So the annual pilgrimage to Dallas for the EMS State of the Sciences meeting has came and passed. All that are left are my notes and many things to be contemplated, discussed, developed and eventually whittled down to what can be implemented locally.
This year I pulled off the air travel while primarily exhausted from dealing with pain secondary to an untimely occurrence of thrombophlebitis. Now that I am a tad better, the notes have been cleaned up a bit and can now be shared. Through difficulties with slow wifi connections, a shorter span of time with presentations and my poor typing skills, the end product has still come to pass.
Once again, please forgive the grammar and I assure you that all of the spelling errors have NOT been caught (although it is cleaned up a lot). These are, once again, raw notes taken during the conference, copied and cleaned up from my social media posts.A nod to Dr. Kaufmann who has suggested that I change the colors within the blog to make this a bit more readable. Done.
So herein are the notes without further delay. I have marked a few I found interesting in a lighter color:
Eagles: Slovis - Nashville - Five of the Most Important Papers from Last Year - 1) Prehospital STEMIs: STEMIs come and go. It is essential to have prehospital 12-leads because the STEMI may not be present on arrival at the ED. Study with 728 STEMI transports. Placed in three categories. 8% became STEMIs. 7.7% STEMI proof disappeared before arrival at ED. Activate off of first proof. 2) Lower doses of Epi: If giving it, give it early. Interval should be more 8-10 rather than 3-5 minutes assumption. Study decreased dose to 0.5mg, and then again at 4 minutes for VF. STUDY FOUND NO DIFFERENCE. Reducing dose does not help. 3) Refractory V-Fib: Is DSD beneficial to outcome in refractory VF. Numbers slightly better, but not a valid statistical difference. Jury is still out. May damage defibrillator. "DSD is a crowd pleaser, so go ahead and try." 4) Hypotension in TBI: Mortality raises dramatically in TBI in the presence in hypotension. Pressors may be used. Guard against hypoxia and hypotension. 5) Steroids in Asthmatic Children: Used oral steroids. Decreased number admitted by 1/3! Course of care was shorter also. Cut ICU admission by 50%.
New Concerns for our Communities, our patients and ourselves - Pepe (Course Director): Guilt is the predominant emotion after an active shooter event by those left behind and those who managed it. Everyone questions what you do after the fact. Responders can be victims of protracted suicide. Public safety suicides are on the rise. This is far from over. These incidents will continue. It is not just guns. Were guns are not used it is bombs when you look at this issue globally. Triage has changed. Prepare for multiple sites not centralized.
Tag, You're Not It: Realistically Re-Thinking How We Carry Out MCI Triage - Dyer (Boston): We have many incidents to analyze in the last few years. Boston. Orlando. Las Vegas... etc. Tags? START Triage? Too complex. Must be simplified.
Terminal Conditions: The 2017 Fort Lauderdale Airport Active Shooter - Scheppke (West Palm Beach): Shooting video is actually on YouTube in the baggage area. He had the gun in checked baggage and got it out in the bathroom. Took only 85 seconds to get the shooter into custody. Why did incident last so long? Communications. There was a belief that there was a second shooter. Mass panic happened in the terminal AFTER the shooter was in custody. It was not communicated to the public present that the incident was over. Over 2,000 police officers responded making the parking lot impassable. 12,000 people were stranded on the tarmac. Mass communication is a must in these situations. Mass evacuation vehicles could be used. Staging of emergency vehicles arriving is a must otherwise gridlock happens at the scene.
SAS RTF for an LAS RTC? The 2017 London Bridge Attack - Moore (London): At around 10pm a van drove into multiple pedestrians and then assailants attacked bystanders with ceramic knives while wearing imitation suicide vests. Then became an active shooter incident. LAS established two sectors, one on each end of the bridge. Most of LAS was wearing body armor during the response. Police neutralized the assailants within 16 minutes. System was in a system overload at time of incident start. Very busy night. Some responders thought the gunfire of the police was gunfire from secondary assailants. Figuring out what is going on is difficult. Maintain situational awareness and keep hospitals aware of evolving situations. TRIAGE IS DYNAMIC. Take care of Staff. Some of these were on a bridge attack and then later the Grenfell Tower fire, Stress must be managed.
Swiss Cheese Preparations for French Table Tops: Planning for Multiple Sites and Multiple Phases - Lamhaut (Paris): Terrorist attacks have evolved. Triage cannot be like Swiss cheese. Your cheese must be solid and flexible. There may be multiple sites and ongoing phases. Resources may need to be moved. Try to preserve the other parts of the system as everything else still continues to happen. Described three different assailants attacking at multiple locations in Paris. Avoid transferring the disaster to the facility and preserve quality of care!
Be Positive, Be Passionate, Be Proud - The Marjory Stoneman Douglas Tragedy - Pepe (Course Director): Four hours before the event Paul was teaching the SWAT team. Peter Antevy's wife is an alumnus of the school. Two lives were saved due to tourniquets from prior stop the bleed training.
The Taint of Restraint: When the Shooter Has Yet To Be Contained - Antevy (Coral-Springs - Parkland): First question in our heads: Why can't we go in? Strong feelings. The fire chief borrowed a ballistic vest and went in to pull kids out. Showed pictures of all of those who were lost. Pepe actually entered the building as well. First thing everyone has to remember is that we are there to fix it. It is not our fault that it happened. We have to do the job. The way we get through it is to train, train, train. You will feel like you should have gotten there earlier, or should have done more. You can't. Hurricane windows kept him from shooting at students and first responders outside. Don't drink alcohol. Visit your crews.
