Eagles XXII: My Notes from the 2021 EMS State of the Sciences Conference

Here we go again with the raw notes from this years meeting. Just the usual disclaimer that I have attempted to be accurate and also decrease grammatical and spelling errors, but... these are taken in real time so no promises. I also missed about three of the shorter lectures while networking and also doing an interview on the Handtevy use in our local EMS system. This year, I drove about a thousand miles rather than flying and I have to admit it was good to get out on the road after over a year of living under the dome so to speak. So here are my notes on 95% of the Eagles meeting:

Day 1 - Eagles 6-17-21

“Welcome back my friends to the show that never ends. We’re so glad you could
attend. Come inside, come inside…” Paul Pepe officially opens the Eagles meeting. Eagles was opened by Paul Pepe, Chief Julie Downey and Ray Fowler with a special salute to Chief Donald DiPetrillo.

 

Many of the European Eagles counterparts are joining via online meeting platform. Pierre Carli (France), Fionna Moore (UK), Mick Molloy (Dublin) (20% fully vaccinated), Roberto Fumagalli (Milano) and others gave short updates on issues worldwide including COVID and vaccination percentages. France is now no masks. Delta cases of COVID on the rise slightly in the UK. Both France and Italy reporting 50% vaccination rates. “We wish this to be over.” – Fumagalli.

 

Scheppke (Florida EMS Medical Director), Antevy (GBEMDS) – The Eagles Re-nest with the Seagulls – Lamping the Way: Safety at the conference. Floodlamp Biotechnologies can test hundreds of people for COVID in less than 30 minutes. Doing a study with testing at the conference.

 

Scheppke (Florida EMS Medical Director) – Heads Up CPR Update: How do you add more water to a full bucket? You must tilt it out. You must use gravity to drain venous blood from the brain. We also do not want all the blood in the legs during cardiac arrest. Heads up CPR is a complex, timed bundle but provides optimal blood flow to the brain in arrest. Six sites using device to slowly elevate head. ROSC improved when applied early in arrest. This was for all rhythms (not just shockable). Standard CPR was one minute faster to apply but that group did not do as good on ROSC. Reporting tripled and quadrupled survival to discharge neuro intact (and improves the earlier the device is applied). The device to elevate the head only produces higher outcomes when combined with ITD and automated CPR. The three in combination provide the improved outcomes (across all rhythms). Controlled sequential heads-up CPR is producing better outcomes and is a “tremendous improvement in resuscitation.” The device is defined as BLS by the researchers. A survivor of cardiac arrest where the device bundle was used spoke and went over contents of the bundle. The speakers stressed the importance of knowing YOUR numbers regarding cardiac arrest outcomes. Crews practice CPR and the bundle of care every Monday. ETCO2 readings are improved during device use.

 

Lurie, Scheppke, Bachista, Dunn, Kewitsch, Miramontes, Kuhlman, DiBernadino. Sand, Levi (and more) – Institutionalizing the Bundle of OHCA: Multiple sites pushing out the bundle of care including heads up CPR. Using ICS as a command function to decrease time in application of the multiple devices. Using the CARES Registry to track outcomes and assure clean data. Implementing throughout Florida at various sites. Request “Hands to Chest Report” from your EMD software.

Creating a state-wide registry for the project as well to look at all aspects including CPR quality, device usage and EMD. President of NAEMSP (Levi) advises that the leaders in EMS are the primary components to drive this. He states that caregivers drive the outcome on this fertile ground. Economics of devices needed was discussed. Each component makes its own addition to the outcome where few of these provide drastic outcome improvement on their own. Levy says we must amortize the benefit of a person saved to the economy if we wish to discuss cost. Scheppke advises that they only transport arrest patients to hospitals that meet criteria of excellent arrest management “resuscitation centers” (defined locally). Criteria driven protocols for how arrest is managed in the ER to prevent individual physician deviation from the arrest management protocol. Hospitals must meet the criteria or EMS does not transport OHCA patients to those facilities. Hospitals must take post-ROSC STEMI patients to the cath lab. Florida is moving forward on this project. Hospitals will not be allowed to be a stumbling block to this project. They simply will not receive the patients if they refuse to be a part of the defined system. They also believe every ER needs ECMO capability if going to receive arrest patients. They are working to get the cardiac arrest taken to cath lab to not count against cath lab metrics as that reporting mechanism is preventing improvement in getting post-ROSC and active VF patients to the cath lab. Florida is becoming known as an early adopter. Once you understand the technology and how it applies, Dr. Lurie believes this becomes a responsibility to provide. Sedation should be included in bundle as the patient can have voluntary movement with increased perfusion while still in an arrest rhythm. All components must be in place to see maximal outcomes. They feel this is a massive BLS improvement that affects outcomes. They stress this is BLS. Some data shows that head up position may be better for post-ROSC care as well.

