"Welcome back my friends to the show that never ends..."
This is how the EMS: State of the Sciences usually starts... typically with Dr. Paul Pepe playing the song off his smart phone to get everyone's attention to get this rapid fire, raw data, progress driven show on the road. I think I have now attended about twelve of these meetings and I always come away with a ton of notes to share.
Once again, the standard disclaimer: These are my notes, typed rapidly and posted to Facebook, then copied and placed here with some grammatical and spelling fixes. 1) That does not mean, in favor of timely posting, that I have found and corrected every spelling error, or 2) that I heard everything 100% correctly. So if there are a few errors, I apologize in advance.
Without further wait, here are the notations:
Slovis - Nashville: The Pentagon Papers - The five most
important publications of the last year. 1) Cardiac arrest during sex, less
than half of the partners start CPR (47%). 2) Isopropyl Alcohol inhaled for
nausea. Placebo controlled trial. 32% decrease in nausea with isopropyl
alcohol. Only 9% decrease with Ondansetron. 3) Apneic Oxygenation - decreases
hypoxemia by 1/3 during intubation. 100% O2 with passive oxygenation. 4) Gum
Bougie vs. stylet during intubation - When difficult airway is present. Bougie
gets the number to close to 100% success rates. 5) Cricoid pressure does not
decrease aspiration and makes view for intubation worse. 6) NTG in r/o AMI -
NTG is safe in MI, it does not drop BP and is sage in inferior MI. The more
tachycardia, the more chance of hypotension. 7) IO in cardiac arrest - Lower
rate of ROSC. No difference in survival. No difference in favorable neuro
outcomes. IOs are excellent access devices, but not mandatory first line in
cardiac arrest 8) DSD - Is it more effective? Probably not. Multiple great
articles this year. Presentation will be available on the Eagles website.
Things keep changing. Keep changing with it.
Clemency - Buffalo: Documents that ABEM wants your doc to
know - 1) Not all prehospital time is equal: Influence of scene time on
mortality: On scene time was the only factor associated with mortality. 2)
Trial of continuous or interrupted chest compressions during CPR: Quality of
compressions more important that ratio. 3) Patients immobilized with a LSB
rarely have thoracolumbar injuries. 0.9% had injuries. Not much. 4)
Observational study of shift length, crew familiarity and injury and illness in
EMS: Shift length was associated with more injury but not familiarity of
partner.
Gilmore - St. Louis, French - Charleston: Captivating
Capnography - ETCO2 use beyond the ET tube. If anything is off you will not see
a normal waveform. ETCO2 less than 28 or more than 50, mortality and ICU
admission potential go up. ETCO2 in pediatrics is not as strong of a
correlation. Capnography in trauma - ETCO2 is the most predictive to tell you
how bad the trauma patient actually is even with normal vital signs. Any
patient with blood loss she be monitored for ETCO2. DKA - with a SG of more
than 550 and ETCO2 of less than 28, probably DKA. In Sepsis - ETCO2 less than
25 can be a strong marker for sepsis. Practical applications? Confirmation of
airway placement, TOR, Monitoring sedation or OD status, need for airway
support, respiratory monitoring, holding medications, CPAP challenges, sepsis
evaluation. Magic numbers: 10 - TOR, 25 - Hypoperfusion, 50 - Hyperventilation
(maybe important). How do we change management? ETCO2 in sepsis has
limitations, ETCO2 is a good marker and maybe this will lead to earlier ED
attention to the sepsis patient. DKA case covered.
Holley - Memphis, Youngquist - SLC, Jui - Portland): Super
info about Supra-glottic airways: How well do they seal the airway? ET, LMA,
Igel, AirQ, King and combitube compared for seal. Airways with distal
esophageal cuffs worst at sealing. In head up CPR this was more accentuated. ET
tube is best seal with LMA, Igel and AirQ being next. Secure them
appropriately, cervical collars can affect flow. Choice of airway affects
cerebral flow. Do not put pressure on the carotid and jugular flow with your
securing mechanism. Tight c-collars have almost a tourniquet affect during
ventilation/airway management. Does the Igel work well in adults and kids?
Multnomah County EMS transitioned to Igel. 94% successful airway control rate.
83% is pediatric airways. in 2018, pediatric airway rose to 100% success in
2018. ETCO2 must be used with the airway to assure patency (all airways).
Pediatric Igel is a viable alternative and as a primary airway. No
complications observed. System competency takes 2 to 3 years. Pediatric airway
training should occur EVERY year. PALS every two years is not adequate.
Jarvis - Texas GETAC: Providing a safe map to the pulmonary
super highway, peri-intubation hypoxia - Peri-intubation hypoxia is common and
harmful. Intubation is
Antevy - GBEMDA: A DASH of DSI, reconsidering RSI -
Ketamine, ETCO2 and then paralytic. Positioning needs to be at about 30 degree
head up. Add PEEP. Two handed seal on BVM mask. Must have 3 minutes of 94% or
above SPO2 before intubation. Ventilate at once every 6 seconds. Maximum of two
attempts and move to Igel. Definitive Airway Sans Hypoxia (DASH). Uses a mobile
CQI App form to collect data post-procedure. Abandon SI. DSI with a checklist.
Follow your data.
Pepe - Course Director: Polk County POHCA, Using
physiological-driven approaches to pediatric cardiac arrest - Effecting neuro
intact survival in children with out-of-hospital cardiac arrest. Grim chances
of survival nation-wide. Intimidating for rescuers. Scoop and run practice has
evolved but is not logical. Over zealously ventilating children. Do not delay
care by leaving scene. Focus on rapid, on-scene patient care. 2012: No
survivors when practicing scoop and run. In 2014 they prioritized on-scene
resuscitation. Use system one thinking. 2016: Prepare prior to arrival
on-scene. 2012-2013: 0% survival. 2014-2015: 23% survival neuro intact.
2016-2017: 34%. Epi on board faster after 2016 (5 minute average compared to 7
minutes after 2014). Expedited care on scene and have a disciplined focus on
arrest management.
Pruett - Albuquerque: No Adrenalin Rush, Results of an
alternative approach to Adrenalin dosing - Timing of Epi administration in
cardiac arrest. Looked at this as an opportunity during the Epi shortage. We
know what Epi does. It also increases myocardial O2 demand and impairs
microvascular flow. Early EPI is beneficial for ROSC but not associated with
neuro intact outcomes. When to give? How often? What rhythms? Best route? Is 9
to 10 minute dosing interval beneficial? Every 3 to 5 vs. 10. No difference in
overall survival. There was an improvement with 10 minute interval patients in
PEA. Small study. No harm caused with 10 minute dosing.
Conterato - Minneapolis: The most practical uses of
epinephrine in resuscitation - How about eliminating or limiting epinephrine?
It has NEVER been shown to improve outcome. We know there are negative effects.
What about Epi early? In VF it is associated with decrease survival if early.