What Happens in Vegas Won't Stay in Vegas - Racht (AMR): Our greatest challenge in EMS today because we are not as trained as we need to be... active shooter incidents. Catastrophic MCI management must be practiced. Ambulances were launched from as far away as Lake Havasu because they did not know if this would be a continuing event or not. When a large scale event occurs the community regular 911 is jeopardized. There were five or six patients per ambulance. Securing patients was out the window in the patient compartment. The initial moments had everyone thinking the shooter was in the audience. No one was looking for an elevated shooter. Trampling injuries occurred. Hard new lessons. The general
What Will Keep Me Up At Night: Evolving Terrorist Threats and Implications for Prehospital Providers - Carli (Paris): Multi-site, multi-modal events kept him awake at night. School attacks keep him awake now. Are you prepared for 200 pediatric victims? Only Hemorrhage? What about chemicals? Gases? Can you provide ventilation for 170
Public Access De-Hemorrhageination: Pros and Cons of Local Ordinances for Bleeding Control Kits - Antevy (GBEMDA): First tourniquets were used by the Romans. We have the Hartford Consensus in 2013. They took on the idea of putting a bleeding control kit with the existing AEDs. In 2009 his area started requiring AEDs in larger buildings so they knew where they were. Forced businesses to comply with adding the bleeding kits. Dr. Antevy is making copies of the Ordinance available for other communities.
A New Twist On Tourniquets, Bleeding Kits and Policy Blitz: Where Do We Go with National Stop The Bleed Campaigns - Hunt (US DHHS ASPR): Stop the Bleed saves lives. Have we done enough classes? No. Stop the Bleed has goals around the general public. They will know how to stop the bleed and have access to bleeding control kits. Even the logo screams "direct pressure" with the raised hand. The general public needs to know how to recognize serious bleeding, use a tourniquet and do wound packing in non-extremity bleeds. Not all people will take a class. That is why we have info graphics and videos. Stop the Bleed is about saving time to increase chance of survival. Learn how to stop the bleed. www.bleedingcontrol.org
Transcending Tragic Trajectories: A Post-Disaster Resilience Check List - Poloczek (Berlin, Germany): Be Prepared. Prepare for the unexpected. Think the unbelievable. 1) Always prepare for the NEXT MCI. 2) Defuse and debrief responders. 3) Know signs and symptoms of stress. In the first days do short psychoeducation. Seek professional help when indicated. Care about the commanders on scene. They are making hard decisions for all of those involved. There will be questioning in the days that follow. The what-ifs you come up with afterward tells you that no scene is ever safe. 4) Prevent rumors. Talk about what happened. 5) Take part in memorial ceremonies. The public wants to see EMS there. 6) Prepare to communicate with the press and the politicians. 7) Inform your colleagues and other professionals. 8) Prepare for the question - do you need more money? Have your shopping list in your office for needs. 9) What's next? 10) Be aware of the anniversary of the event. Recognize it. (my note: Great short lecture.)
Patient Flows for Pinocchio Shows During Disaster Woes: Ensuring Truth-Saying in MCIs with a New triage Approach - Aseda (NYC): Under old process, EMS command had to hospital shop to see how many patients each facility would accept. They now advise the facilities how many patients they can expect. Hospitals closest to the incident and closest trauma centers are notified. If catastrophic event they are notified that they will be receiving an overwhelming number of patients. The numbers each get are based upon the historical daily census of that ER. Made a quick reference card. The plan has been tested by reality many times.
When the EMS Response Interval is 00:00:00 - How the Dynamics change When You Witness the MCI - Elder (New Orleans): Discussed car running through crowd at Mardi Gras. Witnessed by the speaker. Media was already on scene also. Time to respond and mobilize becomes very real. Mental preparedness during response to the scene is critical. Waiting for other resources feels like forever. Time during response helps make you ready. Give bystanders jobs to do. Communications and interoperability matter. If someone asks to help give them a job. Isolate specific scene radio talk groups.
Who Rides... the Magic Bus? MCI Transport in the City by the Bay - Yeh (San Francisco) - Two permitted as ambulances busses are utilized. Busses can take seated or bed confined patients and can be used for firefighter rehab. Activation trigger is used. If there is more than four ambulances are requested, the bus responds. Operators are credentialed. It takes time to deploy. Usually staged.
Protective, Selective and Corrective Tactics: Medical Preparations for Designated National Security Events - Margolis (US Secret Service): What is a NSSE? National Special Event Security Event. These are events that depend on location, who is attending, recurrence and other factors. Dignitary attendance, size and importance of the event are critical factors. A Papal visit is an example of a NSSE as is a Presidential Inauguration. Steering Committees are used. Resources are identified. Plans and protocols are developed. Training occurs and after action reviews are conducted. Challenges: Credentialing of providers takes a lot of time. Access to site is limited. Protective operations take precedent. Ingress and Egress is hampered. Information communication is hard to distributive. Air medical is hampered due to temporary airspace restrictions. Medical support teams are developed to give force protection medical support. US Secret Service medical crews are already trained and credentialed. Communication during the event must be planned with all partners and hospitals. This is a mass gathering within a mass gathering.
Reliance on a Catastrophic Alliance: Integrating EMS, OEM and Healthcare Systems Before Disaster Strikes - Hunt (US DHHS ASPR): Why are EMS systems not part of healthcare coalitions? EMS should be. EMS role is assumed. To be a true healthcare coalition four core members must be present: hospitals, EMS, public health and emergency management. EMS participation is only at 27%. The other three are at above 55% participation with hospitals at 85%. EMS is often not recognized as essential.
Combative Behaviors: Translocating Military Medicine Research Into Civilian Lifesaving - Holcomb (US Army retired): Move from combative to collaborative. We have been translating military medicine to civilian use since World War I. Bleeding to death should never occur in the United States. What is the only silver lining of war? Increased medical knowledge. Tourniquets are the greatest example in recent history. The sooner a tourniquet is applied, the better the outcome. TCCC and Stop the Bleed courses are critical. Transfusion is critical. Crystalloid fluid is useless in resuscitation of trauma. Blood is the answer. ResQFoam coming, study happening this year. More research funding needed. Middle ear infections get more funding for study than trauma. Military medicine leads innovation.
Special Salutes: New record attendance 991 in attendance at the Eagles EMS State of the Sciences Conference today. 30 EMS Fellows present. Congresswoman from the 30th Congressional District welcomes all attendees. Anderson National Award given to Richard C. Hunt, MD for many contributions including Stop the Bleed. The Pepe National Award presented to John B. Holcomb, MD for contributions to trauma care.