 

Antevy (GBEMDA) and Chief Coyle (Palm Beach County) – The Genius of Seamless Transference – What Constitutes “High Performance Hand-0ff” of Cardiac Arrest Patients: EMS personnel are demanding change in the hospital hand-off process. The Chief advises he had a department of personnel demanding this change. I-gel removals and non-use of ETCO2 by the ER were some causal topics. EMS personnel watched as airways are removed (not to be regained) and disregarding ETC02 utilization. Causes rapid distrust of the facility by EMS personnel. Can we integrate? They taught ER staff how we function in the prehospital arena and how we do QA after the call. ER staff including RTs and administrators must be present for training. Showed video of the educational training. Showed ER staff entire arrest process and modeled the handoff. EMS trains with the ER staff. Stop the swap out of airways and cessation of ETCO2 monitoring.

 

Slovis (Nashville) – The Five Most Important Publications of the Year: For more important articles than five, but these are at the top. 1) Epi use remains class one, but the PARAMEDIC2 trial looked at time frames vs. placebo. Epi increases survival but increases cerebral devastation. Synthesis: If you use Epi in OHCA, 9.4% will be neuro devastated if survived. Do not give as much. Maximum of five doses, maybe two or three if short time of arrest. 2) Performing CPR. 86 -128 compressions, depth of 1.5 to 2.5 inches. If not watched, survival plummets. Needs machine feedback. Fewer than 50% have adequate CPR. 3) Double Sequential Defib. It is a crowd pleaser but… systematic review shows DSD does not affect outcomes. But… AP DSD placement was superior. Maybe just changing the vector of the electricity may matter more. Further high-quality evidence is needed. 4) Dosing of Versed to control pediatric seizures. Re-dosing was more common in intranasal. Use IM. If you use IN as opposed to IM, use 0.2mg/kg. 5) Epi must be stressed as first line in anaphylaxis. Number one cause of death in anaphylaxis is delay in Epi administration. Readminister Epi after five minutes if no improvement. Steroids in anaphylaxis being questioned. 0.3mg/IM suggested for Epi in adults. Bolus fluid for hypotension. Five key points: Be careful with Epi, give less not more. Watch CPR performance. Change vectors if defib not working. Change dosing on IN Versed. Give the Epi early in anaphylaxis.

 

Jui (Portland) Note on DSD. Probably works but works on patients without existing cardiac disease. Works for survival in those with electrical storm.

 

Conterato (Minneapolis) – ECMO in the Twin Cities: EMS buys time. Duration of time CPR time and impact on survival. Is ECMO as good as a standard bundle of care? Yes. Survival to discharge far better with ECMO. On scene goal is to get patient to ECMO when VF/VT is refractory. ECMO is essentially and EMS intercept. ECMO team responds to the ER and prepares ECMO there. They go to cath lab with ECMO in place. ECMO now takes place in an ECMO truck outside the ER in a new ECMO unit that responds to meet the transporting ambulance at the ER. The next phase will be sending the ECMO unit to the scene. Stresses that this is a refractory VF/VT specific project. The program has been slowed due to COVID. Same as previous lectures in stating that the existing cardiac arrest management system must be practiced and have all components of high-performance resuscitation in place for this to work. These are complicated patients requiring a specialized team approach. Cost of the truck is $650,000.

 

Vithalani (Ft. Worth) – How Often Does the Mechanical CPR Plunger Drift? The concept of MCD: Majority of arrests have mechanical CPR used in this system. Noted cases where depth target was not being reached. The device can have roll, pitch, and yaw. Called MCD “walk.” Results in poor compression depth. “Walk” is started by an event like defib or patient movement. Use of stabilization and marking of position of plunger with a sharpie has helped reduce MCD Walk. Must use retrospective review or you will not know this is happening. Has ROSC improved since they started looking at the data and watching this? Noting decrease in walk. Neck and wrist straps must be used.

