NAEMSP 2019 - The EBM Road to Austin

So here it is again... my annual diatribe of rapid fire note taking from the annual meeting of the National Association of Emergency Medical Services Physicians. Please remember a few things: 1) that this is a simple collection of my social media posts from the audience at the meeting, and 2) because of the rapid nature and attempting to cram in as much information as possible, there may be a few grammatical or spelling errors (which I will attempt to check before posting). I am also going to add a few more pictures from the presentations as well. I have tried to insert active website links for reference wherever possible to assist you in gaining more information.

So for those of you unable to attend here are the notes, one session per paragraph. I did not make it to every session as somewhere break out presentations and I also had some EMS networking that can only be done with those present at this meeting. I hope that this can help lead the reader to a view of the science being undertaken today.

Enjoy!

NAEMSP - Brent Myers - NAEMSP is 35 years old as an

organization. 1,771 members of the organization. Re-investing in the organization. New website launched which is far improved. Spinal Motion Restriction paper is the most read medical paper in 2018 and all time. More unified approaches like this with a position are needed. EMS must be involved in politics. NAEMSP now has a PAC. It has raised $61,000 so far in one year. Drug shortages continue. Dedicated session in Washington next week on the generic injectable medication shortage in EMS. Number of state chapters increasing. Active online survey utilized to help deliver information to the government.

NAEMSP - Tom Ridge - First Secretary of the U. S.

Department of Homeland Security, past governor of Pennsylvania - EMS has to be ready to move and be invincible at a moment’s notice. He relayed his own personal experience as a patient with Austin-Travis County EMS and his own cardiac arrest. He states he is filled with gratitude. EMS operates 24-7 to help total strangers. Says: "God bless you and your families because when you put on the public safety uniform, your family does also and they live and die along with you." He spoke of the irony of speaking at the hotel where he incurred his cardiac arrest. EMS works daily to get the job DONE, not to play politics in the moment. "I keep my head in public policy." Bipartisan cooperation is needed to get things DONE. Specific recommendations have been made regarding protection from biological and radiological threats. "The audience knows more about EMS than I do." Thinking of his own path and how it has intersected with EMS. The first thought is always regarding our prehospital care. Referenced our roots in the Vietnam conflict. He referenced tornado responses and the response of EMS and the poor response of FEMA at that time before it became robust. EMS got high marks in those incidents where FEMA did not. He remembers participating with EMS in Pennsylvania on statewide disaster exercises and the quality of service. He discusses landing at the smoldering hole of the Pennsylvania crash site on September 11, 2001 and even though no one was alive to save, he was astounded by the level of EMS response that was ready to help at the scene had they been needed. He recalls the Virginia Tech shooting and the panel reviewing it. Again, the response and compassion of EMS was obvious. He talked about the remarkable EMS response at the Boston Marathon bombing. Everyone transported to the hospital survived. The after action report showed the direct connection between training and success in the response to that incident. On scene communication has always been in issue (interoperability). He feels that as a patient he is Exhibit A for the success and professionalism of EMS. "You treat strangers as loved ones. My crew did not give up on me. That is the bottom line. They never gave up." He did not feel good that day. He felt different. He did not feel the same. He looked up his symptoms on his phone. Decided he might be having a heart attack. Barely made it to the phone. He called for help and passed out. He had a widow maker MI. "I would not be here today without you." 450,000 die in car accidents each year. Who gets there first? 850,000 cardiac incidents each year. Who runs those scenes? Opioid crisis. Who runs the scene? Disasters. Who does the triage? Identify the threat and prevent it. If you cannot prevent it, are you prepared to manage it? Terrorism is the only topic that is covered in a President's geopolitical agenda EVERY DAY. When people think of first responders they often forget EMS. You are a broad public safety component crossing from response to healthcare. EMS is worthy of notice. Special interest is not a bad word. The only people without special interest are deceased. EMS must go at getting recognition and support with passion. Nothing is more powerful than a group of people in a profession sitting down with government leaders. It is about you addressing the needs of total strangers. He again notes that radio communication is still an issue. "It MUST be fixed. Maybe First Net is the answer. This is long overdue in the 21st century." EMS has a role to play and must be at the table. Teddy Roosevelt once observed that one of the great prizes in life is hard work worth doing. You should feel good about working in that arena. Elevate your visibility. EMS is not appreciated to the extent it should be. You do the hard work well. "If you ever need Exhibit A, the guy from Pennsylvania is right here." Often times in hard way with your family enduring that harm with you." We are grateful for that. "My admiration, respect and thanks to all of you." Advice: "Be persistent as hell in getting to the table." He added, "They never gave up. Never give up. Never, ever give up."

NAEMSP - "We manufacture luck in EMS through education, training and quality improvement in system performance." Medical Director - Austin-Travis County EMS.

NAEMSP - Dr. Scott Bourn and Peter Taillac, MD - The New National Scope of Practice Model - How do the various components of the model interact? This then flows into the scope of practice to flow downward to the states to develop

their models. The scope defines practice levels in EMS. It defines the floor or the base of clinical practice in EMS. States are responsible for their own scopes so this is only a model. It provides guidance. The last model was created in 2007. 2007 had EMR, EMT, Advanced EMT and Paramedic as the practice levels. One objective was to improve consistency in practice levels nationally while honoring the unique needs of the individual states. Another was incorporating evidence (EBM) into practice. This was done with broad input. This defines the minimum practice level for a new provider. IT IS NOT TO DEFINE OR LIMIT THE UPPER FLOOR OF SCOPE OF PRACTICE. This defines novice level. Literature was reviewed before the first meeting of the group. There is a lot of explanation as to why things were adopted or discarded. Questions asked: Is there evidence that doing a skill is beneficial to patients/public health? What is the evidence that something can be used safely and effectively? Does the benefit justify the cost at each level? Credential program by the medical director is a must! Highlights: 1) All levels must be able to administer narcotic antagonists. 2) Use of wound packing and tourniquets at all levels. Deletions: MAST, Spinal Immobilization as a term, Demand Valve, Carotid Massage, automated transport vents at the EMT level, modified jaw thrust in trauma and assisting patients with their own medications. (My note: GOOD!!). C-collars added to EMR. Basic splinting added to EMR (although some states already allow this). EMR is not to be used as a transport provider (curricula and skill set is not designed for this). EMT addition of OTC pain medication, blood glucose monitoring, CPAP, pulse oximetry and telemetric devices that collect clinical data (not monitoring but collecting and sending data for interpretation). ASSISTING with skills of higher level personnel also added to the EMT model with approval of the medical director and higher level supervision. AEMT additions: end-tidal CO2 measurement, additional IV medications (epinephrine, ondansetron and others). Parenteral administration of pain medication for AEMT. Paramedic additions: high-flow nasal cannula and expanded scope of OTC medications. Many of these changes were already doing these things. So the scope is now caught up "for now." https://www.ems.gov/education/EMSScope.pdf

