hatch from the Accreditation body challenged the Fellows to be directly involved in EMS education. The medical director needs to be out there with the field crews at 3am. 6) Fellows were challenged to know how they fit in CBAs and be able to discipline in union environments. 7) Thoughts on quality improvement? Look at the system before looking at the provider when evaluating errors. Use Just Culture. There are individual situations, but most are caused by the system. No one goes in to EMS to hurt people. Acknowledge positive more than recognizing negatives. Crews must KNOW the medical director before meeting them over an issue. QI will eventually affect funding of EMS. 8) Fiona Moore from London asked: How will you insure that QI findings will be disseminated across your organization? You must have a QI system in place to which you adhere. Loop must be closed on issues to assure that all are aware, not just those who have been involved in the error. You must ask data questions of many areas of system performance. Stroke? STEMI? Trauma? Ketamine? Ask questions and provide solution oriented answers. Continuing education must be provided. Use many paths to communicate, not just one. Take time to clarify when there are questions. 9) Where should you be in the political process? You must be involved in telling the story of your providers, whether it is on social Media, TV or at a city council meeting.

USCOMMD: Jui/Portland: Are on-scene stroke screens accurate?: Large vessel occlusion has changed everything regarding destination. TPA only opens up 25% of large vessel occlusions. Procedures being available are the key in large vessel occlusion. Embolectomy trials have been positive. AHA 2015 guidelines address interventions at a Class 1A level. Discussed circulation patterns that affect the stroke scales. The ratio of necrotic tissue to ischemic tissue on MRI is a primary driver of clot retrieval. Bypass primary stroke centers to go to interventional stroke centers? CSTAT versus RACE? Dysconjugate gaze is an indicator of LVO. RACE has a good number of components. Covered several other scales as well. CSTAT and RACE are validated. They are using CSTAT as opposed to RACE. Out of 115 patient alerts the medics were 82% accurate. The rest were actually stroke mimics which is still pretty good. 20% of strokes are missed though and they appear to be complex strokes. So far 5 out of 6 CSTATs have been positive and had LVO.

USCOMMD: Dyer/Boston: Can dispatchers facilitate faster in-hospital stroke treatment?: Are there more ways to enhance the path to care than just stroke alerts? Can dispatch push information from the caller on the line to the stroke center? Prior CVA? Anticoagulant prescription use? Crew findings pushed ahead while crews are loading? Preregistration? (My note: Pulsara?). They will tell us how a trial goes next year. In design now in Boston.

USCOMMD: Antevy/GBEMDS, Keseg/Columbus and Perrse/Houston: CVA Guideline enforcement to street imaging: Antevy - Which hospital DESERVES to receive our patient? LVO needs to go to the comprehensive center not the primary. In his area they do not transport stroke to primary stroke centers at all. They only take strokes to comprehensive centers and beyond that they look at outcome data and try to transport to the BEST comprehensive stroke center. Stroke centers are required to... give data dashboards to EMS and they bypass poor performing facilities. Right patient, right scale, right hospital, right process, RIGHT NOW! Keseg - Eagles gives the raw, unpolished truth. Mobile stroke unit in Columbus. Sounded like a cool idea. What could go wrong? News report caused other facilities that were not ready were caught off guard. Kum Ba Ya was desired... too many issues. Branding? Hours? Where parked? Disparate parties involved. Committees actually agreed until the MOU came around... then "legal" got involved. Regression occurring. Project stalled. These things are not as easy as you think. Perrse - Mobile stroke unit in Houston. Nothing started till partners were on board first. They sang Kum Ba Ya and moved forward. Can we treat a small number of patients extremely early? Randomized controlled trial active every other week. 42% are being treated with TPA within 60 minutes, 37% more in the next 20 minutes. Early care is happening. Outcomes to follow at end of trial.