A Very Presidential Address - 34 Years to the Day After Hilton Head: A Report from the NAEMSP - Myers (NAEMSP): NAEMSP now has over 1500 members. Over a third are not physicians (medics, etc...). EMS Physicians are now the largest subspecialty in the house of medicine. There is now an NAEMSP political action committee which has raised $60,000. NAEMSP helped create the DEA bill. Covering the award winning abstracts. 1) Timing of advanced airway (any airway) shows that earlier is better. ROSC decreases the farther out the airway is controlled. 2) No substantial delay in IO if user is wearing full PPE (hazmat). 3) If you do not adjust the age you have a 10% over triage rate in kids. Indeed children ARE little adults. 4) Training in death notification helps comfort with the process. 5) If you are CIT certified you are more likely to use de-escalation techniques but less likely to make a safe scene exit. In other words... get out. 6) EMS errors are common in pediatrics. (my note: Is Handtevy the solution? I believe it is.). 7) If you have an EMS certification you are 1.4 times more likely to commit suicide than the normal population. We have to look after each other.
Soothsayers for 911 Players: A Report from the EMS Agenda 2050 Team - Krohmer (NHTSA): A lot has happened in EMS since the original 1996 document. Where do we want EMS to be? Currently drafting the 2050 document. Reimbursement must be addressed in EMS. A strawman document has been published online and they invite comment. Final document will be out by early next year.
When the Lights Go Out in Georgia (and elsewhere): The "emPOWER" Tool to Find the Electrically Dependent in a Disaster - Garrett (US DHHS ASPR): HHS emPOWER overview. https://empowermap.hhs.gov/ This can be added to local GIS data. This helps locate persons in homes who are medically electrically dependent such as ventilator dependent patients. Three tools emPOWER Map 2.0 (public access - aggregate numbers), Emergency Planning de-identified database (access by public health officials) and Response Outreach Individual Dataset (approved users through a process). Patients are identified by CMS reimbursement for electrically dependent devices.
The PSA Re: TXA: Is there Value-Added Benefit of Transexamic Acid for EMS? - Harrell (Albuquerque): Rural or Urban use? Only 23% of Eagle's Medical Directors are allowing use of TXA. CRASH -2 study was discussed. MATTERs study discussed (military). One study showed an increase in mortality with TXA. A 2017 study indicated it should be used in austere environments for hemorrhage. Latest meta-analysis shows rapid treatment increases survival. Delays increase mortality. Sooner is better. Administration should occur within 30 minutes of injury.
Getting There Faster: Police and Civilian transport of Blunt and Penetrating Trauma - Mechem (Philadelphia): Civilian and police transport of trauma victims is safe and effective.
A Cooler Way to stop the hemorrhage: Use of FFP by EMS - McVaney (Denver): Had to customize coolers to carry the FFP at FDA required temperatures. FFP made no difference in mortality in an urban EMS system. There may be a rural application.
DRT or DRC for PTCA? Re-Thinking Post-Traumatic Circulatory Arrest in Austin: Escott (Austin): What is the plan for your trauma patient? Call on scene? Run for the trauma center? The evidence is terrible for traumatic arrest outcomes. What if we could bring trauma resuscitation to the patient? Madrid, Spain did this. 6.6% survived neuro intact from trauma arrest. Time was super important. A short response time was crucial in this subset of patients. Patients in VF had a higher survival rate. Study required a BLS ambulance, an ALS ambulance and an EMS Supervisor with ultrasound on scene. Chest tubes were utilized. How do we translate this to practice? Chest tubes are better than needle thoracotomy. We need to credential for chest tube placement in EMS. It is called simple thoracotomy because it is simple. Must be dead less than 10 minutes for this to effect outcome. The era of hopelessness is over.
Oh What A Relief It Is! Using Ketamine for Pain Control - Bronsky (Colorado Springs) and Scheppke (West Palm Beach): What does Ketamine do? It is a dissociative. Implemented Ketamine for pain control. Ketamine has little effect on vitals. Studies showing that it does well for pain control but has some serious psychological effects. Ketamine dilution is the solution for Ketamine for pain control. 25mg IV in 50ml bag. Most believe that Ketamine is very effective regardless of its classification.
Benzos for Frenzos or On Scene Ketamine? Comparing Midazolam and Ketamine for Severe Agitation - O'Donnell (Indianapolis): Benzos are our old friends for treating agitated patients. Ketamine is the new cool kid on the block. But which kid is cooler. Head to head comparison. Found little significant difference. No difference in need for airway.
Severe Agitation is also a Medical Issue - McVaney (Denver): Advocate for Ketamine. Why do I care about this so much (agitation)? We must take care of our most vulnerable patients. Agitated patients are vulnerable. Ketamine helps protects our people too (police, fire and EMS) from injury and worsening scenes with physical restraint. Sedation vs. restraint: Safer to sedate.
Tracking the Track Marks: Integrating Police and EMS Efforts for Opioid Epidemic Surveillance – O’Donnell (Indianapolis): Police and EMS want the same thing in regards to the opioid epidemic. We need to work together. We know where the OD’s occur. They know where the busts happen. We need a harm reduction strategy. We need to get the EMS and IT people together. What are the two biggest risks for OD? Prolonged abstinence and/or new product being distributed. Do police seizures decrease overdose rates? Possibly answered next year.
Mind your P's and Q's: Subtle Cardiac Effects of the Drugs of Abuse - Colwell (San Francisco): Pill parties are common. Everyone brings pills and puts in a bowl and take at random. Creates an amazing puzzle in the back of the ambulance. What the heck did they take??? Some drugs including Imodium and bath salts cause Torsades. Massive ingestion of marijuana can cause widening QRS complexes similar to cocaine overdoses. Causes sodium channel blockade. Sodium Bicarb is the antidote of choice. Peaked T-waves with hyperkalemia can be seen with bath salts. Again, Sodium Bicarb is indicated. Synthetic marijuana cause dyspnea and extremity paralysis in some cases. They can develop tachyarrythmias. Some patients die. Some of these have Aconite as a component. These include K2. Be ready for cardiac implications.
Implications of the New Marijuana Legislation in the Golden State - Yeh (San Francisco): California is now the largest legal marijuana market in the nation. Edibles are a real problem due to strength dependent on amount eaten and effect is delayed. Nineteen youth in a high school became ill from edibles. Edibles are now being regulated to 10mg. Hyperemesis syndrome is common. Increased incidence with legalization.