NAEMSP - Oral Presentations - 1) Working Arrests on Scene - Stay on scene to work arrests based on CARES data. Better survival directly associated with longer scene times. Could be an issue that management of ROSC may be more complicated than the arrest itself which manifests in a longer scene time. Only looked at agencies that had over 80 arrests in the given time frame. Study did not adjust for crew configuration. 2) Crashing Patient Care Bundle - Bundled care for critical medical (non-trauma) patients may have better outcomes with a bundle of care. Looked at post-EMS contact cardiac arrest patients. Delayed interventions may have led to arrest. Movement of the patient to the unit prior to care was also a factor (my note: more support for in the house delivery care). Load and go is not good for respiratory and cardiac. Introduced crashing patient care bundle. Emphasizes assessment with blood pressure, ECG, SPO2 and ETCO2 and vascular access early. Early airway control with oxygen, CPAP when indicated, and medications emphasized prior to movement of the patient. Case based scenarios used for training. CQI analysis used to reinforce. Looked at cases where arrest occurred greater than five minutes after paramedic arrival. Implementation of bundle decreased post-EMS contact cardiac arrest by about 6% over three years. Care bundles may have significant impact on outcomes. Root cause analysis was used to create the bundles. 3) Ketamine for Excited Delirium - Excited Delirium has an 8.3% mortality rate. Many cases are reported in media of death during ED. The problem exists everywhere. Used 5mg/kg dose for ED severe cases. Highly varied incidence in literature of need for intubation and side effects. 91,000 annual patient contacts over 3.5 years. 244 administrations of Ketamine. 228 patients met study inclusion. 26% were intubated. Median age was 30 and almost all were male. 11% had side effects. Over 60% went home from ER. Most were not intoxicated by alcohol. ER length of stay 11 hours. It was hard to determine what triggered the need for intubation. The need for intubation is not quantifiable. 4) Survival after IV vs. IO administration of antiarrythmics - Multi-location trial via the Resuscitation Outcomes Consortium - Most VF/VT patients may be shock refractory. IO may be faster and more successful at gaining vascular access but is it effective? Studies have been inconclusive with opposing conclusions. This study measured Amiodarone, Lidocaine and placebo between IV and IO. All adults in the study. Looked at survival to discharge and discharge with good neuro status. Amiodarone IV was best. Study showed neither Amiodarone nor Lidocaine was effective when given IO. Both Amiodarone and Lidocaine were beneficial to outcome when given IV, but not IO. 5) Simple Falls Not-transported - Wake County EMS study - Shared decision making between primary care and paramedics may safely reduce unneeded transports to the ER. Study and protocol places patient into injured, possibly injured, and obviously not injured. All patients were in some type of assisted living facility. Reduced transports by 60% with 2% having time-sensitive events with no significant long term effects. Examined repeat falls (within 1 year) and mortality on the non-transported patients. 953 patients, 359 had falls. 60% not transported. 36% of these died within one year. About half had a second fall within one year. Non-transport did not have involvement in the second fall or mortality rate. 6) Identifying Barriers to Prehospital Adverse Event Reporting - Near misses, precursor safety events and serious sentinel safety events should be reported. What are the barriers to reporting? Anonymous survey used to collect data. 897 providers invited (90% were paramedics), 547 responses. Mostly experienced paramedics in an urban setting. Barriers: too busy to report, paperwork, no feeling of need to report fear of repercussion and others. Some did not know how to report. Great concern for remaining anonymous. Fear of repercussion was very high as a barrier. Mainly fear of local government or medical director. Culture increases reporting and decreases number of adverse events. Quality improvement feedback on events helps decrease events. Ideal reporting system is easy to access, simple to use and anonymous. Must be paired with Just Culture and a culture of quality improvement. Remove fear of repercussion.

NAEMSP - Behavioral Health Crisis and EMS: This is Maddening - High levels of alcohol, overdose and suicide rates in New Mexico. They turn to 911 in time of crisis. 15-20% of calls are psych or substance abuse related. Send police = jail. Send EMS = ER. Neither may be the right

answer. The problems do not get addressed by the jail or the ER. Some get restrained and forced against their will and then have an ambulance bill and miss work the next day that complicates their problem. Bernalillo County implemented a mental health tax to bolster their mental health system. Statewide behavioral health hotline implemented. Callers can talk to a licensed counselor on the hotline. All are masters level mental health counselors. CIT teams formed. The CIT concept used here are high profile, acute responses (suicidal, hostage, etc.). Community engagement team formed. Engagement team can be activated by the hotline for sub-acute interventions. They have also implemented mobile crisis teams. They deploy and clear an EMS crew from scene and they perform on site behavioral evaluation. There are six mobile crisis teams deployed during the busiest hours of the day. Findings: Decreased hospitalization and arrest rates. Reduces burden on 911. Increased participation in treatment services. Speaker feels this is getting the patient to the right care and this is the right thing to do. Get them connected to the right help while still at home. 27% are suicidal, 19% are behavioral and 11% are welfare checks. Scene requests come from EMS or police. Dispositions: Arrested 9%, Hospital 20%, Cleared 68% and other 3%. Eligible calls can be recognized by 911 dispatch or by units on scene. The hotline can send as well. You must still ensure scene safety and work well and make good relationships with law enforcement to collaborate. Leads to positive interactions with the community. Periodic follow up after the initial crisis must occur. Team can set up appointments with resources. Law enforcement is getting extensive crisis intervention training. Providing hundreds of hours mental health and substance abuse training online. They use the ECHO CIT website for training. http://www.gocit.org/cit-knowledge-network.html Hurdles have been working across multiple agency and staffing. They are now working on a public inebriate intervention program and a sobering center. This center will be staffed by EMS. They are also developing a crisis treatment center as well.