Epi late? More survivors and less neuro intact. No significant difference.
Lower dose of epi? 0.5mg? No change. Literature review? Red recommendation. Is
the king dead? It depends. Early epi in asystole and PEA had better survival.
What about pseudo PEA? May have high ETCO2 readings. Epi may be beneficial in
that group (more of a push dose pressor?). So when should we use it in arrest?
0.5mg every 5 to 10 minutes. Focus on PEA.
Keseg - Columbus: More efficient training with an Epi drip
model - One pressor to rule them all! IV Pumps are expensive and problematic in
EMS. Columbus got rid of IV
Margolis - U. S. Secret Service: Challenges with Chemical
Attacks - Evolving landscape of chemical agents. How do we approach an attack
with an unknown substance? Why is the relevant? Terrorist attacks are increasing
and involving in complexity. An immediate focus should be on the classes of
opioids, nerve agents and asphyxiants. Moscow theater siege was aerosolized
opioids. Assassination of Kim Jong-nam was VX nerve agent. 4th Generation nerve
agents (A series or Novachok). Very potent and persistent and are at least as
toxic as VX. Require more aggressive care, more medication, more duration of
care and more decontamination. DUMBBELS SLUDGEM acronyms. SLUDGE + Killer Bees.
ABC, then Decon and Drugs. Focus early on decontamination. RSDL can be used.
DuoDote, Atropine, plus earlier and higher doses of benzodiazepines. How do you
make this workable? Decon and assess simultaneously. Look for nerve agent first
ant treat, if not then opioid, and if not Opioid and provide supportive care.
Use a job aid to provide care. Complex terrorism attacks are on the rise and we
must have an all hazards approach.
Carli - Paris: The ethics of triage in terrorist attacks -
Triage is French! Developed in the French revolution. Extensively used in wars.
When you do triage you are doing good in ethics and care. It provides fairness.
Let’s move now to times of terror. Who is first? Classical approach is serious.
Ethical approach is victim first. But before the attack everyone would agree
that the terrorist should be killed? Ethics is not immutable! Victim first
approach may be a legitimate change. Rescue teams do not have time for an
investigation of who is the bad guy. If the aggressor is identified without a
doubt, chose the victim. Do we put a rescue team in danger for an injured
suicide bomber? Saving a life is directly opposed to the objective of terrorism
(kamikaze).
Bronsky (Colorado Springs) and Dyer (Boston): Re-triaging
Triage - Sometimes triage is easy. Sometimes it is hard. Tools don’t help us
when it is hard. How do we make it easier? Bronsky used to be a paramedic in
Israel. He had to reconcile what he was taught there by what we do here. Triage
methods are unrealistic. Who checks cap refill as a component of triage? No
one. Traditional models simply do not work in real life. It is based on false
assumptions in human behavior. No one is going to sit on the green cart and
wait for care. MCIs never look like MCI drills. Greens leave the scene
sometimes before we arrive. Current major incidents all abandoned traditional
methods. No radial pulse and not following commands has a 92% mortality rate.
Figure out models that work. RAMP is more simplified.
Pepe (Course Coordinator) and Antevy (GBEMDA): ASPR-TRACIE -
Roadmap for MCI Triage - Based on the work of John Hick, MD. Technical
resources, Assistance center and information exchange are essential components
of ASPR. ASPR responds faster than entities like the CDC. www.asprtracie.hhs.gov Early unified command is essential. Law enforcement must be a component.
Reinforce Hartford Consensus. Have standardized resource assignments for mass
violence events. Triage is dynamic and you must emphasize transport when
available. Get patients off scene, no waiting. Triage tags have little to no
utility for tracking at any point in the process. Use batch transport or
secondary transport (law enforcement). Hospitals are underprepared to triage.
White paper coming on this issue. At the Las Vegas shooting many left by Uber.
Be prepared and train others who are likely to be involved anyway (stop the
bleed for Uber drivers). Everything changes when you know the victims also.
Look for paper coming out soon.
Roth - Pittsburgh: Did the Hartford Consensus save lives in
Pittsburgh? - Active shooter event at the synagogue. THREAT an acronym, Threat
suppression, Hemorrhage control, Rapid Extrication to safety, Assessment by
medical providers, Transport to definitive care. If EMS is staying outside this
is heresy. Tactical medics on early entry and regular EMS on secondary entry.
TEMS is not RTF. Hospitals need to be prepared for what they are going to
receive. Treat where needed and do not wait for the patient to arrive at a
collection point. ERs need to ramp up staffing on first notification. IFAK kits
and throw bags need to be available for mass shooting events in churches and
other areas.
French - Charleston: The Resilience of Emanuel Congregation
and Community Responders - Discussion of how a Sofa Store fire that killed 9
firefighters in 2007 and how it changed how emergency services functioned. The
consolidated dispatch and standardized culture across geographic lines. Most of
the change was within the various fire services that started working together
and then included EMS and law enforcement. Fire was integrated but EMS and LE
was still in silos. Came together on common ground issues (cardiac arrest,
etc). To be prepared for violence you must increase engagement of the players.
Train in TECC and RTF (Rescue Task Force). Increase peer support teams.
Antevy - Coral Springs/Parkland: EMS as 4th Responders -
Recognizing and adapting to a new chain of survival in MCIs - States that the
survey this morning shows that 75% of those in attendance are paramedics.
Timeline of Parkland shooting covered. Shooter told a bystander to leave
because "bad shit was going to happen." The perpetrator killed 11 and wounded 13
on the first floor without entering any classrooms. In four minutes, all shots
that were fired that caused harm had been fired. First police arrived at five
minutes and 16 seconds. Fire and EMS shortly after. They entered at 11 minutes.
21 minutes and 58 seconds till first patient was transported. 58 minutes and 44
seconds was the time the last patient was transported. Students were there at
the zero moment. So who needs to be trained in stop the bleed? Students,
teachers and call takers. Twelve year olds can apply tourniquets. Never forget.
Per surgeons, eight of the cases were saved by tourniquets.
Scheppke - West Palm Beach: MCI Lost and Found - Re-uniting
patients and families after assailant attacks - This system is not in place
yet, but they want a system that can be used daily to keep patients and
families connected. We track packages, cars, etc... why not patients? RFID
bracelets with sensors all along the path that patients travel. It just
requires patient demographics to be data attached to the RFID bracelet. West
Palm Beach working on this.
Carney - Kansas City: Re-Thinking Disaster Management
Training - Did a level 1 Trauma Center know the Mass Casualty policy? On
survey, they were not prepared. Disaster drills for JCAHO by themselves are not
adequate training. Need overcrowding and crowd control. Hospital areas like CT
are bottlenecked. Proper planning and training are keys to mitigation.