USCOMMD: Carli/Paris, France, Hunter/Orlando, Metzger/Dallas and Scheppke/West Palm Beach: Growing Concerns for EMS in Active Shooter Events: Hunter - Terrorist attacks differ from mass public shootings. Are threats quickly eliminated? Not in the age of terrorist attacks. Covered Orlando Pulse shooting. Gunman fired 194 rounds before police entered. Shooter was re-engaged while trying to pull hostages out. Our job is not over when the shooting stops. Spread out over an area with four different concentrations of patients. 24 trauma alerts arrived in 26 minutes at the ED. Family reunification was an unforeseen need. Mass fatality procedures were needed. What do you do with 10 dead bodies in the ER? Media was an issue. National media sued at the 9 day point for the dispatch tapes. What is the best way to transport shooting victims? Whatever way is fastest! Police transported 30% of victims. Studies show this is acceptable and does not decrease mortality. There is 600 yards between Pulse and the ER door. Could anyone else have been saved if tourniquets were in the club? Not from the injuries sustained. 550 units of blood were used in a short period of time. Most fatalities were shots to the head. Carli - Paris shooting. Facetime feed from Paris. Multiple casualties stressed system. Video quality cut presentation short. Metzger - Dallas police shooting. Told initially there were three shooters triangulating and that bombs were possible. She was in charge of medical command for six hours. There were a lot of minor injuries from the panic and running. 911 calls continued at a high level during the incident so system was at high utilization. The incident itself went well in respect to management. Hard to tell what is going on because every piece of information received may not be true. Paramedics went in to retrieve down officers. Scheppke - Fort Lauderdale airport shooting. Cannot get into specifics as still under investigation. Patients can be in place in these incidents that are sheltered in place with chest pain or low blood sugar. It is not just about the trauma victims. Things will go wrong so have ability to adapt. This requires flexibility in decision making. You may have to search for those who are hiding when the incident is over and they may not know you are the good guys. These incidents go on for hours. It is never over until it is over.

USCOMMD: Collins/Cleveland, Mechum/Philadelpia and Margolis/US Secret Service: EMS at the National Republican and Democrat Conventions: Collins - RNC Convention. Law enforcement was nervous. Privates utilized for coverage as well as municipal departments. RNC brought in contracted medical teams for delegates. Hospitals got along well. Hospitals were not allowed to advertise. US Capitol medical team was there as well. There was a lot of offsite medical capacity that was staged... for a possible event. Volunteer group called "Street Medics" provide medical care for protesters. Many have no medical training or are not certified. It was like planning for a wedding with 50,000 guests in 10 months. Build in time to orient as the arena will change and routes of access and egress will be obstructed. There were two tent ERs and two mini EMS units on site. Learn nomenclature of law enforcement as it will be used. Think of rehab for your EMS that are in body armor. Practice before going operational. Mechum - Wells Fargo center in Philadelphia for the DNC. Airspace restrictions and rail constrictions were put in place. Secret Service credentialing was performed and all vehicles were swept using dogs. "The Wall" was deployed surrounding the entire site. Medical coverage was anticipated for protesters but they had no clue where they would be as it was expected they would not stay in the designated areas. Saw far more protesters than Cleveland but were fairly peaceful. Estimated at 50,000 protesters. Police were professional and preemptive. Practice patient movement. Security measures are very time consuming. Building good relations are key. Preparing for protesters brings many unknowns. They used the template they had for the Papal visit as a starting point.

USCOMMD: Perrse/Houston and Dyer/Boston: Super Bowl Planning: Perrse - Planning took a year. Objectives were established. ICS is effective if you use it. Don't be the only person in the room that does not understand the command structure and how it works. Credentialing was done months in advance. Vehicles were screened. The NFL owns the game. Period. You get to know people due to the number of planning meetings. Brings the response community together. Protesters were there too. The anti-circumcision group protested the NFL Experience and the "Street Medics" were there too. There was an intelligence operations center utilized. There was one trauma call from a fall at a loading dock but that was the worst injury at the Super Bowl.1079 patients were seen during the week that were related to the Super Bowl. Dyer - Patriot's Day. Parades are big events in Boston. One million football fans showed up. They try to have it in the middle of the day during the week to decrease alcohol consumption and make it safer. Whatever you come up with for more resources, add more. Cell phone towers are typically overloaded.