How Marijuana Became a Serious Health Issue in Colorado - Bronsky (Colorado Springs): Highway deaths are rising with marijuana found in the system. Some deaths with both alcohol and marijuana. Issues are getting worse, not better. This is not benign by any means.
The Continued Evolving Role of EMS in Public Crisis Detection - Elder (New Orleans): All responders able to give Naloxone. Noting spikes in opioid overdoses based on Naloxone usage. Heat maps utilized to show spikes in use and geographic locations. Sent info to the health department. Public health emergency declared based on Naloxone usage. Integrated plan implemented to help get the users help.
Toxic Concerns: A Reality Check on Responses to the Carfentanil Crisis - Dyer (Boston): We need to have respect for Carfentanil, but it is not the boogeyman. It can be a respiratory hazard, far less likely topical. Gloves do protect from Carfentanil exposure. Water is the best decontaminating substance, NOT alcohol. Alcohol increases chance of absorption.
Update on the Philadelphia Opioid Crisis Task Force - Mechem (Philadelphia): City-wide crisis. Kensington is the biggest effected area. Centered on a shantytown along railroad tracks. Task force created a year ago. The shantytown was dismantled but they moved to under overpasses. Increased treatment access. Number of patients given Naloxone is still on the rise. What if they refuse transport? System runs out of ambulances frequently. They are working on an Alternative Response Units to respond to these calls and will be the handoff for those refusing to direct to addiction services.
Columbus Discovers a New World for the Opioid Crisis - Keseg (Columbus): We need to break the cycle. We are simply going to run out of Naloxone if we do not break this epidemic. The city opened a 55 bed facility to treat opioid addicts. Using Vivitrol. The facility has been open for a month and has seen 103 patients. 80% are agreeing to go to detox at the facility. If you build it they will come.
Approach to Addiction Stabilization Centers - Schepkke (West Palm Beach): Created a regional addiction center. Naloxone is not the answer. Getting them to treatment is the answer.
The Northern California Experience with Sobering Centers - Yeh (San Francisco): It is easy to have compassion fatigue on the subject of any addiction. Is a sobering center safe? The alcohol sobering center is ADA compliant. They sober there and there is referral to detox available. Social workers available. EMS triages to this center. Intoxicated with normal vital signs can be taken there. Decreases sobering in the ER. The sobering center has become a healthcare hub as it directs patients to needed care. These patients do not need ER care.
Wheeling Up a Sobering Unit in Los Angeles - Eckstein (Los Angeles): Alcohol is still a much bigger problem than drugs. A huge morale problem in EMS is that they transport the patient to the ED only to see them again the next day. This is a huge waste of resources and tax dollars with low impact. There has been pushback on allowing EMS to transport to sobering centers. LA is paramedic heavy on staffing. This unit checks glucose and is also staffed by a paramedic, a NP and a social worker. The unit transports to a 50 bed sobering center. Goal is to get them back on their feet and to give them resources to address alcoholism. All transported so far have been homeless. Very few repeat transports. Speaker is 100% confident in his medics to transport to the sobering center rather than to an ER. Patients prefer the sobering center over ER.
A Police-Based Transport Program for Behavioral Health Patients - Miramontes (San Antonio): Psych patients continue to clog up emergency rooms that are not suited for treating psych. Created a system so that law enforcement could transport psych patients directly to the free standing behavioral hospitals. The little known secret was that many law enforcement officers were already doing this. Formalized the process to allow for EMS clearance. Police makes the call to ER for clearance. If there is an OD, confusion or trauma they go to ER. The patient must be stable to go to the psych facility. Only a small number now go by EMS.
Managing the New Hepatitis A Epidemics - Perrse (Houston) and Dunne (Detroit): Incubation period of Hep A is 28 days. Patient is infectious from two weeks prior to showing symptoms. Hep A was on the decline until 2016. Emerging cases started in San Diego. Rapid spread due to poor sanitary conditions. It spread to multiple other cities. Now in at least four states including Kentucky. Detroit vaccinates for Hepatitis A in the EMS workforce. Public health docs are from an emergency medicine background in Detroit. Detroit FD EMS is now vaccinated the police and the community. Work with homeless healthcare outreach to make an impact. There is a national shortage of Hepatitis A.
Advanced Practice Providers for Alternate, Cost-effective Dispositions - Eckstein (Los Angeles): EMTs and Paramedics are good at what they do. Using NPs and PAs in the prehospital environment to drive low acuity transport destinations/dispositions. There are a lot of Super Users. When a map area turns red they are out of ambulances in that area. Resources cannot be held up in ER for low acuity patients awaiting report before hand off. EMS must have ability to provide other dispositions other than transport to an ER. Navigate super users to somewhere other than the 911 system. Why not use Community Paramedics? California law is difficult on this subject. Having an independent practitioners helps. The nurses lobby is against paramedics transporting to locations other than the ERs. The APP also does suturing, ultrasound and labs. They also write scripts. They also work with social workers. The APP clears walking wounded at MCIs as well. They also provide for routing of behavioral patients. Speeds care for Psych. Patient gets psych evaluation within 25 minutes of arrival at the psych facility instead of long wait at ER.
RADAR Rapid Assessment and Redirection in Memphis - Holley (Memphis): Medic and Physician team to self-deploy or by request. Used for Alpha level EMD calls or respond to request from other units for the RADAR car. Physician provides the exam. There is very little treatment and more redirection to appropriate care. Accessed over 800 patients in six months. 96% of calls were low acuity patients. 73% of these patients have Medicare, Medicaid or both. 12% have private insurance. 15% were uninsured. Only 38% did not have a primary care physician. In many cases they reconnect the patient to the PCP and RADAR sets up the appointment. Very effective at re-routing to appropriate care. Saved over $100,000 so far in additional ambulance deployment costs. 80% of users did not repeat call within one week. 90% of appointments made were kept.
A Social Medium for the Needy Providing Case Management - Yeh (San Francisco): Intensive Case Management. Shared goal of recovery. Indefinite period of time. Diverse settings. Must have fewer than 20 clients per team. It is not just about getting appointments, it is about improved outcomes. A simple connection is not sufficient. Housing is a huge issue. These patients need primary care. It must be a patient centered system. It has to have social support. There must be relentless advocacy for these patients. Redefine success. Keeping a daily caller out of the EMS system for a week is a success.