Physicians must be trained in disaster management. You have to teach where to
find a policy let alone follow it. You do not have time for that. These events
are frequent, just not in your community. Train to meet desired goals. Are SALT
and START actually used? Must have post event operational debriefings. Must be
multi-jurisdictional. Prepare and plan based off history. It’s not about having
time, it is about making time.
Perina - ABEM and Charlottesville: How the medical practice
of EMS got recognized in the house of medicine - EMS is our specialty. This
discussion is half history and half politics. This is owed to Ron Stewart and
Paul Pepe. In the start, physicians had no training in EMS. Delegates met in
1992 to discuss EMS as a subspecialty for physicians. Subspecialty is defined
by meeting a set of criteria. Core curricula was completed in 1994. It was like
herding cats. ABEM tried to kill the effort. In 1995, NAEMSP and ACEP worked
together to try again. This took from 1995 to 2003 when the IOM report on EMS
at the Crossroads was published. Politics came into play. At this point Perina
was elected to the ABEM board. In 2003, ABEM was totally opposed to an EMS
subspecialty. Naysayers were plentiful. Again, the criteria had to be met.
NAEMSP grew. Publications and journals were created. Clinical trials and
literature reviews concerning EMS became more prevalent. She had to wait for
attrition off the ABEM board. There was a short window opportunity and she was
banned from helping with the application while she was president of ABEM. She
went to NAEMSP before being president and had them prepare everything.
Submitted in 2009. ABEM sent letter to ABMS in 2009. ABMS approved the EMS subspecialty
in September 2010. First exam was 2013 and another in 2014 due to demand. There
are now 625 EMS board certified physicians, ABEMs largest group.
Lightning Round: Medical directors on stage - 1) Many
problems are not medical process or system problems, they are environmental to
EMS and they are worldwide issues. - Carli, Paris. We need quicker ways to
notify hospitals in MCI situations. Physicians on scene are needed to save
time. 2) Role for Nitro? Some discordance between docs on NTG and hypotension
in AMI. Slovis says use it. Forget about the hypotension issue. It is not real.
Discussion on V1 ST depression vs V4R elevation. PWMI mentioned as well. One
system mentions using Fentanyl as first line instead of NTG. 3) Use of whole
blood - say it has saved lives. It requires a whole system to use blood, not
just carrying it on the ambulances to expire there.
Eagles Awards - Pierre Carli (Paris) receives the Ron J.
Anderson Award for Public Health. "If you go out, you will be more
efficient when in (the hospital)." The Paul Pepe Award goes to Debra
Perina (ABEM). "This was a labor of love and I have great respect for our
EMS providers. What I accomplish, I accomplish by standing on shoulders of
giants."
O'Donnell (Indianapolis): Managing an additional mass
gathering event within an already massive mass gathering - Indianapolis 500
event. 34 ambulances, 7 on the track, 15 on the grounds and 12 outside. Cooling
stations and cooling busses used. Fully functional hospital in the infield.
Typically 28 to 30 transports on race day and maybe 150 to 200 seen at the
infield hospital. Then there is the snake pit. A musical festival in the 3rd
turn. 2018: 363 runs, 110 from the snake pit. By 11am 90 patients had been seen
at the hospital. Reunification with families was impossible. Now they are going
to treat this as two separate events. Transports will be coordinated with the
infield hospital.
Yancey - Atlanta: Effect of Super Bowl on the surrounding
community EMS Call volume - Call volume during the nine day event went down in
the community and then spiked afterwards. Traffic incidents were low before and
higher during and after. Violent nature calls rose after the event. No changes
in hourly call volume pre, post or during. Gives a realistic basis for future
planning. Estimation does not work. This will help.
Taillac – NASEMSO: The 2018 National Scope of Practice Model
- 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
Gautreau - San Jose: Strategies for an early win at the
state legislature - while the speaker was in Massachusetts, they wanted to
embed medics with the SWAT team which was against law in how to grant authority
to function. Also, had to figure out how to schedule to reduce fatigue. Then
there was how to fund it. What it comes down to is get a bill filed, talk to
legislators, get buy in from those who are truly in command. Got the bill
passed and the Governor of the state vetoed it. The legislators’ overrode the
veto. The program proved its usefulness in saving an officer fairly soon after.
They decided to protect the funding.
Persse - Houston: Consequences of Advocacy Efforts - Houston
was behind in pay rates for firefighters. Firefighters did a good job of
connecting with the public and it was voted into local law to pay FF the same
as LE. This costs $100 million the first year. May result in 400 FF layoffs and
up to 200 LE layoffs and all departments faced cuts. It caused a focus on
civilianizing the EMS force within the FD. They are discussing a public utility
model. Do not know what will happen next.
Colella - Milwaukee: 2019 Methods to deal with hospital
diversion - Any good policy, people will find a way around it. Number of
available beds and services are decreasing across the country with more of a
move to outpatient services. So when the hospital is full the ED is backed up.
ED overcrowding is a hospital issue not an ED issue. The hospital closes the
door through EMS diversion. Diversions cause more diversions. Patient
satisfaction is instantly impacted. Sicker patients may not get to the closest
hospital. Patients decline service rather than going to a hospital they do not
want to go to. Hospitals lose revenue when this happens. Patients will deny
ambulance transport in a diversion and go to the hospital they want anyway. EMS
cannot dictate hospital behavior. First and foremost this is a patient safety
issue. Frame it as a community issue. Patients have a right to make informed
choice including destination. Position the hospital to be the community
benefactor. They started first by not diverting with ROSC, then Stroke, then
all patients for EMS. Ended with a no diversion policy for the community for
ALS transports. Zero patient safety events have been reported since diversion
ended.
Racht (AMR): Evolving Emergence of antibiotic resistant
organism exposures that we will encounter - what you can’t see can hurt you -
Bacteria on an aircraft discussed. When Ebola was a thing we spun up and then
we spun down. Sepsis is a huge killer in hospitals, more than stroke. EMS
bacteria prevalence discussed. MRSA, VRE, ESBL, PRSP and multi-drug resistant
TB are all out there and evolving. In
the past 18 months there have been
multiple patients that were resistant to ALL antibiotics. We as EMS have to
understand what is coming. From emerging disease perspectives, we have to
change our habits. Use hand sanitizer, it is important to stop transmission.
Interior surfaces of ambulances such as grab handles must be cleaned.
Technology is improving to help with these issues such as UV light. Enjoy your
dinner. What surfaces in a restaurant would you suspect?
 |
| The seat back pocket on my flight home. Someone before me had used a lot of Ricola! |
Dyer (Boston), Jui (Portland): Hepatitis A - Do you have
homeless in your community? Drug abuse issues? Worldwide there is a lot of Hepatitis
A out there. US and Australia are low in incidence but we have pockets of Hep
A. Users of injection drugs are high in incidence. Can be killed with bleach.
Jui - "My job here is to put the fear of God in you." Infection
control folks do not understand EMS. We have a lot of splash exposures in EMS.
