Faith, Family, Forests and the Field: Eagles XXI: My Notes from the 2019 EMS: State of the Sciences Conference

"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

useful and has patient benefit when performed by persons skilled in the application. We can fix the frequency of peri-intubation hypoxia. 2% of all ED intubation attempts end in arrest. It is predicatble and preventable. Watch SPO2. Stop intubating hypoxic patients. If SPO2 is not at 94% or above, chance of peri-intubation hypoxia is high. Increase the saturation BEFORE intubation. Position the patient, PEEP, two-handed seal, ETCO2, apneic oxygenation, flush rate O2, DSI. Do not intubate unless at 94% for at least three minutes. Sedate with Ketamine to be able to do what you need to do. Rate of peri-intubation hypoxia dropped from 44% to 3%.

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

pumps and have one pressor: Epi. Symptomatic bradycardia, non-hypovolemic shock, and post ROSC hemodynamic support are the three major prehospital uses. Math is bad. 1mg Epi, 1L Saline, wide open to clinical effect, concentration is 1mcg/ml, 20-30mcg a minute. Macro drip set. Medics loved it. Simple. Easy to train. Not worried about volume overload in a system with 10 minute transport times. Overall positive.

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

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. 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. The document is on the web site, but not yet officially released.

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 seat back pocket on my flight
home. Someone before me had
used a lot of Ricola!

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?

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.

https://www.ems.gov/projects/cpr-lifelinks.html

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

this well with adults. Kids need to have the same benefit. Stay on scene with pediatric arrest just like you do with adults. If you move early you are delaying care. Dispatch is typically delayed starting CPR via telephone on kids. Do it the same you do with an adult. Start CPR at the same point in EMD where you do an adult. Pre-plan while rolling when you know it is a pediatric arrest. Pre-planning is

a game changer. Someone stays with the family and tells them why we are not leaving and explains each intervention. LifeLinks reflects this also.

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

bystanders. One killed, 20 injured. Fire commissioner wanted a different type of apparatus for mass gatherings. Mini-ambulances are used in other areas of the nation. Full size stretcher. Has heat and AC. Controlled cab to protect crews. They have ten and want five more. Assigned to high crowd areas. $60,000 each.

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

containers to be used in the simulations. Proctors are out of sight. Crews discuss simulations off of videos after scenarios. But it still was not real enough. How to decrease the level of realism? Credentialing must measure affective ability and critical thinking. Simulations have to be reproducible and fair. It must be measurable. Put interpersonal relationships as a component of credentialing. These are non-negotiable items to prove performance. Jui: Low Tech simulation of critical simulation. Used a manikin and connected it to a drill to pump and made a mechanism to pump simulated blood vomit into the esophagus of the airway manikin.

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

What is your MPDS distribution?

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.

My note: I had the privilege, after an idea expressed by Dr. Peter Antevy, to introduce Dr. Peter Stevenson in celebration

Dr. Antevy, Dr. Stevenson & Dr. Pepe

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!

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.

They have a sober unit also. Transport to sobering centers once medically cleared on scene. Establishing public-private partnerships. Healthcare orgs pay for the APP, LAFD funds the paramedic on the APP truck. Had to get buy in from the IAFF. SOBER unit transported over 500 to the sobering center in the first year of operation. 32,000 hours of EMS and healthcare utilization avoided by SOBER. Telemedicine coming to the 911 dispatch center. An

alternative destination unit is being launched in April for mental health patients. Two medics with additional training will clear metal health patients for an alternate destination without higher approval. Financial stability is always a challenge. Applying for ET3 funding. Reconsider if you are "You call, we haul."

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

scareplane and now sit finishing this our kitchen table. Hope you fins as much value as I have have in the content.

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.