Why EMS, Criminal Justice, HUD and Hospitals Need to co-mingle Data - Cabanas (Raleigh): Social issues drive outcomes. Housing alone is huge. Define what a high user in EMS is. If you only look at frequency you are missing chronic use patients. Identify patients that show up in jail, EMS and medical system data bases. If in all three, they are in need of intervention. Goal is to break the cycle. Housing must be addressed first then other social factors.
How Information is Shaping Healthcare and EMS Systems - Augustine (Eagles Librarian): Prevention is the key to decreasing incidents. Fire prevention has been very successful. We should learn from that success. It is much easier to prevent an incident than to mitigate one. If you go in to an ER by ambulance you are 40% likely to be admitted. If EMS succeeds in your case you get to get old. That is success. If we prevent trauma you get to get old and get ill later. Trauma is decreasing and illness is increasing. Mental issues are increasing. We still must be prepared for anything. We must practice all hazards emergency preparedness. We are building more patients for later through prevention. Odd but true concept.
ELVO: Statewide Stroke System in Louisiana - Elder (New Orleans): Large Vessel Occlusion has been a common topic. Treatment is VERY beneficial compared to many other therapies. We must bypass facilities that are non-interventional if LVO is indicated. Several LVO triage tools available. There is a statewide call center for finding the appropriate facility for Trauma, STEMI and Stroke. Comprehensive facilities are always in larger population centers. Bypass built into the protocols. Availability based on geography is an issue.
Data Driven Improvements In Stroke Care - Antevy (GBEMDA): Who is the right hospital? PSC vs. CSC vs. TSC. We know ELVO works. NNT=2. This is a very rare finding. Nothing in medicine has a NNT of 2. JACO, DNV, HFAP or by state certified? State level certification tends to be the weakest certification. The more patients a CSC sees the better they are. Stroke registry participation is mandated in Florida. EMS and the Neuro Interventionist are the two most important pieces in success.
Should EMS Triage patients directly to the CT Scanner - Harrell (Albuquerque): We hammer on the time issue in stroke. EMS must be involved to the point of creating accepted norms. New guidelines from the AHA on ischemic stroke coming out this month (March 2016). Study shows that transport direct to the CT scanner did not change door to needle time for TPA.
Dispatchers and Stroke Triage - Miramontes (San Antonio): Implemented stroke screening by dispatchers. Dispatchers advise crews and remind them that the cot goes to the house as the first piece of equipment in suspected stroke. The stroke module is already in EMD ProQA, you just have to turn it on. Dispatchers prod crews to eliminate delays in these cases. Check blood glucose in stroke. Only use O2 if SPO2 is less than 95%. Goal is to get them on the stretcher and do not delay transport in stroke. Median scene times around 10 minutes are possible.
Evaluating the Components of Time Delays to Definitive Stroke Care - Pepe (Course Director): Biggest problem with stroke care is recognition of a stroke and calling EMS. The sooner they are recognized, the better the outcome.
Communications from the Cutting Edge - Augustine (Eagle's Librarian): Eagles focuses on how to improve patient care and how we can make lives for our EMS personnel better. Always ask others what they are doing to resolve problems. Use short questions and only accept short answers. No discourse. Send supportive documents rather than discourse. Current average wake up dose for Naloxone is southwest Ohio is 6mg now. About 20% of the Eagles doctors have police department roles as well. Medical Director presence must be written into the agenda for the future. Fluid warmers making a comeback. Digital thermometers... no good answer for EMS on reliable thermometers. Many AEDs nationwide are ending their life cycles, replacing costs could be a crisis. Video laryngoscopy is up to about 40% saturation. Most are not using the recording capability. Drug shortages are a huge issue. Most agencies now limiting Epi to a total of 3 to 5mg. TXA saturation up to about 20%. Most systems using Ketamine. This week 104 different emergency medications are not available. 50 different IV fluids are not available. This started in 2011. Be ready for just in time training on replacement drugs and fluids. Diversion is being seen less. Drowning protocols are very inconsistent across the nation. Stroke scales are still all over the place. Paramedic initiated refusals now allowed in 25% of agencies. TOR averages around 20 to 30 minutes but should not be in the back of the ambulance. Increased use of Twiage and Pulsara. Trauma is on the decrease (15% of calls in some places). Active shooter programs are becoming common and are needed. Sharing best practices is essential.
How Often Are Protocols Modified? - Goodloe (Tulsa-OKC): How often do we massively change protocols? Not just tweaks but big changes. These are your clinical standards. How often do you upgrade/change? Most agencies change 1 to 12 protocols every three years. Others change quarterly. In large agencies it takes 10 weeks to train a change. Most change protocols annually. You must update at least annually. Change is inevitable but growth is optional.
Why Do Patients with Non-Shockable Rhythms Survive? - Jui (Portland): PEA Agonal is different from PEA Bradycardia. PEA Bradycardia is much more survivable than agonal PEA. PEA classification in outcome data is therefore confusing. What are factors in good PEA outcomes? What is neuro status of PEA survivors? Many are CPC1 or CPC2. Non-cardiac causes of PEA have a much better survival rate than cardiac. What does the literature say? Data suggests that again, non-cardiac arrest causes have better survival rates. Appears there may be better ROSC with Epi (no final outcome discussed on that study). PEA that goes to VF has a three to four times higher chance of survival. The earlier that Epi is given the higher the chance of survival. Same thing in Peds.
ECMO/ECLS for Persistent VFib - Keseg (Columbus): Keseg: Good things take time to implement. Mechanical CPR is essential if you are going to get the patient to ECMO. Simulated drills used before going live. Witnessed arrest, bystander CPR and mechanical CPR is essential. First patient was discharged with CPC1. They have performed seven in six months with a 67% survival rate. Bystander CPR has now been removed from criteria, just persistent VF as clinical indicator. Must find ways to impact survival. Needs more study.