NAEMSP - Mountain Medicine - Will Smith, MD, Jackson Hole, Wyoming - Medical Director for the National Park Service - www.wildernessdoc.com - Case study presented from March of 2017. Wilderness EMS Systems can include ski patrol, search and rescue teams, traditional front country EMS, military and other resources. Suggests the Wilderness EMS textbook for learning the differences including to those involving medical direction. Listened to 911 call where they got coordinates from a cell phone on Maverick Peak on a chest pain call with difficulty breathing. Back country incident command post utilized. Span of control is important in back country operations. Played radio traffic as CPR in progress was confirmed. CPR was provided based upon nothing more than people in the party knowing to push hard and fast. This was a witnessed arrest with early CPR so the typical wilderness medical perspective of time and distance was less of a TOR situation than generally perceived. AED was one of the few pieces of equipment taken in by the rescue team. Patient was in VF. You have to know how to run an arrest without an ECG on a screen. Shock was delivered then no shock advised. Mechanical CPR device was requested (needed to provide CPR during movement out of this geographic situation). Patient was resuscitated and stabilized. 12-lead showed a STEMI. Patient had awakened and was talking ASA and Amiodarone given. Held NTG (no reason was given in the lecture). One hour and 33 minute response time with 30 minutes on scene. Over three hours till balloon inflation in Cath lab but still had great outcome. Chain of survival very important. AED is important. Have a PIT Crew CPR concept and a ROSC checklist.

NAEMSP - School Shootings - K. Moses Muhayamaguru, MD - Arizona - Covered history of school shootings. Referred to the Bath Township Massacre (Note: I refer to this when talking about the history myself as we tend to use Columbine as the start when this is far from true). Covered the numbers

on several incidents. It keeps happening. Very difficult to confirm actual numbers of patients and deaths in available reports that are public. Risk factors: Social rejection and bullying are key risk factors. Consumption of violent media and access to weapons are another commonality. Most often the perpetrator is a male, bullied student at the school. The key targets are those that perform bullying, typically males in sports. There was one female shooter in 1979. This shooter has been documented as wondering remorsefully as to whether she started the modern trend. East coast has a higher number of school shooting events. No correlation to socioeconomic status. Odds of dying in school from a homicide is actually 1 in 2,000,000. Schools are still safer than most places. What is the role of EMS Medical Direction in this? ACTION CHANGES THINGS. School design and safety, policies, upbringing, training, advocacy. Work on the EMS response. Implement ICS. "We can pretend it is not a physician problem but it is." Psycho-social issues such as PTSD occur in the aftermath. Long term impact of reminders and vulnerability must be confronted.

NAEMSP - Pediatric Readiness in EMS Systems, A Joint Position Statement from AAP, NAEMSP, ACEP, ENA and NAEMT - Brian Moore, MD, University of New Mexico - This statement has been worked on for many years. Many of the co-authors are in the room. This is a board level document that has not yet been released so this is a progress report. Work began in 2014. It was a 17 page document and it was recommended to get down to 5 pages. Language needed to be revised to match that of the corresponding statement for emergency departments. 55 edits and revisions. The original 17 page document is now part of a technical report. What is the meat of the report? Providers need a PECC (Pediatric Emergency Care Coordinator). EMS Systems should: 1) Include pediatric considerations in planning, operations and oversight, 2) Collaborate with professionals that have experience with pediatric elements, 3) Integrate pediatric EBM, 4) Peds specific supplies and verify training and use, 5) pediatric competencies, 6) insure knowledge of what makes kids unique, 7) reduce errors in pediatrics, 8) introduce specific peds QI, 9) safe transport policies, 10) insure proper destinations for peds, 11) promote family centered care, 12) Allow families to be present during treatment and care, and 13) use reference guidelines. The final statement is out for board review and should be done by mid-February 2019. Making a position statement takes multiple champions of the cause that can build bridges, collaborate and be flexible. Technical report will now be 31 pages. Next comes publication. Children and families have unique needs that are magnified when the child's ailment is serious or life-threatening.

NAEMSP - Oral Presentations - 1) Double Sequential Defibrillation - 310 OH cardiac arrests, 239 standard defibs, 71 DS. Airway management was similar in both groups. DSD group received more Amiodarone. Survival 14% in DSD and 21% in standard defib group. No benefit too DSD in this study. DSD was allowed after 3rd standard defib. DSD may not be helpful in OHCA. One potential flaw in the study was that DSD required online medical control authorization in each case (time delay?). 2) Double Sequential Defibrillation (next study) - Some patients remain in refractory VF after standard defibrillation. This is another comparison. OHCA arrests retrospectively reviewed. This study was after 4th standard shock moving to DSD. What is so special about the 4th shock? Most survivors survive before or after the 3rd shock and rarely after the 10th shock. Demographics of both standard and DSD groups relatively the same. Epi use was higher in the standard defib group. Late DSD probably not beneficial. Unfortunately, no actual survival data was presented with this presentation. Needs more study. 3) Disparities in receipt and utilization of Telecommunicator CPR - 350,000 OH cardiac Arrests each year in the US. Literature suggests great impact of telecommunicator instructed CPR. Do race or income have an impact on receipt of instructions or performance of CPR? Demographics from participating dispatch agencies were matched with CARES data. Only cases where there was telecommunicator CPR were reviewed. Older patient age was the only factor which affected receipt of instructions. On actual performance there was a 5% increase of actual performance after instruction for every $10,000 increase in income leveling off at $60,000. 4) Ventilation variability in OHCA - Pauses in CPR are detrimental. Compression variability affects outcome. What about ventilation? A simulation center was used for measurement. Cincinnati FD paramedic used for measurement in the sim lab. Simulations measured with on duty personnel. Personnel were blinded to the study. 22 simulations ran covering 158 minutes of manual ventilation with a BVM. 18% had a correct ventilatory rate. 62% had the correct tidal volume for 41% of breaths given. Better methods to standardize and measure manual ventilation is needed. Impact on actual outcome is unknown. Ventilation variability is common on a case-by-case basis and a breath-by-breath basis. More research on actual outcome is needed. 5) Identifying patients for emergency trials - Can an automated classification model be used to identify patients for multi-site trials? Essentially, can a learning algorithm identify inclusion criteria of patients for studies? Study showed this method saved time.