14% are to non-intact skin. 16% of prehospital providers screened had Hep A
antibodies. Vomit aerosolizes! Families can be at risk during the incubation
period. If you have been vaccinated and then exposed, get another dose after
exposure. There is post exposure prophylaxis: GamaSTAN S/D. Older individuals
over age 50 can be killed. If you contract you will be off work 2 to 3 months.
None of us are immune. 90% of those who come in contact with measles will
contract it. Incubation is about four days, with rash about five days after
starting symptoms. We live 8 hours away by aircraft from epidemics. Do not
forget that.
Savinsky - Hamburg and O'Donnell - Indianapolis: Ruling out
mitotic disease and FMS for EMS - 1000 different substances in smoke. Some are
harmful. Firefighters inhale and absorb them through the skin. Create
awareness, Educate and then equip for prevention. The last point is long term
and expensive. We don’t want to see soot anymore. We do not want firefighters
getting cancer from their exposures and gear. Use SCBA. Protect skin. Don’t eat
or drink at the scene before washing face and hands. Get out of PPE on scene.
Showers should be between garages and restrooms. Air lock in the station
between clean and dirty areas. Specific places for cleaning. Maybe have a pool
of various sizes of PPE. Biomonitoring should be implemented (being studied in
Germany). Start a register of exposures (log). Care for those affected.
O'Donnell - Comparison of injury in the workforce. Functional Movement
Screening assesses movement capability and predicts injury. Finds limitations.
People volunteered for the initial program and had to be seen in 2 follow up
visits. Less time lost for those who are injured who took the screening. Costs
were less as well. Savings of $37k over 10 months and 21 injuries. EMS is a
house of pain! Consider FMS as part of your injury risk plan.
Taillac - NASEMSO: Managing Fatigue in EMMS - EMS is also a
fatigue place. Evidence-based guidelines are now available. 1) Incorporate a
tool to measure fatigue, 2) Work shifts less than 24 hours, 3) EMS workers
should have access to Caffeine, 4) EMS must be able to nap on duty (end
sleeping policies that deter napping!), 5) Teach stress reduction and issues
that reduce sleep. nasemso.org/projects/fatigue-in-ems
Mechem - Philadelphia: When EMS Providers are victims of
violence - 3500 EMS assaulted in 2016 were seen in EDs. Surveys show that 88%
verbally assaulted and 80% have been physically assaulted. Training on situational
awareness and verbal de-escalation is needed. Males and females are equally
likely to be assaulted. Women more likely to be injured. EMS is 14x more likely
to be assaulted than firefighters. Underlying patient conditions contribute to
the assault. Personal protection tools are shown to be desired. Incidents need
to be reported. There needs to be follow up both with the EMS victim and with
prosecutors to assure charges are followed up on. SAVER project is trying to
identify a checklist for risk factors. Apps need to be developed for reporting.
Need better reporting and research. Can impact job satisfaction and longevity.
Dunne - Detroit: EMS Wellness Experiences in the Motor City
- In 2013, no N95 program or TB testing outside the EMS division. TB test solution
was not even stored properly. 2015, 900 EMRs were added and it was time to
clean this up. Created a compliance center and employees placed on a rotation
basis based on pension number and had 30 days to complete TB and fit testing
and review immunizations. The started a vaccination program. Fit testing is
quantitative. Working on a wellness and rehab program. Looking at expansion of
the vaccination program to other agencies like LE.
Isaacs (Dallas) and Moore (NHS): US and UK Initiatives for
First Responder Wellness - Isaacs: PTSI (post-traumatic stress injury not
disorder). Multiple events over months and years impact this issue. Suicide of
first responders should never happen. Many feel a stigma if they come forward
for help. Many fear being labeled as week. If we can’t talk about it how can we
address it? 30% of responders have problems with alcohol. We need initial
training and ongoing training beyond CISM. Dallas implementing a response
algorithm. There is a book called the Resilient 911 Professional. Employees
come first. If you take care of them, they will take care of the patient.
Moore: 40% report feeling unwell due to stress. This is an increase over past
years. Excessive workload and pressure from management cited as big stressors.
Retention was poor. Staff did not feel cared for. No single point of contact
existed. Pilot ws so successful that it was fully implemented six months early.
Used a directory of services, direct referrals, out of hours support and more.
Used most by frontline staff which would be expected. Used workshops and lunch
and learn sessions. Improved retention by 6% over one year. Reduction in long
term illnesses as well. Therapy dog was implemented.
Weber (Chicago), Mason (Little Rock), Bronsky (Colorado
Springs) and Goodloe (Tulsa/OKC): Best Practices in CVA Management - Mason:
Only three hospitals in his area can care for large vessel strokes. This is an
operational nightmare. Used RACE scale. RACE was 54% accurate in the assessment
of LVO. There is some over triage. Weber: LVO scales have real world
limitations. Window is now out to 16 hours and even 24 in some subsets. There
are a bunch of scales and they use different combinations of measured findings.
Some elements are not routine assessment items for EMS. There is no perfect
scale for the prehospital setting. None are validated for EMS use. The result:
Over and under triage. We need a single tool for all strokes, not one tool that
indicates to use another. Goodloe: Escaping perfection in EMS stroke care.
Right destination is important. There is no perfect stroke screen for EMS. What
is the normal baseline? What is abnormal from baseline? Neuro deficits? Can it
be fixed (Hypoglycemia)? The Sensitivity is weak in these scales (around 70%).
EMS cannot accurately screen LVO at this time. Just go to a comprehensive
stroke center. Trust your instincts. Bronsky: Time lost is brain lost. Using a
tool that can be used while moving and uses satellite, cellular and Wi-Fi
without dropping. It allows a stroke neurologist to talk with the medic and see
the patient while moving in the ambulance. No need for a stroke ambulance with
CT. It creates a true integration of care.
Sporer - Alameda County: TXA management across several
counties - The sooner you get it the better the outcome. About 10% improvement
in mortality for every 15 minutes saved in bleeding trauma. 362 patients with
severe trauma got TXA. Not a randomized trial but an outcome review. 3.6% mortality
in the TXA group and 8.3% in the control. Significant decrease in transfusion
volume. The hospital side infusion is sometimes missed.
Manifold - NAEMT: What is the best dose of TXA in TBI? - 2gm
bolus seems to be beneficial in ICH. Double blinded trial. Either got 2gm
bolus, 1gm bolus and 1gm infusion or placebo. Overall no improvement. 10%
improvement in mortality in subset with ICH. It is the first therapeutic with
evidence of benefit in acute ICH.
Miramontes and Winkler - San Antonio: EMS Carrying Whole
Blood - Whole blood has everything you need to promote clotting in one package.
No need to do component therapy. There are a lot of logistics that take extreme
planning and tracking. It is $500 a bag. It cannot be wasted. It is a vital
resource that cannot be wasted. Must have regular donors and infrastructure.