ECLS Pathway in Utah - Youngquist (Salt Lake City): Having good outcomes with ECMO. Five challenges - 1) Inclusion exclusion criteria is difficult to develop. 2) Limiting scene time is not easy when most arrests need more scene time. Dispatch reminds crews that if it is a VF patient, time to ECMO is essential. 3) Resuscitation in the back of the moving ambulance is not easy. MCPR is needed if transporting in arrest. 4) Breakdowns in communication occur. Vernacular EMS language can be problematic. "Found down" can be interpreted as non-witnessed in error. 5) ED overcapacity is frequent. These patients challenge ER staffing.
Survival After ECMO is used to Transition to PCI - Frascone (St. Paul): Refractory VF considered to be the case after 3 shocks and 300mg of Amiodarone (determined early in the arrest). 911 to CCL is 58 minutes. Many had coronary artery disease on PCI. Most of them had no symptoms prior to arrest. Best predictor of survival were ETCO2 over 10, gasping respirations and any episode of ROSC during resuscitations. ECMO and then PCI can be a paradigm shift in VF arrest management.
ECLS Tours to the Louvre and Other Parisian Sites - Lamhaut (Paris): There is a golden hour for ECPR/ECMO. 60 minutes. There are vertical and horizontal limits to load and go egress to get to ECMO. A prehospital ECMO strategy has saved time in Paris. It has been performed in public a lot in Paris. They use helicopters to reach patients outside of Paris. They are also showing survivors at CPC1.
Should Helicopters Be used for Cardiac Arrest? - Frascone (St. Paul): In flight OHCA occurs. Lucas must be applied to patient before leaving scene. No difference in survival. Probably out of compliance with FAA regulations. It may be compromising crew safety. Clear air turbulence is a problem. Manual CPR probably not an option due to safety.
TOR: What is a Reasonable Duration for cardiac Arrest Efforts? Youngquist (Salt Lake City): Twenty minutes is common as a minimum duration. Literature is mostly observational. TOR with asystole, non-witnessed, non-bystander CPR and no ROSC, 10-15 minutes may be acceptable. Others should be at least 20 minutes. 40 minutes adds a few survivors. What is the max dose of Epi? Non-shockable, 30 is reasonable, shockable at least 45 (transport to PCI?).
Mandating ROSC to Cath Lab - Perrse (Houston): AHA states that post-arrest patients with STEMI should go directly to cath lab. If unconscious they should still go to cath lab even without STEMI evidence. It is also reasonable whether they are comatose or awake. These are 2015 recommendations! One third of these patients had a lesion without evidence of STEMI. Survival to discharge is improved. Cardiologists are reluctant to do this as these are high risk patients and could affect quality metrics (my note: metrics need to exclude this!). Limit things that would exclude the patient from cath lab. More is better. A resolution may be coming out on the effect of the quality metrics. If they did not go to cath lab... why?
Economics of OHCA - Levy (Anchorage): Is OHCA costly? CA is leading cause of death in the US? 350,000 are OHCA. 56 years of age is the average resuscitation. What is the economic impact? Direct and indirect costs. Rough cost of an OHCA response is about $960. This looks at actual and long term equipment costs. It costs $17 to each tax payer for those who survive cardiac arrest. The ones who die cost tax payers more as the cost if all are included is $38 per tax payer. Cost to families of failed arrest is in the trillions. A 1% improvement in OHCA management would save taxpayers 9 Billion dollars.
Instituting Statewide CARES - Keseg (Columbus): CARES helps us improve OHCA outcomes by showing us our outcomes. 1.6 million Population covered by CARES. Uses Utstein arrest measurement model. This gives outcome data including neuro status at discharge. The data shows us where to focus our improvement efforts. (my note: AMR Evansville is a CARES participant). Two years of conference calls before a statewide upload occurred in Ohio. Saved each site many dollars. A state coordinator is required to upload at the state level.
Who CARES? 8,000 in the Windy City Do! - Weber (Chicago): CARES drove protocol changes and improvement to better survival rates. Used sim labs. Added dispatch CPR. Using crew feedback. Training and feedback. No longer transporting arrests with lights and siren. Feedback to EMS and fire is essential.
A FEMA-Driven Community Safety Grant - Dunne (Detroit): In 2004 Detroit was at less than 1% survival rate in OHCA. Used strategic partnering to improve the numbers. Automated CARES uploads. Used FEMA Heart Rescue Grants. Survival in 2016 up to 6.9%. Targeted CPR training to needed areas by census tracks. Also used Friends and Families CPR kits. Have an increase in bystander CPR to 32%. Have distributed 800 F&F CPR kits.
De-MSing EMS: Why I'd Get Rid of Morphine Sulphate - Colwell (San Francisco): Prehospital Pain Management. Morphine has been used for CHF and chest pain as well as traumatic pain. Morphine has highly variable effects based on the presence of the enzyme that is used in metabolism of the drug. Morphine causes nausea. Morphine causes histamine release. MS has a negative impact on anti-platelet therapies. MS causes increased infarct size and an increase in mortality. Fentanyl is fast acting (30 seconds). Fentanyl causes less nausea. Switch to fentanyl.
Changing STEMI Management - Goodloe (Tulsa and OKC): What is wrong with MONA? A lot. Oxygen. New NEJM study. If not hypoxic, MI mortality is not impacted. No oxygen unless hypoxic. Worse outcomes if oxygen is used when not hypoxic. Nitro? Nitro is good but concentrate on getting to PCI. Aspirin very beneficial. Use PIT crew concept for mobilizing STEMI patients should be used. LISA: L -Let everyone know. I - Interventional destination. S - Scene coordination. A - Aspirin Early.
Deoxygenating During Intubation - Levy (Anchorage): Deoxygenating during intubation is more common than usually thought. There is a drop in oxygenation between induction and intubation. If you desaturate it increases mortality. If SPO2 is low at start of procedure the patient is predisposed to more rapid desaturation during attempt. ETCO2 monitoring must be present to rapidly confirm placement.
Clinical Decision Making for RSI - Conterato (Minneapolis): MAAM (Medically Assisted Airway Management) is there to help control the airway by placement of an adjunct. Are BLS skills working? If you move to MAAM: Can the airway be maintained? Failure of oxygenation or an airway? Is there a need to control the airway? Just because the hospital is going to intubate is not a reason to do it in the field (my note: amen). BLS airway interventions are acceptable. Have everything ready you need before MAAM. SPO2 and ETCO2 essential. Have suction ready. Apply nasal cannula to use No DESAT. Do not over ventilate. Over ventilation kills.