Brent Myers NAEMSP President

USCOMMD: Myers/NAEMSP: The NAEMSP National Meeting Update: 300 research articles were presented in lectures and posters. NAEMSP is more aligned than ever before. 25% of membership is non-physician. Paramedics are members. The research portion of NAEMSP is chaired by a Paramedic. Best cardiac arrest research was an article that looked at skills rather than coding and looked at ROSC and discharge for ALS versus BLS. It showed a 2.5 X success of ALS over BLS. Another looked at spinal restriction. No difference in using spinal restriction and not using it. Legislative issues were discussed and they are trying to move the DEA bill. They placed the bar in the poster room so a lot more posters got viewing. There are highlight podcasts available from NAEMSP of the meeting. Next year's meeting is in San Diego.

USCOMMD: Manifold/NAEMT: Advocating for Advocacy in EMS: Why become engaged? Contact legislators on issues that matter. Build relationships with legislators. Become the expert that they go to for questions regarding EMS. The more money your PAC has the easier it is to get heard. Build coalitions to move legislative efforts. Identify road blocks and address them before final form. ACEP, NAEMSP, NAEMT, AHA, AAA, IAFF and IAFC are organizations at work for EMS advocacy and lobbying efforts. If you are not asking for funding there is far better chance of success. Address public safety and public trust as a component of your needs. Stay focused on the patient and provider oriented in discussions. DEA bill status: HR 306 is on board - Passed at 100%. Senate has to be reintroduced. Working on payment reform and strengthening the EMS Act. The National EMS Memorial issue was reintroduced this year as well. Looking to construct an EMS Caucus. HR 880 is regarding trauma and funding for trauma centers.

USCOMMD: <<READ THIS ONE TO THE BOTTOM>> Eagles Special Time with the Audience: Medical Directors take the stage. 1) New format of conference effective? Yes. Stayed on time. Multiple experts on stage at once. Increased to 83 or 84 specific talks. 2) Hotel ok? Yes. 3) Old hotel good? Yes. 4) Parking better at this hotel. 5) Entertainment better around old hotel. 6) Date of meeting? Good timing. Stay away from spring break. 7) Easy to ask questions? Maybe have stand up microphone. 8) Vendors? CEOs were actually here for many companies. Good, high level EBM vendors. Let Paul Pepe know of any suggestions. Largest Eagles Meeting ever. CME credit explained. Presentations will be on the website in about a week. http://gatheringofeagles.us/ 910 in attendance this year. Primarily paramedics and medical directors. Taking questions: 1) Noted seeing patient with High Quality CPR, patients with spontaneous movement in Asystole and VF... can Ketamine can be used for this? Yes. Same with Ativan or other sedatives. It is rare but happens. There are intra-arrest waking protocols. Remember to verbally reassure the patient as they can probably hear you. Ketamine may cause coronary artery spasms. Fentanyl may be better choice. Needs further study. 2) What do you do when you perform EBM and best practice and get chewed by the ER doc because they do not agree? Some medical directors give crews business cards to give to ER docs or hospital staff that may disagree with the medical director. They can make direct contact. Be professional. Slovis (Nashville) directly takes the issue back to the ER doc and does not stand for paramedics to be abused or demeaned (when right) and "does not take shit from anyone." The term "Disruptive Physician" was used and is seen as a barrier to proper team care of the patient. Should not be allowed to occur in front of the patient or family and paramedics should attempt to direct the discussion to occur outside the patient room. The paramedic needs to stay professional and contact the medical director through proper channels. Several agencies have zero tolerance on this topic. 3) Public Access Defibrillation at an airport. Is it utilized? If not can they be repositioned in the community? One locations reports 5% utilization over all arrests, BUT... they are usually survivors. San Diego has 8500 public access AEDs. They target Boy Scouts and churches for distribution. Man saves through the program. One hotel has saved seven people so far. Columbus targets athletic facilities and offers CISM after AED use. PSAs are used in airports as to AEDs being present.

USCOMMD: Pepe told the story about Copass sleeping with the med control radio under his pillow. He had a compulsive public trust. His job was to guarantee the safety of every 911 patient in his system. The Michael J. Copass, MD Award for National Excellence in EMS is awarded to... the recipient is currently on an airplane... it is Anchorage Fire Department Medical Director Michael Levy.