 

Frascone (St. Paul) – Do We Need to Revisit the Airway of Choice? Ventilating about Ventilation: There has been an alarming number of patients presenting for ECMO with hypoxia. They have ET or SGA in place. They take blood gasses on arrival. As SGA use increases, seeing some SGA patients with hypoxia. Believed to be cuff leakage in SGAs with inflatable cuffs. Also believed that SGA may be dislodged by “violent compressions” from automated CPR. Also discussed decrease in cerebral venous return with cuffed SGAs. Most SGA studies are with manual CPR. Big difference in provider skills in studies and huge differences in hospital after care. Proposed study on this is commencing.

 

Pepe (Program Coordinator) – Elements of Quality Ventilation - Take a Deep Breath and Give One the Right Way: Oxygenation and Ventilation are intertwined. We need to clear CO2. You need PEEP to re-inflate collapsed alveoli. Smaller ventilatory volumes are for intubated patients with no PEEP and no diffuse lung injury. Blood flow to the lungs is essential. Cardiac arrest has little need to ventilate, but there is a need to oxygenate. Lungs need to be inflated and an occasional breath. One system has gone to one breath every 10 seconds in kids with dramatic improvement. If you increase perfusion, you need to give more breaths to clear CO2. Ventilation may be out in OHCA in a few years.

 

Holley (Memphis) – BVM Device Approach to Help Optimize Better Delivery of Breaths: There is much more variability than we think there is and the answer is “it depends.” 47 providers were asked to ventilate a simulated patient for one hour. Some with a flow limiting device and others without the limiting device. All providers did both arms of the study. Metronome was used. Wide variability with peak pressures and tidal volume with BVM only. This is BVM vs. Sotair Device and BVM. No one was good at this by gender, number of hands or experience or even field of care (RT vs. EMS). Message was that no one was good at this with just BVM. Humans cannot manage the pressure related methodologies that affect cardiac arrest survival. We need to find a way to manage the parameters. The Sotair device between the BVM and patient stabilizes these parameters and produces a much narrower consistency in ventilation. Also, use a steady squeeze with quick release when ventilating with a BVM.

 

Antevy (GBEMDA), Banerjee (Polk County), Miramontes (San Antonio) – What Should We Think About the Latest AHA Recommendations: Pediatric respiratory rate guideline? Increased rate? Venous return from brain is decreased with over ventilation. CPP is limited when bagging a patient too fast. AHA guideline based upon a study where the patients were not in cardiac arrest and had congenital heart problems. ILCOR did NOT go with this recommendation. We agree with ILCOR. ETCO2 was not mentioned in the study (this is a weakness). Ventilation impacts blood flow. Slower rate produces better outcomes in a far larger data set than the study used to change the guideline. This rate matters and should not be increased. How do you retrain? Contradict PALS after the class? Did not work. San Antonio simply created their own course and abandoned AHA. They do not teach PALS. They teach Handtevy as part of their course.  Treat kids like little adults in cardiac arrest and use age-based protocols. Keep ventilatory rate slow. Do not over ventilate. Suction should always go to patient side in pediatric patients. Largest post-admission killer of post-arrest patients in ICU is related to aspiration earlier in arrest.

 

Garrett (NDMS) – Defining What is Pediatric: There is no clear definition of a pediatric. We design systems of care around children but what is a child? The speaker does not have a solution but notes a problem. Looked at definitions by state in protocols. Many definitions. Very wide range. Age? Weight? Development? Length?  Have they reached puberty? Needs further study and definition. 

 

Levy (Anchorage) – Could Persistent VF Actually Be Persistently Recurring Iatrogenic VF? No one should die in VF. Case study on a three-year-old in VF. They backed off on Epi after 10th shock and got patient back. 48% of successfully treated VF returns to VF within two minutes. Vector change seems to be the most successful. Is it refractory or recurrent? Refractory VF is rare, recurrent VF is common. Once you find the usual method is not working, find a way to treat it. Change vectors. Work fine VF to course VF before shocking. Pauses in care are ok to determine course of action. Sometimes we need to look at the rhythm under CPR. We need “see through” technology to be able to see the actual rhythm under CPR compression rhythm on the monitor.

 

Mattu (Baltimore) – Minding your P’s and Q’s and QRS’s and T’s: Severe Hyperkalemia produces severe ST Elevation in AVR, V1 and V2 with axis deviation rightward in Lead I. Look for the big S wave in Lead I with ST elevation in AVR, V1 and V2. Manage the hyperkalemia. No emergent cath lab needed.