Must have low titer O Positive donors. Blood must be kept cold. Training does
not use regular EMS supplies. Mainly carried by supervisor units and two
ambulances in strategic locations. Case study on trauma arrest patient with a
spleen laceration. Whole blood saved her life. Used for GI bleeds and post-partum
bleeding as well.
Colwell - San Francisco: Continuing Major Myths in Trauma
Care - 1) Binding pelvic fractures - no need to x-ray before binding the
pelvis. Not being done enough. No data that suggests harm with binding the
pelvis. Close the book. Don’t need a commercial device. MAST may work for this
(2017 article). Sheet tie is enough. 2) Ketamine and Head Trauma - it does not
raise ICP. Period. It has been debunked. 3) Cervical Collars are good - not!
Used way too much. Never based on data. May be harmful. Routine use can be
safely avoided. No evidence that it immobilizes. Increases ICP. Complicates
airway management. Patients don’t like them. Joint position is out from NAEMSP,
ACEP and ACS-COT on spinal restriction. No SMR in penetrating trauma! 4) Pain
management is bad - We are still not treating pain well. Many reasons. We must
remember that masking symptoms is not an issue, but when the need is real take
care of the pain. Ketamine is great for pain. 5) Fluids in trauma - We are
still giving too much fluid in hypotensive trauma patients. Dilution is bad. We
are causing dilution and affecting coagulopathy. No role for fluids in
normotensive patients. Limited role in hypotension. 70 systolic is acceptable
for permissive hypotension. Do not use saline for sure. If you use fluids, use
lactated ringers or PlasmaLyte. No prehospital survival benefit in giving
plasma either. Blood products are the answer. Use caution with TXA as this is
not clearly defined as when to use and how much. Data is still coming in on
TXA.
Yeh - San Francisco: Electronic Scooters - Don't drink and
scoot! Thousands of these appeared and it was mayhem. Injuries, traffic issues
then a ban. Then there was a pilot program to reintroduce. Scooters are an
invasive species. Lack of regulation is bad on these. Injury patterns? 40% had
head injuries. 31% had fractures. Not wearing a helmet and intoxication were
common factors. EMS data is matched with trauma registry data on scooter
accidents. CDC is measuring this issue in Austin. ACEP has a scooter campaign
for safety.
Eckstein - Los Angeles: Confined Space Amputation - Very few
systems have protocolized ways to get professionals to scene to do a field
amputation. Case study on a response for a hospital emergency response team.
HERT team has only been activated about a dozen times in the last 30 years.
Challenges with access to site, access to the patient, confined space, heat and
coal dust. Legs caught in an auger in a coal hopper. Used a reciprocal saw to
perform the amputations after the auger could not be reversed manually. Humeral
IO was used to give Ketamine. 90 minute extrication. He went into arrest and
was resuscitated. Six minutes in ED before going to surgery. Fair amount of
press on the incident. Survived. Patient does not remember a lot about the
incident and does not remember the amputation experience. Any low frequency
high risk procedure needs review afterwards. No egos made this a successful
incident.
Donofrio – San Diego: Heeding the Bleeding, the Special Case
of Pot-Partum Hemorrhage – Most of the wealthier nations seeing a drop in
maternal mortality rates while the U. S. was increasing in mortality.
California reversed this trend in that state. The trauma triad of death is not
unique to trauma. Coagulopathy, metabolic acidosis and hypothermia can occur in
post-partum hemorrhage as well. California labor and delivery centers made
changes: Made preparations to stage needed items and stop the bleeding and made
provisions for early packed RBCs and massive transfusion protocols. This starts
in the field! Perfusion matters. Oxygenate, keep warm, stop the bleed, early
blood and TXA, and transport to definitive care. California has bucked America’s
mortality trend and so can you.
Manifold - NAEMT and Bronsky - Colorado Springs: Early
detection of shock - compensatory reserve. Vital signs do not help us predict
who is going to live or die in shock. CRI gives a model of the patients’
ability to compensate during shock. Gives an earlier warning of shock in the
prehospital environment. CRI useful in continuing resuscitation in shock
trauma.
Frascone - St. Paul: Elevated CPR Update - Head must be
raised slowly. Prime the system with CPR before elevation of head. There is a
preferred sequence. Human studies starting soon. Currently using pigs on a tilt
table. Uses ACD CPR and ITD combined with head up elevation.
Colwell - San Francisco: Subtle ECG Changes You Might Miss -
12-lead ECG? Paramedics are accurate at interpretation. Prehospital 12-lead
reduces time to balloon in cardiac cath lab. RBB: the right bundle pattern can
confuse the machine. ST elevation in RBB is unusual. Any issue in V1 to V3 with
elevation in RBB may actual STEMI. Hyperacute T waves, specifically de winter T
waves can be an evolving MI followed by classic ST elevation (has upsloping ST
depression). Wellens’ Warning: an evolving waveform with biphasic T wave
inversion becoming symmetrical and deep. May indicate LAD occlusion. AVR the
forgotten lead: not always non-diagnostic. Serial ECGs: Repeat ECGs are very
important. If you can capture a piece of the story you are ahead of the game. Repeat
with any patient change.
Slovis - Nashville: Five ECG Changes with high potassium -
Hyperkalemia is the most dangerous electrolyte abnormality there is and kill a
patient during the short time of transport. Always use ECG on dialysis
patients. T up, P down or wide QRS, think Hyperkalemia. T goes up, P then goes
down and away, then the QRS widens as the potassium goes up. It evolves. Main
cause of a sine wave QRS is hyperkalemia. Calcium Chloride 5-20ml. If
bradycardia with hyperkalemia, calcium is lifesaving. Atropine probably will
not work.
Gautreau - San Jose: Recognition of Brugada - Case of a 20
year old healthy athlete, body temp elevated at football practice. Medics show
up, transport denied. Two weeks later he died. V1 and V2 will show elevation.
Look for this after syncope. Brugada is genetic. It is a sodium channel defect.
It causes Ventricular Tachycardia and Ventricular Fibrillation. Kills young
people. More prevalent in Southeast Asia. Young people with syncope should not
be an easy refusal. Looking for things like this creates a culture of
excellence. Issues like Brugada are at the heart of learning medicine.
Youngquist - SLC: ECG analysis in arrest - Can paramedics
define fine VF from asystole? In most cases yes. VF should not be allowed to
persist without shock. 70% of the time it is within 2 minutes of recognition.
Pruett - Albuquerque: POCUS in OOHCA - Using Phillips Lumify
and an Android tablet. Deployed with supervisors. Supervisors go on every high
acuity call. Trained in ultrasound by physicians. Looking for one thing: Is
there any squeeze going on in the heart. Video can be uploaded from the device.
PEA case: PEA with rate of 60 to 80 and ETCO2 of 50 to 60. POCUS showed heart
was actually beating. Used pressors. Ended up being hypotensive from Pneumonia.