USCOMMD: Peter Antevy receives the 2017 Ron Anderson Award for his efforts in the betterment of pediatric EMS care and his personal delivery of education.

USCOMMD: 8,250,000 social media views regarding this conference. Just surpassed NAEMSP in social media views. Peaked during the mass shooting lecture earlier today. 6,300 tweets from this room in the last two days.

USCOMMD: Moore/London: Proactive Marketing of the Benefits of EMS: Communicating with staff and the public. Can we influence the public? London sees about 1 million responses a year. Currently they have a very young workforce due to attrition and replacement. Staff needs to be recognized to the public and get the recognition they deserve. Internal communications need to be there and be trusted and seen/heard. Media inquiries must be addressed. They allowed the BBC in for a prime time TV series. They allowed it as the staff is very proud of the care they provide. The thought was it might cause those living in London to consider a career in EMS. They hoped it would allow people to see how the service work and maybe get the public to take pride in EMS. Surveys showed that the public was more understanding of delays, non-emergent issues being delayed or referred. Most of all it showed a favorable view of London EMS. Job applications for the control room increased. Massive impact on social media. The documentary ran for three weeks. During the broadcast each week, ambulance demand dropped while on TV (laughter). There was a massive feel good factor for the staff and the public is now more supportive. They also have an "eat, drink and be safe" campaign during the run up to Christmas when alcohol issues spike. They saw a decrease with alcohol related issues after the program was implemented. They educated the public not to call EMS for things (such as inebriates) that would delay ambulances getting to higher priority patients. Again, alcohol related incidents dropped after the program. Communicating with the public has a positive effect and can change public behavior.

USCOMMD: Asaeda/NYC: How to Cope When an EMS Partner Goes Broke: 1.44 million calls a year in NYC (FDNY EMS). 320 square miles. 8.5 million Residents, but up to 13 million during the work day. 2,500 EMTs, 1000 Paramedics. 4,000 calls per day. 1,146 ambulances shifts each day. Some responses are from hospital based EMS and volunteer ambulances. Some hospitals have contracted commercial ambulances. 2/25/2016 one of the commercial ambulances went bankrupt. They filed Chapter 7 without notice. They lost 81 shifts that day. Impossible to fill overnight. They did have some plans in place as there were signs. FDNY personnel were held over. Employees working both places were emailing FDNY telling them they were shutting down. They asked other hospital based units to put on extra shifts and fly cars were utilized to arrive on scene and take care of patients. Added a tactical response group with one supervisor and 10 BLS units. Warning signs were there at the commercial provider: 1) Paychecks were bouncing. 2) Summer of 2015, state department of health advised that they could not pay workman’s comp insurance. It was thought they would file Chapter 11, but they liquidated under Chapter 7. Watch for early warning signs when dealing with any provider and have a plan in place. Bouncing pay checks is an ominous sign as is missing insurance payments.

USCOMMD: Goodloe/OKC and Tulsa: An alternate Approach to Re-Routing Requests (Diversion): Sometimes seeing offloading times of up to 2.5 to 3.5 hours at ERs (wall time). We cannot control the behaviors inside the hospitals. Diversion must be allowed. What if we diverted the unstable patients? They divert the STEMIs, strokes and traumas. If patient is stable override the diversion. Typical viewpoint: "We hate adults. We hate Kids. We hate Koala Bears. We are on diversion. Do not come here." (My Note: Evansville does the same, we divert the most unstable or ALS).

USCOMMD: Gallagher/Wichita: Considerations in Credentialing EMS Personnel: If he picked a name on your roster, would you stake your career on that person’s performance capability? Your medical director does this every day. How do you credential locally? It is a public protection issue. Certification is an attestation. Licensure gives you the privilege to work... it is not assuring you are mission ready for the system. Need for local credentialing. Cognitive knowledge is needed. Remediation must be there. It must be fair and consistent. It must keep up with the changes in the medicine. Establish requirements apart from what the government allows. What is the length of time? Re-credentialing should occur every two years. Credentialing drives us into a practice model similar to that of physicians. This should be done by all EMS providers of all types. Government is not exempt. Credentialing must be provider specific. One size does not fit all. Written tests are needed. Protocol tests are needed. Critical thinking should be evaluated. If we want to be treated as a healthcare sub-specialty this must occur (my note: I totally agree and am glad this has been said).