QI Strategies for High performance Airway Strategies - Sayre (Seattle): Using audio recordings on all intubation attempts. Showed example of Codestat summary with audio overlay. Use OP and NP airways. Assure that everyone can make a two handed mask seal. Train the signs of poor ventilation. ETCO2 is essential even with simple BVM ventilation without a controlled airway. Review all resuscitations.
Asthma in Extremis: Ketamine in Peri-Arrest/Arrested Pediatrics - Ellis (St. John, New Zealand): Does Ketamine have a role in life threatening Asthma? It has consistent bronchodilator properties. Reduction in need for advanced airway. System uses Ketamine extensively for other issues. There was ad hoc use for asthma without a protocol. When Ketamine was used, clinical improvement seen and intubation was aborted. Small group in cardiac arrest from asthma, five that received Ketamine. Four had good outcome. Non-Ketamine group, 7 out of 8 died. Interesting. Needs more study.
The Safety of High-Dose Nitro - Gilmore (St. Louis): Multiple papers show that Nitro is safe. Tried two tablets on each dose in CHF. No issues with blood pressure. Bioavailability of NTG is not good orally. No IV is needed for NTG first dose. Conterato takes over lecture: What about push doses of IV NTG? It takes 60 to 300 seconds to get CPAP to work. As soon as you take the mask off to give NTG you lose your CPAP effect instantly. Common IV dosing 800mcg-2000mcg for initial. 400-800mcg every 2 to 5 minutes. They are going to do 400mcg IV push every two minutes until systolic is under 140.
Push Doses of Epi: When Do They Work? - Jui (Portland): Push dose Epi easier than Norepinephrine on an IV pump. See EMCrit Podcast on Push Dose Epi as a pressor. Outcomes between Push Dose Epi and norepinephrine are virtually the same. Watch MAP, not systolic/diastolic. Works in most cases of medical hypotension. Works in 3 to 5 minutes. Improves ETCO2. Safe. Effective.
Strategies to Ensure Neuro Intact Survival in Children - Pepe (Course Director): Intubation and IV drugs are commonly associated with poor outcomes in kids. POHCA: Grim survival chances, intimidating to rescuers. Scoop and run used because kids "are portable." Conventional wisdom says do not intubate, Also says respiratory is primary cause. The reason outcomes are dismal could be that we do not stay and work the arrest like we do adults. System switch to working the POHCA on scene with focus on care delivery, controlled ventilations. Went further to prepare drugs prior to arrival to decrease time to meds. Results? Time to first Epi improved greatly. ROSC and survival to discharge dramatically improved even in the neuro intact group. Stay and work the Peds arrest (My note: Peter Antevy preaches this also... all the more reason to use the HANDTEVY system and abandon/de-emphasize PALS).
System 1 Thinking for Pediatric Dosing - Miramontes (San Antonio) McVaney (Denver): Miramontes: Ditched PALS. Incorporated Handtevy. Uses Handtevy App as well. Retrained workforce. Medics love the program. No math. "Broselow Tape is stupid." Work Peds medical arrests on scene. Error rate dropped on Peds dosing. McVaney: With Handtevy, more meds given to peds with less deviations. Error rate is less than 1%. Handtevy means more kids’ lives saved!
Taking Another Look at pediatric Intubation - Frascone (St. Paul): Difficult to control airway pressures in kids. Looked at DL and VL first pass success rates. No significant difference in success between the two. Much more likely to try with VL though. VL truly works best in the difficult airway. This is where they shine. The peds study that said ET was bad is now 15 years old. Is it time to repeat the LA trial with VL?
IGel Placement and Video Laryngoscopy - Jui (Portland): High success rate with IGel. High success rate with IGel in kids as well. VL for ET intubation could be useful to both experienced providers for difficult intubations and inexperienced for routine use? Thinks providers need VL and DL consistent training and skill. IGel, VL and DL all needed. Train every two months.
EMS Education for Future Non-EMS Medical Professionals - Yancey (Atlanta): EMS interfaces with medical professionals beyond the ER. We interface with surgeons, cardiologists, respiratory therapists, etc. How do we educate other medical professionals on what EMS is and does? Start with a broad paint brush of what EMS is and then what they should learn during a ride along experience. The practice of EMS is in the public eye. It is recorded in many cases. Teach them the organization of the service (guidance of operations, guidance of medical care, medical direction). Discuss specialty medical destinations and specialty teams. Explain how EMS is a practice of medicine and all of its components.
A More Efficient Credentialing Process - Cabanas (Raleigh): How long does it clear a new provider in your system? NAEMSP has a position statement on credentialing EMS Providers. Training does not equal knowledge. Experience does not equal competency. It also teaches things that are unique to the system. Wake County in the past has had a five week didactic program, 4 to six month supervised clinicals and physician final evaluation and oral interview. New system now allows it to be done in 160 days now by moving more of the credentialing to the field.
Adjusting the Target with Great Dispatch - Moore (London): Time based targets are used in response to cardiac arrest. This has caused a focus on stopping the clock rather than care. 8 minutes 75%. Lesser patients have much longer response times. New targets are designed around getting the right resource the first time every time. Four categories used. Stratified response time requirements. This allows for better manpower utilization for on scene care. Demand and resources are now equally matched. Reintroducing of target times for call answering.
Employee health Issues During Major Disasters - Kidd (Acadian): During deployment during Hurricane Harvey there were quite a few issues: water issues, GI Illness, toxic chemicals. Dehydration was an issue. Must plan for potable water sources. Mainly GI illness amongst providers. Problems keeping responders hydrated. Improper refrigeration and food storage. Not enough food for employees. Food left out and being eaten later. Tetanus needed if open wounds in contact with flood waters. Live wires in salt water caused electrical injuries. A lot of dermatitis. Conjunctivitis common. Biggest request was for socks. Foot maceration was seen. Mental health support was needed. Many employees lost homes and still worked. Acadian had work teams to help employees with homes. Food, water, clothing and hygiene, shelter and emotional support are all needed.