Survived. Another PEA case: rate 120, POCUS showed actual beats, again used
pressors. Was resuscitated by succumbed later. Another case: PEA with rate of
37, went into asystole. Asystole confirmed by POCUS. Limit time off chest for
POCUS.
Gilmore, Levy and Jarvis: Improving STEMI Systems of Care -
Covered history of the development of STEMI systems. False activations are not
harmless. If no ST Elevation in two contiguous leads it is not a STEMI.
Feedback to medics must be given to identify false positives. Cannot be done by
discharge diagnosis. Must be based upon what the medic saw and interpreted at
the time, in the moment. That is what determines whether it was a false
positive. Speaker got cardiologist to look at it from that point of view. Do
not forget the patient story in connection with the 12-lead ECG. If either
story or ECG is viable speaker calls a STEMI alert. Review should use the story
and the ECG for training. Starts with story only then look at the ECG.
Transmission of 12-lead? Most do. Most are not transmitted directly to
cardiology. STEMI criteria used by most. Most do not require specific symptoms
to activate the cath lab. Highly varied response on acceptable over triage.
Frascone, Fumagalli and Keseg: Extra-corporeal Technology
and Mobility - Frascone: Used in recurrent VF. Video of ECMO being placed in
the cath lab. 4.5 minutes to start ECMO. Being very fast in application is
important. 40 to 50 minutes arriving at ECMO is the sweet spot. ECMO usually in
within 7 minutes of arrival. CPC of 1 in most surviving cases. 45% required
IABP. 91% of the patient showed that cardiac arrest was their first sign of
cardiac disease. All had severe left ventricular compromise. Why are we
thinking about mobile ECMO? Takes 72 hours to train the physicians. The
ambulance for this will be huge (21 foot box). There is a 20 million dollar
grant for this. Does it have to be physicians? Is it worth it? Vehicle will
respond to hospital needs or intercept with ambulances. "This is not a
fantasy." They are actually approaching phase 1 (August 2019). Keseg:
Protocol for ECMO shown with inclusion and exclusion criteria. Mechanical CPR
required. They have had five survivors in Columbus. Lactate levels seem to be a
factor in survival. Again CPC of 1 in survivors. Small numbers though. If the
hospital does not play after alerting it becomes a morale issue. Fumagalli (Milan,
Italy): Italy has a regional based healthcare system. He is from Milan. Manual
CPR produced better outcomes than mechanical. Used ECLS. All of those who
survived had a shockable rhythm. Five hospitals have an ECLS team.
Levy - Anchorage: Mechanical CPR, Difficult to Prove -
Discussing Time Bias in observational resuscitation studies. Time frame can be
a factor. Looking at time frame can reverse results of a study. The fact that
early saves occur before mechanical CPR during standard CPR means it cannot be
compared to mechanical CPR because mechanical CPR never occurred. Be careful in
what you are comparing.
Sporer, Miramontes and Scheppke: Regionalization of Cardiac
Resuscitation Centers - Scheppke: A bundled system of care. You have to look at
the whole system to produce outcomes. Trained a lot of public and implemented
PulsePoint. Then implemented ITD with ACD (flow oriented therapy). Sporer:
Discusses resuscitation centers. Again, PulsePoint used in his system. Train
CPR in 7th grade. They train the 7th graders to go home and train adults in CPR
at home. Uses PIT crew CPR. Has had arrest centers since 2013. Mechanical CPR
did not increase survival but did help with CPC level. Uses CARES for arrest
performance measurement. Case study given of a patient progressing through the
entire system, CPR for four hours with good neuro survival. One starting place
is to send all ROSC patients to STEMI centers. Miramontes: Discusses San
Antonio. Three arrests a day. Has a regional system with trauma and STEMI
centers. Now has resuscitation centers. Used the Take Heart model. Remove
inconsistencies between facilities. Resuscitation centers have to be a high
volume STEMI center. ECMO will soon be at the main center. Targeted temperature
management is a must. The sicker they are the longer they need to be cooled.
Resuscitation has to be a system of care. Family support through the whole
process is a must as well. There needs to be an "Attack Nurse" keep
everyone accountable to adhering to the process. Post arrest survivor support
is another component. ROSC with STEMI goes direct to cath lab. ROSC without
STEMI goes to cath within 2 hours. Another case study of success was presented
by the patient and his wife. He states the destination played a critical role
due to ECMO. He and his wife both discussed the stress associated with the
event.
Levy - Anchorage: CPR LifeLinks: A national initiative to
link EMS to 911 centers. 911 dispatch is a component of CPR chain of survival.
Toolkit produced. You must measure to improve. Toolkit will be up April 1.
Antevy - GBEMDA: High Performance CPR for Kids - Every wolf
in a Pack has a role. The Pack does not work if the roles are not complete. The
same must happen with CPR. We do
Donofrio - San Diego: Why we are no longer using PALS: Every
minute of not breathing takes four minute of ventilation to keep up in a
newborn. Two things you need to know: Are they breathing and what is heart
rate? Ventilate and do CPR if the heart rate is slow. Mom and baby protocols
should be in the book together. We don't have two specialties (OB and neonatal)
in the back of an ambulance, we have one paramedic who does both. OB and
neonatal events occur at the same time, run scenarios that way.
Weber & Tataris - An Interdisciplinary Approach to
Mental Health - Chicago: Large fire-based EMS system. One in five Americans
will suffer a mental illness. One in twenty five live with a severe mental
illness. Chicago has a lot of gang violence. Chicago Police have worked with
NAMI to make CIT teams. Over 64,000 combined CIT and mental health responses
between police and EMS. That is using a non-coordinated response which can
cause confusion over leadership and policies. NAMI brought police, EMS,
dispatchers and the medical directors together on the issue. Now a unified
Crisis Identification and Management Training Course. Using an alternative
destination as well. Transport to the ER is not the right destination.
Sporer and Miramontes: Miramontes: Bypassing the ED to a
special mental health unit - Created an easy button for LE to get mental health
to a correct destination without a lot of barriers. Get them to the right place
at the right time the first time. Trained police to medically clear mental
patients. They already knew sick from not sick. If not sure there was a hotline
to call. Still availability to call EMS to sedate to take to ER. If trauma
including wound care, OD, super drunk or super high or ports, tubes, lines or
oxygen then cannot go to an alternative destination. Mainly males 18 to 54.
Sporer: We are in the middle of a mental health crisis in this country. 10% of
EMS calls. Patients need more than a quick ride to an ED. De-escalation is
every day. Alameda County Care Connect created to have a standardized approach
to the homeless and psychiatric cases. That takes an army of social workers.
Just patients having an ID is a huge problem. Looking at increasing use of
Olanzapine. Mental health workers will soon be paired with an EMT. EMS will be
able to see where beds are available. Projecting 10 units doing this per day in
the next year.