 

Doerries (Artistic Director, Theater of War) – What Were Emergency Professionals Reactions and Responses to the Past Year’s Theater of War Productions? Presents presentations of the morale suffering of frontline emergency workers. Uses Greek tragedies to open discussions and assess reactions. Currently, responders feel betrayed. They saw the 7pm acknowledgement in New York during the pandemic, but the rest of the nation has not acknowledged what EMS has been dealing with on the frontlines. They feel the public has not helped with the burden. They feel betrayed by lack of PPE. They feel betrayed by allied health agencies. There is guilt by many on the changes that impacted patient care during COVID. Healthcare inequality was found in many cases. This was a mining of the mind on EMS. After the scenes it is good to talk. ACEP feels these presentations are very beneficial.

 

Marino (New Orleans) – Promoting the Rationale and Tools for Accomplishing a Culture of Inclusion: How does your workforce compare to the demographic diversity of your geography? Do outreach programs help change the makeup of your service? NOLA EMS reaches out to high schools for future workforce individuals, and they focus on diversity. They also address diversity feelings during interviews for hiring. Increased transparency around promotions and hiring. Employee spotlights and social media campaigns. Can diverse populations feel like they trust your EMS agency? They do not have solid data that efforts are working, but recruits have been more diverse.

 

Levy (NAEMSP) – NAEMSP Update: 22% of members are NOT physicians. NAEMSP is involved in legislative advocacy. “If you are not at the table, you are lunch.” NAESMP has very important position papers with resources. New NAEMSP Systems textbook is being released. NAEMSP has a strong medical director course as well as a quality and safety management course. There are multiple state chapters of the NAEMSP. There are multiple committees tackling a variety of topics. Annual Meeting is held each year.

 

Schneider (ACEP) Covington and Draper – Reports from ACEP including Pending National 988 Behavioral Health Emergency System of Response: 300K views of the ACEP textbook of COVID online. Transitioning to focus on the epidemic of mental health. 9-8-8 is the designated telephone number within the United States for the purpose of national suicide prevention and mental health crisis. It will be accessible by all persons by July 16, 2022. It will have centralized network routing. It will also have a crisis care services, will link to care, and outreach. It will be free to all. Back efficiencies are built in. The process will be uniform across the country. Much can be provided over the phone. Much can be done without generating a 9-1-1 response. It is NOT on large national call center. Calls will be distributed to 190+ specific call centers depending on language, topic, and geography. Most are unfunded now that are currently providing services. Next steps are planning grants and the development of practice protocols. They plan to collaborate with centers to provide mobile resources. Estimating 9.8 annual calls to start. Establishing coalitions of stakeholders. There will be public messaging to advise when to call 9-8-8 versus 9-1-1. NASEMSO and NENA are involved. Building out deployable resources will be crucial for this to come to full fruition. Hoping to shunt behavioral health away from the ERs. New Hampshire Supreme Court ruled that hospitals cannot detain mental health patients as it is against constitutional rights. Trying to ensure platform is robust with tangible resources that are alternatives to hospital and law enforcement. Hoping to avoid ER use and unnecessary incarcerations. Medical clearance is an issue that needs to be overcome.

 

Levy (Anchorage) – the 4-1-1 on 9-8-8 in the 907 – Piloting the 9-8-8 System in the Upper 49^th: States are trying to get ahead of this implementation. Meetings already occurring in Alaska. Medicaid is preparing to reimburse for an EMS mental health resource response in Alaska.  Call routing will be by area code. Capacity, stability, and coordination will be very important going forward towards full implementation.

 

Gilmore (St. Louis) – Program for Decreasing Behavioral Incident Calls for Police and EMS: SAMHSA has guidelines for these types of initiatives that are online. Without these resources, hospitals and law enforcement become quickly overloaded. Having someone from the office of the mayor directing things, they then tend to happen. In St. Louis, the callers are asked if they would like to speak to a counselor and 911 diverts the call and exits. Many are diverted. It takes a system to make this work. The crisis response unit is a law enforcement officer and a social worker. 84.44% were diverted away from EMS and no one went to jail. Opening a sobering center that is not just for alcohol. Issue remains complex.

 

Morshedi (Dallas) – Getting it R.I.G.H.T. in Big D, what is a North Texas Approach to BHE Response? How does Dallas handle behavioral health responses? In 2018 the crisis was surging with a 17% overall increase, with one area having an 85% increase in three years. Jail or ED and neither are appropriate. Duplicated response system from Colorado Springs. Get the right care to the right patient at the right time. Stakeholders at the table is essential. Pilot launched in 2018. 16 hours a day. Wrapped up in January 2021 with over 6000 responses. 61% decrease in arrests. 19% decrease in 911 calls. 20% decrease in ER visits. The pilot is now permanent. Five teams now in place adding another five teams next year. Saved community 40 million dollars.