What You Need To Know Before You Go Out The Door - Holley (Memphis): Call in people to help your folks get on the road for deployment, Have credentials together ahead of time. Screen for health issues (Hypertension is the most common problem). Harder to take care of responders in an austere environment. BP Checks before they go. A responder down just makes everything worse on already taxed resources. Responders with illnesses can harm team function. Be very detailed on what you will allow. Be prepared to handle animals. Monitor responders after return home for issues. Watch for PTSD.
The STARS Program: Providing Special Needs for Special Needs - Gilmore and Casey (St. Louis): Special Needs Tracking and Awareness Response System. Tracks children with special needs. Hospital based program. Each child has a unique identifier which assures that responding crews can access the plan of care for that patient before arrival. This gives crews much needed information. One Kid Counts is the motto. Identify, Educate and prepare. Many different kids qualify with a great number of illnesses. Information on each child includes meds, allergies and special instructions. Even covers some kids in Illinois. STARS is not just a simple registry. Requires a business agreement and training. Dispatch has to be involved and internet access in the field.
A Community Paramedic Program To Facilitate Appropriate Care - Pepe (Course Director): Hospice can be an important disposition for some patients. Community Paramedics can be used for this function. This decreased 911 utilization by sending a community paramedic for hospice care and acute management. Over a 90% reduction in 911 responses.
Transitioning Care - Cabanas (Raleigh): Uses Advanced Practice Paramedics to move patients to transitional care. These APPs also respond to high acuity calls. Partnered with a care network to help CHF patients. This became a payment source for community paramedicine. APPs make home visits, some with a care manager. They do med reconciliation, general assessment and look for red flags. They also assess barriers to care. Case studies shown on reduction in healthcare expenses. Dramatic. Use of APPs creates a transition to home. Patients are highly satisfied.
Stopping the Revolving Door of Narcotic Abuse - Schepkke (West Palm Beach): We are essentially treating the next epidemic of HIV and Hep C with Naloxone. That is where the narcotic abuse is heading. Naloxone will not fix that. Using Suboxone as a bridge to recovery. Paramedic goes to patient and gives Suboxone. 66% more effective than abstinence programs when coupled with 30 days counseling. 911 utilization dropped as well.
Hexed texts and Discarding the Carding - Aseda (NYC): 1) Alerting 911 through your I-phone. Most texts to 911 are law enforcement situations. Some carriers do not allow text to 911. Not at all dispatch centers yet. Most EMS callers are asked to make a voice call if possible. Text volume could become problematic. Texting in other languages can be problematic also. 2) Discarded card based call triaging. Moved to computer based system. Old card system did not work as designed. Hard time finding some conditions. Better compliance on script with computer based triage of calls. Accuracy of call types more correct.
Revisiting Pre-Arrival Instructions for Pediatric CPR - Antevy (GBEMDA): Grade the lay person, grade the dispatcher in T-CPR and grade EMS performance on every ped cardiac arrest. Then you know where your issues are.
A reality Check on Scene and Transport Time Intervals - Goodloe (Tulsa and OKC): Can we? Should we? They are sometimes different answers. Assume nothing, question everything, Measure it or you do not have a clue on the time frames for your system. Most EMS crews have 30-40 minutes of active patient care time. Quit thinking about just the transport time when designing what we do.
EMS Response without an Ark: The Nuances of Widespread Hurricane Flooding Dramas - Perrse (Houston): East Houston Regional Medical Center was closed before Harvey hit and has not yet reopened. 58 inches of rain fell in Houston. Plans are nothing but planning is everything. Disasters don't read your plans. Are the tools in your plan realistic? Medical need grows with shelters. Goal was to protect the already overwhelmed hospital system while delivering quality care. Many left home without medications. Dialysis: No power... no transportation... means no dialysis. K2 problem moved into the shelter and had small MCIs with the K2.
Dealing with a Flood and a snowstorm in the French Capitol - Carli (Paris): In 1910 there was a major flood. It has left the city in fear since. They have plans in place. Usually only 12-15 hours warning of flooding on the Seine. Some hospitals had to close do to the flood plain. They must be evacuated. EMS must maintain daily activity. Flood occurred again in January of 2018. Pumping in basement kept hospital open. Then the snowstorm hit. "48 hours of nightmare!" 15cm of snow along with the flood. Freeways closed. Healthcare personnel not able to get to work. Prepare for the worst and prepare to be surprised.
Birth by Bearcat: A New Kind of Tactical Response - Antevy (GBEMDA) - Hurricane Irma hit. When winds hit 70mph
Coordinating Hurricane Care Across South Florida and Texas - Augustine (Eagles Librarian): What kills people in big events is water, wind and walking (into electricity). Electricity and fuel are essential to recovery. If sewage pumps run out of electricity the sewage comes out of the ground in south Florida. That creates a whole new health problem. Extended care facilities must be helped. Evacuation centers require medical support. Mold becomes an issue as well. Bad food is another health issue.
The Great Debate - When Transport for Life Threatening Care is Refused Should EMS Respect Patient Autonomy or Do What They Think is Right? Moderated by Gallagher (Wichita):
When Eagles were polled they said that Risk Management issues kept them up at night... so...
Fowler (Dallas): Do What the patient wants: They call us for help. How can they tell if they need help? If you can communicate do you have capacity? Does the K2 addict have capacity to refuse? Referred to an AMA check list. Why can't we do capacity? Is there compassion fatigue as a component? Is legal assistance available to answer questions? Just do the refusal.
Richmond (Ft. Worth): Follow Your Thinking: Lift assist calls. Placed back in chair. Found later in arrest. What was the assessment truly? 15% of your calls left on scene are at risk of dying. Some need to be transported based on capacity. Others need specific routing to needed care. Some don't need us. Capacity is important. Patients do not understand risks of refusal. It has to be more informative than "you might die." It must be informed consent to refuse. You must have medical history and assessment on all contacts. No easy answers. Know your regulations. There is a constitutional right to refuse treatment. Follow guidelines and get people to care when it is needed and appropriate within guidelines. Do not be involved in paramedic initiated last rites by just taking the refusal. Involve med control and law enforcement when needed.
Competency is determined by a judge. Capacity is a bit more obvious with proper questioning and informed decision making. If EMS has to go back to the scene there will be questions.
Who won? You decide.