French - Charleston: Treatment through TelePsych - About 80%
of mental health patients were being transported to the ED. Mobile Crisis team
was there but could take up to an hour to get to scene. Soon learned that they
had more services available and EMS wanted to partner more. Linked via
tele-health. Used meeting room technology for video assessment. ALS ambulance
with a QRV response. Must have no medical complaint. ALS ambulance clears and
QRV stays with the patient and LE and tele-psych assessment is started. This
allows mental health clinicians to see the patient and reactions. If transport is
needed, it is provided by LE. EMS personnel became Notaries for witnessing
detention holds. Alternative destinations used here as well. EMS transports
reduced dramatically. 80% down to 5% transport rate for psych. 50% are kept out
of the ED. 10% go straight to a psych bed in a facility. From 2017 to now there
have been over 670 diverted from ED. For this to work you have to change the
patient disposition.
Ellis - Auckland: Reducing EMS Responses Despite Increasing
Call Volume - Not everyone needs or wants a transport to the ED. Assessed runs
where no transport went wrong to assure safety. Found some recurrent themes,
mainly around complete assessments. In the program some are scheduled to see a
nurse practitioner. Patient is full assessed and has to agree to alternative
treatment. Vital signs have to be normal. The patient has to be ambulatory and
be able to go to the bathroom unassisted. 30-35% non-transport rate. Discussed
low rate of adverse events associated with non-transport.
Calhoun - Cincinnati: Capacity to decline care - Capacity is
needed for patient safety and legal declination. Educated his system on
capacity. Where you trained? Do you have a system to figure out if capacity
exists? Orientation and GCS of 15 does not equal capacity. Can they understand
the information and appreciate the situation and consequences? Can they
manipulate information rationally? Are they making the decisions themselves?
You must provide them with detailed information about their condition. Have
them explain to you why they do not want to go. Is it rational?
McVaney - Denver: It's Not Just an Opioid Crisis - We hear
about the Opioid Crisis all of the time. All the talk is on this topic. Denver
commissioned a data person to look at the numbers. Denver is flat on opioid
deaths year over year. Found that Meth was the real culprit and was a component
of multiple causes of death including trauma. Denver's drug story is
polysubstance abuse deaths. The most common OD death was five or more drugs.
This is a drug abuse crisis not an opioid crisis.
Lightning Round: 1) Eagles agree that Opioid is not the core
of the drug crisis. 2) Discussed bundling cardiac arrest therapies like ITD,
ACD and HU CPR. 3) Complications of ITDs: Pulmonary Edema an occasional
complication but it could be treated. 4) Time frame of LUCAS application? Most
not applying right away. You cannot stop CPR to apply the device. Keep doing
CPR during application. One location applies Autopulse as soon as possible.
Paris using LUCAS as bridge to ECMO in recurrent VF.
Slovis Education Award: Glenn Asaeda - NYC. Copass Award:
Miramontes - San Antonio.
Jarvis - GETAC: Striking similarities of issues between
urban and rural EMS - Maybe they are not that different? Skill dilution is a
thing. It is a ratio of skills vs number of paramedics. None of us measure our
practices the way we should. All of our needs are greater than our resources.
We all have a trash can for our long spine boards. The work we do is dangerous.
Everyone hates being treated badly. Ketamine works everywhere. We get assaulted
everywhere (this should be zero tolerance). All systems are above average at
intubation until they look at their data.
Gautreau - San Jose: Cultural, Logistical and Clinical
Demand differences faced by subcontinental EMS Teams - In India traffic is a
huge issue. Cows are in the streets. There is no traffic control. No helmets on
on two-wheeled transportation. Half of the deadly snake bites in the world
happen in India. 30% of EMS calls were for women in labor. They did a
tremendous amount of training in childbirth. They want the EMS team to deliver
their baby but wanted to stay home after. This resulted in a high rate of
perinatal mortality due to postpartum hemorrhage. Once they made transport home
available, this changed. Animals are their livelihood. They now have a
veterinary ambulance that does procedures on site. India has a wide income
disparity. Large industries have to give back to the community through large
ongoing public service projects such as EMS support.
Carli - Paris: Managing the Labor Protest - Still ongoing.
Multiple currents in the protest. Decrease of revenue, retired complaining
about taxes and other issues. Protests are blocking traffic. Mass gathering
protests every Saturday. Violent protests last November and December in Paris.
They wear yellow safety vests, hence they are called yellow vest protesters.
Massive use of non-lethal weapons being used by law enforcement. Rubber bullet
guns being used. Over 10,000 rounds have been fired. Rubber ball cannons
causing head and orbital trauma. Tear gas grenades are being used. Rubber
stinger grenades cause blunt and penetrating trauma. So far 144 severely
injured protesters so far. Eleven deaths due to traffic blocking. Traffic jams
affect response. Very difficult to access. Many fires being set. "Street
medics" have no relationship to EMS. Hospitals get walking wounded.
Transfers occur due to specialized need impacting the system.
Savinsky - Hamburg: G20 Summit and Hamburg EMS - Business as
unusual. First objective was no disturbances. No restrictions affecting
individual medical care. Response times established during the summit.
Preparations needed for mass demonstrations. Scheduled for mid-summer during
heat. Massive press coverage was expected. Hotel rates skyrocketed. Did exercises
in preparation for the summit. Practiced decontamination. Exercised with police
forces. Set up national and military medical support. Twenty four military
physicians were utilized. Twenty one emergency hospitals were placed into the
plan. Looked at each hospitals ability to handle 50 patients. Looked at making
sure psychosocial emergency care was available. Purchased triage kits. Six MCI
support vans. Additional support from other countries. Established medical
outposts.
Asaeda - NYC: Mini-ambulnces for Major Incidents - 2017 was
a busy year for NYC. Several multiple patient incidents. Times Square
intentional jumping of curb and hitting
Cabanas - Raleigh: Telemedicine During Hurricane Florence -
Three Raleigh shelters received busloads of evacuees with chronic medical
issues and special health care needs such as oxygen. They contacted a
telemedicine group to provide equipment and they set up Wi-Fi at the shelters. Prehospital
providers then worked as the eyes and ears of physicians to do minor care,
prescription refills and other areas of need. Average wait time at the site to
be seen was 5 to 7 minutes.
French - Charleston: Tele-education - Proven teaching method
in medicine. Limited access to equipment. Can be expensive. Allows you to share
expertise over a larger area. It is hard to teach decision making with a
PowerPoint. Tele-education helps when you still have to run a 911 system. You
can also do distance simulation. What if the facilitator stays in one place and
the simulation occurs hands on at a different site? Best of both worlds. Not a
replacement for full simulation training, but helps increase frequency. Start
with a pre-test, then a recap lecture, then scenarios, a debriefing and a post
test. Improved confidence of personnel and high training satisfaction.
Gallagher and Jui: Gallagher: Realistic Simulation Models:
Made a simulation center with an ambulance, residence, street, bar and yard.