USCOMMD: Antevy/GBEMDA: Top Five Challenges in Pediatric Medical Care: 1) Peds Airway - stick with BVM and SGA (mentioned I-Gel as well as others, but likes I-Gel as there is no cuff to inflate). Smaller I-Gel sizes need the strap hooks. Neo-bar works to hold it in though. All SGAs should have a gastric port. BVM is still king. 2) Peds pain control - document pain scores. Fentanyl and Ketamine are the leaders. MS takes too long to take effect. 0.1ml dead space in a MADD nasal... device. Ketamine is great but watch concentration and dilute if giving IV. Give Ketamine slow. Fast IV admin causes laryngospasm. 3) Seizures - no Ativan. Versed is better. Versed is best for Peds seizures. Non IV is best, use IN or IM. Fast in fast out. 4) Hypoglycemia - D10 is best option for adults and kids. Period. 5) Fluid restriction - use boluses as needed only.

USCOMMD: McVaney/Denver: The Outcome of Rolling Out a New System of Care for Children: No financial interest in Handtevy. Handtevy does everything you want in a comprehensive pediatric system. You should be really angry about how you have been trained in pediatric care. Peds resuscitation is broken. We were taught to be calm and look things up. That is what PALS teaches. We need to be quarterbacks and are trained to be step followers. You develop into being a quarterback. When the time comes to do the resuscitation you are most successful when you are surveying and controlling what is going on. A culture change is required. Culture change is not luggage and a guidebook. What else? Didactic training then garage time talking to crews and training as they come on duty. Happy paramedics matter. They are engaged when they are happy. No one loves a complicated pediatric call. Why? We are trained wrong. Bad cases must get good feedback. He states he is done being part of the problem in negative reinforcement of paramedics. Use the Handtevy SYSTEM.

USCOMMD: Gilmore/St. Louis: How to Manage Kids with Special Needs: Special populations are the young and the old. What about special needs? Vents and IVs with kids at home. Is resuscitation equipment already present on scene? Does that cause a pucker factor? The number of kids with special healthcare needs is increasing. The percentage of them in the population is increasing also (it is now 1 in 5). ACEP has a specific form for info on special needs kids. It is too complicated.... There is another form designed by a paramedic with a special needs child that is better. (STAR). Addresses side effects of autism such as pain responses and noises. It also includes normal vitals and GCS for that child. Also covers normal neuro status for that child. Do we train on babies with trachs? No. That is why we need initial info and ability to pull up the form on that child. It is available on the Cardinal-Glennon website.

USCOMMD: Racht/AMR National CMO: Assessments and Decision-Making for Possible Concussion: Concussion is a silent personality thief. Concussion must be viewed as a mild form of traumatic brain injury. 1.6 To 3.8 million concussions each year. Football is number one but Basketball and soccer are next. Wrestling is on the list as well. The number one incidence of spinal injuries in sports is cheer-leading. NFL has acknowledged the connection with concussions. Second Impact Syndrome (SIS) is essentially another physical impact before the brain heals from a prior injury. The second injury can be fatal or more impactful. NASCAR is expanding a concussion protocol. It changes risk stratification. Get the detail from the patient on signs and symptoms. Use the SCAT 3 assessment. SCAT 5 may be out in the future. It is a very organized approach. Crash sensors for helmets are $149. Low price to pay for protection in knowing the level of impact. If it shows red, they come out of the game. Period. Parents and athletic trainers need to stop pushing to get kids "back in the game" quickly after head impacts. CT scans do not seem to help. Medical clearance to play post impact needs to be made objectively using scales and cautiously. Ignorance of this can change their future life significantly.