NAEMSP - Using Data Visualization - Rachel Stemerman - Physicians are suffering from data overload. EMS is starving for information. Data visualization allows us to tell a story and focus on the information that is important to us. There is a difference between data and information. Has to be understandable and have meaning that leads to action. Know what stakeholders need is important. Focus on the process. Use data to make decisions. Use teamwork to improve. Make quality improvement continuous. Demonstrate leadership. What is data visualization? It is anything that changes data into actionable information. Infographics are a great example of data visualization. If the data does not automatically update, infographics become outdated very quickly. In 1854, John Snow created a map of locations of cholera deaths. It overlaid to hot spots of the outbreaks. Good visualization: Information, story, goal and visual form = successful visualization. 1) Define goal and target audience. 2) Know your data. 3) Explore your dimensions/charts/layout. Individual care providers never think they are part of the problem (they set themselves aside). Speaker showed examples of EMS data used in data visualization projects. What do you want? What information do you want your groups to be aware of? Can be used for workload analysis, success rates, patient improvement and anything where you can get the data. Works well in comparing local data to NEMSIS. Data caters to the paramedics as they are the foundation of the delivery of care. Datawrapper, chartblocks, infogram and tableau are examples of tools used to create infographics. Translate data to information to knowledge and action. Great example here (be sure to click on areas of the visual after the animation is done): https://guns.periscopic.com/?year=2013

NAEMSP - Quality Improvement in EMS: Lessons from the 2018-2019 NAEMSP Safety and Quality Course - Scott Bourn, PHD and Michael Redlener, MD - How many measure something? How many are not satisfied with a measurement? How many are frustrated over a measurement? Frustration comes when you cannot fix the

things that are broken. 62.5% of EMS agencies follow clinical quality metrics. 37.8% Use CQI software. 33.3% participate in outside research or a clinical quality network. There is a difference between research and quality improvement. QI is not learning new evidence to improve something, it is assuring that we are using what we do know. You can focus on many components of things to improve (example: telephonic CPR to improve cardiac arrest save rates). The education on this starts with preconference pre-work on baseline terminology and fundamental concepts. A one day NAEMSP preconference workshop model was created to educate on these concepts. It culminates with a yearlong local improvement project with sharing of best practices. Methodology taught is the IHI (Institute for Healthcare Improvement) model for improvement. Training includes how to analyze and interpret data and use of data charts. Course model has been changed between years to be two days to discuss leadership trends and issues regarding improvement. Day one focuses on quality improvement while day two is advanced topics in quality improvement. The course gives you the tools to succeed.

NAEMSP - EMS Care for Transgender and Gender Non-conforming Patients - Eric Lowe, MD - You do not learn this from a manual and you do not learn this as physicians. 1) Vocabulary and background. 2) Statistics and health risks. 3) Practical approaches. Medical definitions: Sex - Physical attributes. Gender - today more one's own definition from a sense of identity (can be further defined as gender identity and gender expression). Sexuality - deals with attraction. There seems to be no set alignment between the three definitions. They may align or may not. Gender expression and gender identity does not define biological sex or sex determined at birth. The lecture today will limit the variety of terminology being used. Transition - Social changes with dysphoria, gender affirming medications, gender affirming procedures. Our healthcare catchment areas are homes to transgender individuals. The numbers are increasing. 0.7% of the population currently identify as transgender. This does not include those who do not openly identifying. In K-12 schools, 54% reported harassment, 24% reported physical assault, and 13% incurred sexual violence. 17% left a school. 40% attempted suicide. Those with unsupported family, 60% attempted suicide. 4% with a supportive family. 59% avoid the use of a public restroom. 32% limit the amount they eat and drink to avoid using the restroom. Rates of UTI are higher. 23% do not seek healthcare due to fear of mistreatment. 30% state that none of their healthcare providers knew their status. Data from the 2015 Transgender Survey. 90% of emergency physicians state they have treated transgender individuals. Case study presented using documentation examples and variances. The ambulance is a place for medical care and not a place for judgement. "How do you prefer to be addressed?" is a statement that has always been taught in EMS. That practice still works well for addressing these patients. Verbal assessment questions must include medications and procedures/surgeries as it may affect current health issues. What has been changed since birth? A transgender female to male may have PID or ovarian conditions. Assessment and organ presence/absence makes a difference in differential diagnosis. Insurance may also require biological sex in the medical record for billing.