Had availability of many medication
Scheppke - Speaking for Augustine (Eagle's Librarian): Tales
from the Eagles Emails - Eagles conversations are tracked. They poll each other
to see what is being done to improve patient care, make life better for
responders and be better
medical directors for the populations they serve. They
upload and exchange policies and write position papers. 95 members. Overseeing
507 agencies covering 82 million people with medical direction. Covers 13
million EMS responses. Eagles is publishing an Opioid statement. Discussions on
TXA, IV fluids and blood products. Medication shortage list is still 106 lines
long. Glucagon is a discussion issue (many went with drill and fill with D10).
Service animals were a topic of discussion. Stroke scales were a big topic of
discussion. Palliative care protocols increasing. MPDS response level
distribution across the nation is being compared.
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| What is your MPDS distribution? |
My note: I had the privilege, after an idea expressed by Dr. Peter
Antevy, to introduce Dr. Peter Stevenson in celebration
of his 40 years as
Medical Director of AMR Evansville and predecessor companies. He was very
surprised. He was also recognized for his donation of paying half of the costs for any paramedic wanting to attend this conference (20 individuals over the past two years) from AMR Evansville and Posey County EMS. Thank you to Dr. Paul Pepe and Dr. Peter Antevy for recognizing him!
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| Dr. Antevy, Dr. Stevenson & Dr. Pepe |
Eckstein - Los Angeles: Evolution of MIH in LA -
Homelessness on the rise. Had rats in city hall. Disease outbreaks. 4.2 million
Population with 650 transports a day. Utilize Advanced Practice Providers.
Goodloe - Tulsa/OKC: Destinations Other than Traditional
Hospital-based EDs - Sometimes making a difference decisions are really no big
deal to make. They are logical. They make you ask why we have not been doing
this all along. He was receiving individual call requests to go directly to where
patients needed to be so they decided to make it standard practice. Right
treatment includes right transport modality and the right destination for
continuity of care. In cases of surgery, it needs to be related to a planned
surgery within seven days or related to a surgery at a facility within 30 days
after. Surgeon must approve before leaving scene with a 10 minute time limit.
Micro hospitals are free-standing EDs with five to ten bed in patient units
attached. Now transporting lower acuity COPD/Pneumonia, cellulitis and
gastroenteritis to the Micro hospitals. Paul Pepe then covers paper from
Prehospital Emergency Care (PEC) Journal (NAEMSP) on the safety of transporting
to free-standing EDs. FSEDs are becoming more common but are inconsistent
operationally. Could transport to FSEDs improve turnaround times? Can it be
done without creating secondary transports to higher level of care? A protocol
was developed between EMS and a FSED prior to the FSED opening. 625 transports
analyzed. Minor injuries, muscoskeletal complaints, dizziness/headache,
slightly AMS. 16% received secondary transport. AMS was 4% of the total. Dr.
Antevy followed up and none of these patients died. Patients were satisfied.
Impact on EMS? Slight decrease on turn arounds at about a two minute per run average.
Overall transport to FSED is safe in this particular model.
Antevy - GBEMDA: An IT-based Non-Emergency Patient
Navigator: What if the patient needs food? What if their wheelchair is broken?
If you get involved you can help keep people sober (52% at one year). You have
to document the course of each patient to prove the value of these programs;
overall numbers are good but they do not tell the stories. Grant money will not
last. The project has to be sustainable and you must have the data to prove the
value. If it is dependent on grant money, do not even start. Unique software
can get silos of data to coordinate. The MIH paramedic can advise multiple
entities of what is being done (from hospitals to mental health providers) with
one entry. Julota is the name of the software. Essential to ET3 involvement.
The 2019 Great Debates!
Round 1:
Dr. Tataris "Southside Katie" vs. Dr.
Sophia "The Fenway Fender" Dyer - Endotracheal intubation: Essential
or detrimental?
Tataris: Her system does 600 intubations a year with no
DSI/RSI in Chicago. "Intubation is a dinosaur." SGA is better than
ET. Less harm with SGA. Look at good airway research. No strong evidence to
support intubation in arrest. No known benefit for peds either. ET is a complex
skill. “Intubation is a unicorn.”
Dyer: "Katie, you are wrong. People like
unicorns." There is some data to support RSI and ET. Attempts are an issue
and we should not be doing multiple attempts at ET. What about bougies? Apneic
oxygenation? Capnography? Most agencies still have ET as the primary airway. ET
use is only as good as your QI program and you need to have 100% case review.
Who won?
Round 2:
Dr. Ray "Sugar Ray" Fowler vs. Dr. Terrence
"Be Very Wary" Valenzuela - What about Epi?
Fowler: Con. It is not really clear whether we should use
Epi in cardiac arrest. Where is the evidence? Evidence that it causes worse
neuro outcomes even with higher rates of ROSC. Japanese Utstein database showed
that when they added Epi to an all BLS system, survival went down. Paramedic 2
trial was a randomized trial of 8000 patients. No significant difference
between Epi and placebo on survival and Epi had worse neuro outcomes. Epi may
causes suboptimal oxygen exchange. Epi may had adverse effects on receptors in
the brain. Covered A&P of hypercoagulopathy in arrest. 112 years ago they
stated that Epi could resuscitate if within one minute of arrest. At three
minutes no (in dog studies) survival.
Valenzuela: "All of Rays’ people have left for the bar
at the airport." Use of Epi is controversial. There was science in the
adoption of Epi dating back to 1968. Without the Epi there was no ROSC in that
study with dogs. With Epi, seven dogs got ROSC, three were neuro intact,
meaning if you threw the ball they would chase it. 2012 Japanese study showed
greater ROSC but less survival at 30 days. You must carefully consider use of
Epi. Perkins study from 2019: Epi causes severe neuro impairment in arrest
survivors. Another 2018 article says keep using Epi while we look for the key
to better neuro outcome. Nichol in 2016 asked what it would take to change practice.
The better your performance is now the larger the numbers must be to get you to
change with results. Future research needs to focus on neuro protection.
Who won? Epi is unclear.
And that is it for Eagles 2019. This group has been meeting to enhance and improve EMS for the last 21 years. Many of the faces are the same that you will see at the NAEMSP Annual Meeting as well.
The PowerPoint presentations for this and past years can be found at: http://gatheringofeagles.us/
So, I have been through the scareports, boarded the
Again, a special thanks to Dr. Peter Antevy and Dr. Paul Pepe for honoring Dr. Stevenson's 40 years of medical direction in Evansville.
Thank you Dr. Peter Stevenson for going the extra mile to get quite a few of your local paramedics to this meeting experience to enhance their knowledge.
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| The 2019 group from the Evansville area representing AMR Evansville, Deaconess Hospital and Posey County EMS |
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| Shannon Marshall thinking INSIDE the box |
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| Maybe not... |
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| The view from the scareplane on a snowy return to Evansville from Dallas |