Human Trafficking Heat Map

USCOMMD: Valenzuela/Tucson and Dyer/Boston: Human Trafficking: Valenzuela - People being trafficked are lured in by false promises they do not intend to keep then find themselves unable to leave. Trafficking is often hidden in plain sight. There is both sexual and labor trafficking. Wages are held or less than promised. Sometimes held hostage. Improve your intuition. Look for what is not right. Look for locks outside doors on scene. Tattoos may serve as brands. Look for skin ...infections. Look for headaches and back pain as somatic signs. If suspected, transport the patient alone. Keep companion out of the ambulance. If under 18 report to CPS. We see the scene and can relay otherwise unknown information. Dyer - The east coast perspective. We need better tools in recognizing trafficking. It is a 32 billion dollar a year business. She believes EMS is the key to identifying trafficking. It does not look like abduction. Heat map shown of human trafficking in the US. The I-95 corridor is a hot spot. Ask if you can: Is anyone forcing you to do anything? How do you pay for your drugs? Can you come and go as you wish? Victim may have a criminal record that is not their fault (forced to do). Use your assessment skills of the scene. Follow senses when something looks or feels wrong. EMS is good at this. Goal is not to perform rescue or disclosure. Goal is to get trust to enable rescue and disclosure when in a safe environment. National Human Trafficking Resource Center 1-888-373-7888.

Truth

USCOMMD: Richmond/Ft. Worth: Sudden ADULT Death Syndrome: 1966 was now 50 years ago... EMS is 50. Now we think about responding to mass casualty events. Shift gears. What about those cases that are routine emergent calls that suddenly up and arrest? We have an MCI every day and do not recognize it. So, let’s make up a name... SADS. Sudden adult death syndrome. You need an ECG monitor, Capnometry, CPR quality and Capnography. Watch for bradycardia. Is adult sudden arrest in routine EMS calls a product of lack of recognition and watching for indicators of demise? Are other things done before CPR? Case studies used. Use your monitoring capabilities. Watch them. QA processes have to be in place to assure crews know how to use monitoring devices. If you are not monitoring the airway you have no business controlling it. Manual skills like BVM use must be mastered. Cognitive and affective skills must be credentialed.

USCOMMD: THE GREAT DEBATE 2017: Fowler/Dallas and Valenzuela/Tucson: Free Standing ERs, Pro and Con: Con/Fowler - EMTALA cited. There are several types of FSEDs. There are satellites and truly free-standings. Why would a person with an emergency want to be transported to a FSED? Capabilities? Satellites are EMTALA bound where Free-standing is not and has no relation to a hospital. Free-standing may require cash to treat and will not cover transport to another facility. CMS implications? Can a STEMI go somewhere without a cath lab? Minor emergencies? Then why not a cab instead of an ambulance. Should ambulances even try to figure out whether they can transport to a true free-standing? What additional resources do they have? EMS takes care of all things. Does the FSED? Pro/Valenzuela - Between the two, only the Satellites will survive in the future. Satellites use the same ER physicians and are integrated into the EMS system. Transfer agreements not needed as they are a satellite of the hospital. Satellites have needed diagnostics. Showed a video of a Satellite and its capabilities? Bypass protocols exist. STEMI should be diagnosed in the ambulance and the appropriate destination selected. Trauma goes to the trauma center. Are there overblown concerns? Delays are normal whether in a hospital or not. The surgeon will not get anywhere more quickly because it is in or out of a hospital. Satellites can get EMS back in service quicker and back into coverage quicker. Allows for better geographic distribution of many ED services. Look at your community and current ED locations. Does not support free-standing type. Bound by EMTALA whether you can pay or not if a satellite. And besides... they have free coffee. I think Valenzuela won personally. No vote was taken on a winner.

USCOMMD: 9.9 million social media views regarding this Eagles meeting. Wow! That's it till next year. Now for some Dallas area food!

And with that was the summation of the entire conference. 910 people listened on for two solid days of 10 minute lectures and are now trying to wrap their heads around the information and translate what is applicable to their EMS systems back home.

Till next year... If you decide to expend some money on EMS education for yourself, I strongly suggest you consider Eagle's 2018.

You will not be disappointed.

I would also be remiss if I did not mention the Café Pacific in Highland Village. We try and eat there every year and they have the most wonderful food. This year, our waiter was Peter... a most fun gent from Great Britain. If you ever go to the Dallas area, be sure to stop in. Just like with the Eagle's meeting, you will not be disappointed.