Oral Presentations - 1) EMS Burnout - Starts with workplace withdrawal. Prospective cohort study. Copenhagen burnout inventory used. 238 participants. 64% male. 65% paramedic. 48% judged to be experiencing burn out. 7% turnover. Single provider agency measured. Increased sickness and turnover threatens EMS workforce stability. Absences increase workload on those at work. Injuries were not associated with burnout. This was an exploratory look at one agency. 2) Stress and Social Support in Nova Scotia - Since 2014, 264 Canadian public safety and military personnel have committed suicide. A lot is known about police and fire suicide while EMS suicide is not as well studied. How can we help if we do not know how? 344 responded to survey out of 1,348 paramedics in Nova Scotia. Perceived stress score was used. Paramedics are more extroverted. Paramedics scored far higher than normal, significantly on the scores. Females scored higher on coping mechanisms than male paramedics. Social support scores were lower than normal levels. Less useful coping styles were prevalent in paramedics. Paramedics are more emotionally volatile. Paramedics show a predisposition to psychological resiliency. 3) Dependence on Overtime or Multiple Jobs - Speaker is from the National Registry. EMS is a unique career with high stress and pay issues. Many work more than 40 Hour weeks and hold multiple jobs and eventually leave the field. Survey of National Registry recertification applicants. 22% response rate. 71% said they were dependent on overtime or multiple jobs to make ends meet. Two-fold increase on intent to leave EMS based on need for overtime or multiple jobs. Future work should focus on improving pay and benefits.

NAEMSP - Oral Presentations - 1) Accuracy of Prehospital Stroke Scales in Predicting LVO - Retrospective observational study. IRB approval. Patients had a stroke screening and outcome data was available. LAMS and RACE were utilized as well as other comparable scales. 1,712 patients included.242 had LAMS or RACE. 1,600 had another scale. More of the second subset actually had an LVO for comparison. Predictive value of all were low in this study for LVO. 2) Is use of Lights and Sirens a Higher Risk for Ambulance Accidents? - The majority of fatal crashes are during use of lights and sirens. No association of lights and sirens use with outcomes. Nationwide comparison used. NEMSIS data used. Response and transport were evaluated separately. Crash related delays used as the marker for an existing crash in the record. 12.4 crashes for 100,000. Lights and sirens responses and transports were significantly higher in crash related delay data element uses. Did not consider environmental issues. Higher with lights and sirens and even higher in lights and sirens transport. 3) Weight Estimation in Agitated Patients - Agitated patients are critically ill in many cases. Midazolam is most common sedative used with Ketamine being an emerging therapy. Validated Altered Mental Status Scale utilized. Severely agitated got 3mg/kg and profoundly agitated got 5mg/kg. All were IM. Weight estimate mean was within 1.6kg of actual (that is amazing!). Not a randomized trial. Weight estimation is fairly accurate. 4) Exploring Paramedic-Physician Handoffs - A survey was used and then focus groups were formed. Qualitative data analysis. Many paramedics felt that physicians were dismissive of their reports. Paramedics felt as if their reception with a patient was unwanted. Perception of skill capable was another issue. Both sides recognized that paramedics transport to several facilities that have different expectations. Handoffs are affected by many factors. Not an observational study. A multi-faceted approach to this is needed. Tools are also needed. 5) EMB Assessment Tool used by Community Paramedics - Targeting patients who are at high risk for increased emergency department usage. Retrospective review. Process: ID patient, refer, home visit and care plan and then look at 911 calls and ED visits. Purpose of tool is to assess for potential increased usage and prevent increased usage. Statistically significant reduction in 911 and emergency department usage. Perceived as positive by most patients. 6) Determining destinations based on off load Delay - Nova Scotia study - Off load delay is a pressing issue in many countries. Impacts ambulance availability. Objective was to mitigate this issue. Real-time monitoring of ED crowding was made available to ambulances. If all are crowded at once, it makes no difference. Markov Decision Process was utilized. 2016 data was utilized. 22,243 calls analyzed. 7,833 hours of ambulance availability was saved using the process by diverting primarily medium acuity level patients to a farther away facility. Also reduced turnaround times and the amount of crowding by distributing patients.

NAEMSP - Load and Go or Stay and Play? The Reality of Time Criticality in Trauma, ACS and Stroke and Implications for Prehospital Treatment and Transport (Note: room is packed!) - James Nania, MD, Spokane, WA - How much time should we spend in each phase of these time critical conditions? FMC is a better starting measurement that "door to the ED." Response times do not seem to be any negative part of the equation in this study. Need to measure from time of cardiac arrest event to first defibrillation (not a CARES data element). Stay and play especially after ROSC. Stabilize ROSC patients before moving. Induced Hypothermia still viable in the hospital, just dismal in the prehospital environment. Time to first shock and stay and play in Cardiac Arrest seems to be the most viable option to a good outcome. Angioplasty is better therapy than thrombolysis. Strategy needs to be to get more patients to angioplasty over facilities that offer only thrombolysis. Decrease delays in access to either. Assessing high risk criteria can be more predictive of an MI than a 12-lead. ED bypass is essential to get patient to the Cath lab more quickly. Maybe we should be doing 12-lead at contact and all other therapies on the way to hospital in STEMI? Nitroglycerin is very effective in reducing size of infarct. Pre-alert that translates to understood action is needed. EMS and ED should agree on pre-alert content (this should not be dictated by one side). Stroke: Again, time critical. 15 minute intervals on brain reperfusion correlate to morbidity. Delayed interventional therapy is devastating. Mentioned CSS scores. Way too many patients are presenting outside the window for treatment. Earlier is better. Again, notification of the ED is critical. Not much to do for stroke patients in the field. Direct to the best facility for care. Trauma: At least one study concludes that scene times that are very short have a negative effect on mortality. The root cause: Hypotension and hypoxia together kill. RSI was associated with desaturation 43% of the time. Mitigation of this is possible. Permissive hypotension is good. Speed is important, but it is also important that you seal the sucking chest wound correctly (this takes a little time). Open book pelvic fractures take a few minutes to stabilize correctly. Time taken doing the job right is essential to outcome. Look for areas of waste that do not affect outcome to decrease time, not the time itself. Speaker states that the biggest area of time waste is between the ED and the OR, not with EMS. No interval should compromise safety.

NAEMSP - If you want to make enemies... try to change something - John Lyng, MD, Minnetonka, MN - Change management in EMS. Facilitation of adoption is an independent function of the project itself and is crucial to success. Identify change catalysts. Like drug shortages? Resources? Staffing? Devices? Regulations? "Two things firefighters hate; the way things are now and change." Case study in switch from Fentanyl and Hydromorphone to an alternative therapy using Ketamine presented. Covered the Diffusion of Innovation model and adoption curve. Curves of adoption can be short or long. Everyone who is touched by the change must have input. The media can be an external stakeholder at times. Stakeholders should be engaged in person whenever possible but get information out with reminder tools as well. Repetitively cover the information. Repeat at least three times. Case study presented on removing pediatric ET tubes. Notified the staff of the change. Resulted in some emotional responses. Some responses were nuclear level. Know the personalities that you are communicating with and cater the communication to the personality type. Some need you to draw a picture (think infographic). Your creative people are your early adopters. Creative people make your best change agents. Remember your project managers are stakeholders also. Answer what, when, where, why, how and who. Make small, medium and large versions of your communication. The Goldilocks Targeted Communication Strategy. There is resistance to change... three levels: I don't get it, I don't like it, and I don't like you. Educate using multi-media approach, address emotion and build trust. Resistance is natural and the first human response to change. The vocal may be the minority. Silence does not mean acceptance. Resistance can be a powerful expression of caring. Resistance is a source of data. Only 15% of an individual’s motivation is based on what we say. 30% from what we do. 55% comes from reinforcement and holding people accountable. Reflect on your own leadership style. Use more direct communication instead of email. Be physically present with your teams. Remember to engage stakeholders. You make less enemies that way. Nurture understanding of the change, not compliance. Change is often imperfect. Change does not cause organizational dysfunction, it merely exposes it.

NAEMSP - Patient Handoffs: A High Risk Area for Patient Safety - Toni Gross, MD, New Orleans, LA - Speaker states that the lecture will come from a hospital perspective. What constitutes a good handoff? The handoff is like a football or the pass off of a baton. We do not have four downs to get it right. We get one chance to get it right. 80% of serious preventable adverse events contained a communication

failure. NAEMSP, NASEMSO and NAEMT identify handoffs as a very important issue. The handoff is a transition of care exchange of mission specific information, responsibility and authority over care and treatment. Handoffs include many situations: EMS to ED, EMR to EMS, Bystander to EMS, Hospital to EMS, EMS to Coroner, PD to EMS, EMS to PD, Sports trainer to EMS, School to EMS, etc. Handoffs need consistent structure and content, timely and concise, time for questions, clear and direct communication, proper environment. Barriers to good handoffs are distractions and disruptions, lack of attention, ineffective communication practices, lack of common language/terminology, professionalism and authority gradients. The handoff is an opportunity to maximize the quality of care. The process helps detect and mitigate failures. Opportunity to limit the effect of negative human factors. Structure and consistency are the most important factor in good handoffs. Checklists can be very beneficial. (Note: this is about the 100th time I have heard the Gawande book, The Checklist Manifesto mentioned in regards to EMS. I am starting to believe this should be mandatory reading for EMS personnel). Checklists are low hanging fruit. Easy to make and easy to use. Checklists simplify processes. Checklists create cues that eliminate the need for memorization. Checklists aligns practice with expectations. Several tools: MIST, DeMIST, IMIST-AMBO, ISBAR etc. MIST is the most prevalent. Several studies on handoff tools have been performed. Use of a tool decreases time of handoff report and increased content. One study on ISBAR found that 65% of reports followed the format completely. There were three abstracts presented on handoffs this year at NAEMSP. There is enough information on handoffs to make the issue a standard core principal of care and a continuing education topic. We do not know which tool is best or what is the best practice/process. IMIST-AMBO covered in more detail in the lecture. Adopted, provided brief education, visits with crews on duty for direct education, posters in EMS stations and ED rooms. Steps: Structure the process, evaluate process, establish a culture success that values handoffs and provide training. Practice and simulate handoffs. Handoffs impact safety and care. Picking a tool is more important than which tool you pick.

NAEMSP - EMS Agenda 2050: Envision the Future - People centered EMS is the goal. Sustainable, adaptable and equitable. https://www.ems.gov/projects/ems-agenda-2050.html "Think Jetsonian not Flintstonian." - (quote by Mike Taigman). What would it be like to work in a system that works for patients? The document was built to maximize the input from all stakeholders. There was an original strawman document made to irritate and engage people in the process. The new agenda is like a Venn diagram where everything overlaps everything else. The system must be designed to deliver care that is beneficial, seamless, safe and effective. Risk mitigation and injury prevention is a key component. We need to develop tools that allow us to stop doing the things that hurt and kill EMS providers. Data collection needs to occur without clicking boxes. A case study was presented. Compared this actual case of a Ped with Rhabdomyolysis with how it would be treated by projection of existing

technology and systems in 2050. A key point is social equity. How do we get equitable, quality care to various populations? Race, gender, socioeconomic and geographic differences need to not effect availability and accessibility to care. More care will occur where the patient is rather than sending the patient to the care. EMS needs to foster innovation through listening and providing good leadership. We have to be more nimble than randomized, controlled trials. The agenda discusses education, volunteers, medical direction and vision. It does not discuss nomenclature, providing a road map, how to fund EMS or credentials of EMS providers. EMS physicians lead a collaborative system of medical oversight and direction that allows others to draw on that expertise. It is easy to count on others to take action. It is harder to take action ourselves that is needed to bring this to fruition.

NAEMSP - The Future isn't the Same As it has been: High Stakes Low-Incidence Events Not So Rare Anymore - Benjamin Abo, MD, University of Florida - EMS is not cookie cutter. "Denial is not just a river in Egypt." You have to plan

for what can happen. Be dynamic and adaptable. You need the right stuff and assure that is going to work. Protective gear is a great example. We are not paid for what we do but what we are prepared to do. We must have appropriate skills and training (medical and technical). 1) Case study regarding a field amputation decision and how the decision to not amputate was made (vehicle accident). 2) Another case study on a parking garage collapse. Is a surgeon going to go there? These things do not happen. Yes, they do. 3) Discussed a bridge collapse onto cars at FIU caught on dash cam of a car. "If you fall, I'll be there." - Floor. If you do not have the specific gear and the specific training then do not go to help. Get the gear, get the training and then go help. Practice makes permanent. Permanent practice makes perfect. "If you do not wear your helmet I will fart in your ET tube." - Dr. Abo. 4) Discussed SAR and a bariatric

rescue during flooding with Hurricane Florence. Someone suggested she would float. "I would rather she be face up and float." - Dr. Abo. 5) Coast Guard Mayday played on a boating disaster with a three boat collision of shore of Key Biscayne. 22 injuries. 21 went to trauma center. Multiple trauma arrests. Absolute mayhem. You can't do triage with moving boats. Where do you set up command? What about multiple calls on the same event? 6) BMW high speed collision case study where guard rail pierced vehicle. Amputation performed in the car. Three amputations on this response. 7) Another case study on an on water response of a foot caught in a propeller. You can't turn the engine on to go to shore if there is a foot in the propeller. Key was to keep patient from drowning while entrapped. PLAN AHEAD. Esse quam videri. “Be, rather than to seem.”

NAEMSP - 35 Years of MCI Presentations at NAEMSP - John Lyng, MD, NRP. Minnetonka, MN - Evolution of threats: 165 events from 1984-2019. 12,213 killed, 49,565 injured. 1984- Hazmat, infrastructure failures and natural disasters. 2002 - CBRNE, All hazards focus. Now: CBRNE, Ebola, Active shooter, vehicles as weapons, coordinated attacks

and civil unrest and natural disasters. Rune, hide, fight in our minds. Weapons being seen include more than guns with use of IED and CS gas. Edged weapon attacks are on the rise. ISIS produced a "how to" guide for knife attacks. Use of vehicles as weapons has increased in recent years, not as bomb carriers but as projectiles. ISIS is now teaching arson as a terror weapon. Complex coordinated attacks are becoming more common worldwide. Civil unrest in the U. S. has not produced large causality counts to this point but have potential. Wildfires are presenting a more frequent MCI logistics challenge. Hurricanes are up in number but number of deaths dropping. Lately there have been issues with Volcanoes. The natural disasters create more issues with children, elderly, pregnant patients and those with special needs or language barriers. Evacuation compliance has become crucial. We need to have methods to identify vulnerable populations before a natural disaster occurs. Emerging Infectious Diseases (EID). We are always one airport away from an EID. Scene access with ingress and egress being blocked continues to be a problem. Think: How I am I getting into this scene and how am I going to get out? Think this on every call daily and you will be better at it on the larger events and incidents. Resource management: self-deployment is a real negative issue and problematic with not having appropriate training and/or equipment/supplies. Those freelancing do not have ability communicate or know the mission. It is dangerous to self-deploy regardless of good intentions. A self-deployed nurse was injured and killed in the aftermath of the OKC Federal Building bombing. Response Team composition includes many disciplines dependent on the event/incidents and may include certain civilians trapped in or affected by the event. After Action Reports typically criticize a lack of early incident command (ICS). We have all been trained so why is it so hard to utilize ICS? Even in a

unified command structure, police are not as indoctrinated in the federal ICS command structure as Fire and EMS. Front line staff need to practice ICS on arrival. Tactics: Do we do point of EMS care (POC) in the cold zone or point of injury care (POI) where they are in the warm and hot zones. EMS must be integrated into police response. Chest seals and tourniquet use with personal IFAK kits make a difference. POI care within 20 minutes, transport within 60 minutes, OR within 90 minutes. You are RED or DEAD in the hot zone. RTF (Rescue Task Force) seems to have barriers to use. In many cases the barrier to early RTF use is in command delay in allowing RTF access. Leadership barriers need to go away. Staging is no longer acceptable and we must deliver POI care. We can either abide by the Hartford Consensus or get out of the way for those that can

and will. THREAT mnemonic. Standard triage does not work well. We need to realize this. Triage does not correlate to outcomes on the color system. Triage Tags are rarely used and rarely useful. POI care is the answer. Fatal casualty injury patterns discussed. Absence of ballistic vests allows more thoracic trauma. In urban settings, ALS care for trauma patients is not beneficial. No support to delay transport for vascular accidents or use of crystalloid fluids in the field for trauma. Finger thoracotomies may be beneficial. IV access in route may be beneficial but not for fluid. NAEMSP has a position statement on adult traumatic cardiac arrest management (your protocol must be clear). Many patients in MCI situations get to the hospital by a means other than ambulance. Pack the ambulance full of patients during MCIs. 911 was only in 50% of states in 1984. Now we have text to 911. First Net and social media are now available. Interoperability of communications is still one of the biggest things we need to fix. Have a single PIO for all involved agencies. The event does not stop on scene. Care goes on long after the event to the community and the responders. We must adapt and be ready. Improve command and control.

NAEMSP - Response Times - Jarvis, MD - Response times do not matter. They have been the sole measure for a long time for EMS systems. There are far too many issues and it is a flawed metric. It is not an indicator of outcome or quality of care. Domino's no longer guarantees a pizza in 30 minutes or less because they ran over too many people trying to do it and killed them. We over staff to decrease response times which dilutes skill experience. What should we look at? Things that bring quality. We need performance measures. PMs: Structure, Balancing, Process and Outcomes are types of performance measures. Types of measures may affect each other. We have to hunt the data down today. Each measure must be measurable, manageable and meaningful. Ii is not manageable if you cannot affect it. EMS Compass is a great place to start. https://www.ems.gov/projects/ems-compass.html They are bundled. NAEMSP has a position paper on performance measures as well. Benchmarks are important. Example: If we get a defibrillator to a patient in need within 5 minutes we only need to see 8 patients before we have a positive outcome (NNT=8, 95% CI). If you have CHF with defined vitals range with positive pressure ventilation and nitroglycerine you again have a NNT=8 if you avoid intubation in producing a good outcome. NNT=4 to stop persistent seizures with benzodiazepines. Beta agonists

in asthma How many get it? NNT is unknown. We need to expand on EMS Compass. There should be a consensus documentation standard for metrics. We really need to have reimbursement tied to performance and not just fee for service. Metrics should be in system RFP criteria, not just response times.

NAEMSP - Evidence-based Guidelines - Martin-Gill, MD, Pittsburgh, PA - Wide variability in EMS care. Incorporating evidence into practice is challenging. There is a lack of uniform measurements. Position statements are not the same as evidence-based guidelines. Position statements address a special interest area where EBGs are scientifically supported. Identify the gaps where we do not know what is beneficial and research those areas. EBGs must be placed in EMS education. https://www.ems.gov/ficems/plan.htm It is now required to have research in your continuing education to renew your National Registry certification. We now have unified data collection in the form of NEMSIS. There is a process for creating an EBG. Then we must measure to see if the EBG impacted our patients or not. You must use a method to evaluate the quality of a recommendation. It is difficult to create a guideline that can be supported. See the PEP (prehospital evidence-based practice website (see

comments below). There will not be a complete set of EBGs on every EMS presentation within our lifetimes. Again, implementation is hard. EMS Compass is a component in creating guidelines. The fatigue risk management guidelines are an example. We must have common goals and synergism in the creation of EBGs. None of this will continue without funding. See also:

https://emspep.cdha.nshealth.ca/

https://www.ems.gov/pdf/advancing-ems-systems/Provider-Resources/National-Model-EMS-Clinical-Guidelines-September-2017.pdf?fbclid=IwAR33_25AWFoeAt2UlJYzkiHnXHUQ3Dpsoy1C93N1QqOz1F3F17JAhdLOVSM

https://nasemso.org/wp-content/uploads/Fatigue-Guidelines-Infographic-11Jan2018.pdf?fbclid=IwAR0aSbV-Imzl2Dznt2zYfh9L_KgiIDMmxusNhVXLA8zKI53M7eeA1zjA1UE

http://prehospitalguidelines.org/?fbclid=IwAR1GGQrBnEY8F_J7FOS6Uaa8arwXWGQdL5pUMGx1i6xzWosFIMUvOVM4YEc

NAEMSP - Top NAEMSP Position Papers for 2018 - Gallagher, Wichita, Kansas - "This is a fun lecture because this is the voice of the organization." Some position papers are based on evidence and others are based upon expert opinion. All of the position papers are available under the PEC tunnel for member’s login on the NAEMSP website. 1) Epi in OOH Treatment of Anaphylaxis - All levels of responder should be able to treat for this condition. Epi is the first line treatment. Personnel should be well trained on this function. Medical directors should be the decision making authority on this issue. There is a jab at the industry on the price of epinephrine auto injectors. 2) Physician Oversight of Specialized EMS - What is specialized EMS? Tactical? USAR? Wilderness? Dive Rescue? MIH? Dispatch? Critical Care? Whatever the area, if there is specialized care and specialized training, it must have physician oversight. There can be no last minute rush jobs to decide on scope and training for specialized environments. If it contains animals then a DVM should be involved (dog teams, animal patients). 3) Spinal Motion Restriction - (most read paper for 2018 and all time!) - AS-COT, ACEP and NAEMSP consensus document. Changes the terminology. There is no such thing as spinal immobilization. It is spinal motion restriction. Many devices such as the ambulance cot itself are sufficient. "Distracting injury" redefined to be something that impairs the patient's ability to contribute to a reliable examination. Reliability is a judgement you have to make based on circumstances. There is no role for SMR in penetrating trauma. Children are not by nature unreliable. Peds still need padding under the shoulders. Includes an appropriately-sized cervical collar as a component (this was part of consensus as there is no evidence of benefit). Some feel this position is not that much of a step forward, but it is because it is going to keep it on the forefront and get involvement in more research. Three great papers published this year.

NAEMSP - Top Five Articles 2018 - Crew from the PEC Podcast - 1) EMS Airway Management - Actually two articles. ET, SGA and just BVM have all been put forth as being superior to each other in literature. PART Trial and AIRWAYS-2 Trial. PART showed a King to be superior to ET in arrest outcomes. I-Gel showed a significant advantage over ET as well. The bottom line: These airways are at least as good if not better than ET. 2) The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse and Crime - The article is scientific trash that bypassed peer review and was published on Twitter, and the media loved it. There is a rebuttal. Over 70,000 people died from overdoses in the United States last year. Sensationalized, non-reviewed literature should be burned and then thrown in the trash. 3) Prehospital Plasma for Hemorrhagic Shock - Criteria driven trial on two units of plasma infusion. The study shows that plasma is both safe and effective with a 5% improvement in mortality from hemorrhagic shock. 4) Fatigue Management Guidelines - Truly 15 publications referenced in the guidelines. The guidelines highlight the need to evaluate your working environment and that more research is needed. We have to start somewhere. Napping improves performance. Napping should not be hindered. This guideline set is applauded along with one of the investigators (note: this is a high point of 2018 for me. It is time to call out all naysayers who support fatigue causing practices). 5) Pediatrics: What should prehospital care for Peds look like over the next decade? - Facilitated discussion on needs and needed research. 27 stakeholders identified 153 needed areas of research. Measure mortality. Link EMS to hospital data. Train appropriately. Bottom line is that if you take care of pediatric patients, this paper tells you that needs to be measured. And a bonus review: 6) Epi vs. Placebo in cardiac arrest - Epi does not approve survival and may be detrimental to neurologic outcomes. Is it time? Great review! https://pecpodcast.libsyn.com/

Now that my fingers need a rest from three days of rapid-fire

typing and posting these note to social media, I will bring this blog entry to a close. I will be doing this again for the 2019 U.S. Metropolitan Medical Director's: EMS State of the Sciences Meeting coming up March 1st in Dallas. Stay tuned!

I will leave you with a one final picture from our trip to Austin, Texas.

Hoosiers in Austin at NAEMSP:
Right to Left: Ben Purdy, Dr. Stephanie Gardner, Jennifer Knap,
Angela Webb, John Zartman, John Heald, Annette Turpen
and Myself