 

Kidd (Acadian) – Multi-disciplinary Approach to Mental Health Crisis in South Texas: Bexar County, Texas. Acute care is regionalized in Texas. Paramedics do the medical clearance in the field without transport to the ER. Shunting 1,100 patients a month to proper mental health and away from ER. Specialized Multi-disciplinary Alternate Response Team (SMART). Las LE, social work and EMS team members. They wear jeans and non-threatening clothing. The team intercepts 911 calls and reduces unnecessary utilization of ER and jail. They also perform follow up visits. 25% are resolved on scene without any directing of the patient. Surveys show 100% satisfaction by patients using the team. Challenges? Planning as they go along. They feel like they are missing a lot of calls. They need more teams. Looking at system loads and times to add resources. Emergency detentions used by facilities has been a barrier (team feels a different approach is needed by facilities).

 

Kahn (San Diego) – Can the Conservative Approach Be a Feasible Approach for High Volume EMS Users? San Diego monitors high use individuals. One patient was costing the EMS system about $300,000 a year. Systems of care only work if the person is willing to accept help. San Diego is using an entity (organizations or family) to gain conservatorship over individuals who are high EMS use individuals. Not a quick fix, but once in place allows for care. Needs an attorney and a psychiatrist on the team. Dropped on patient from 90 calls in 9 months to zero.

 

Fowler (The 1^st Eagle) – Rolling Out the Advanced Mental Health Life Support(AMHLS) Course: Discuss history and trends, perform differential diagnosis, identify clinical spectrum, respiratory mechanics and positional asphyxia and other topics. Course length is four hours with a post-test. It covers non-pharmacological management and best practices of patient positioning. No prone positioning, hobbles or hog-ties. Treat agitation, hyperthermia, and acidosis. Must treat related and underlying conditions. Standards must be held to, and we must be accountable to the standards. TASER barb removal is covered. Pediatric agitation is discussed as well as language barriers. There can be no prone positioning with weight on the chest. In 10 minutes, the patient dies from respiratory acidosis if held prone under pressure. Virtual pilot course next month. This course is for all who need to hear. No one wants to go to a behavioral health call as no one knows what to do. We do not send people out to work cardiac arrests without ACLS. Why do we do it on behavioral emergencies?

 

Conterato (Minneapolis), Jui (Portland) – Should We Be Treating Acute Onset Pulmonary Edema Patients with IV Nitro? The answer is YES. SCAPE: Sympathetic Surge Crashing Pulmonary Edema. Only high doses of nitrates are effective in treating this. Studies show IV nitro is safe and effective in the prehospital environment. 1mg IVP. 90% of patients identified correctly. One reaction with transient hypotension. CPAP mask must be removed to give SL NTG. Another reason why IV push NTG is better. Ui implemented this protocol as well. Does it really work? Ten patients looked at regarding this usage. Conclusion: Safe and effective. Also effective in those who do not tolerate CPAP. Effective in patients not responding to CPAP. Prevents intubation. Medics were great at determining need. Only IV NTG was used. No adverse effects noted. Minneapolis ran their own study as well. No cases of hypotension. “Very, very effective!” Over 50 patients so far. One patient needed intubation. Highest dose was 10 mg with repeated boluses, and they did well. IV NTG keeps you from breaking the mask seal to give SL NTG. Excellent presentation.

 

Frascone (St. Paul) – What’s the Rationale for Infusing Sodium Nitroprusside? The SNPeCPR Trial. ACLS focused on central circulation. What about the periphery and other organs? What about SNP and eCPR? SNP decreases preload and afterload. Carotid blood flow and ETCO2 both have marked increase with SNP and eCPR. Lactic acid was decreased with SNP and eCPR. Survival in animal models was increased. Better survival with CPC of 1 or 2 in the SNP with eCPR group. No survivors in the standard CPR group. No Epi was used in the SNP/eCPR group. Epi was used in the standard CPR group. Looking to do a randomized trial. SNP will be given up to three times IVP in place of Epi. Protocol is written. Should start trial in 18-24 months.

 

Cabanas (Raleigh) Roach (Ft. Lauderdale) – Cardiac Arrest with an IV Epi Drip: Is Epi effective in cardiac arrest? “It depends.” Somewhere in the middle is the truth. Covered available Epi literature regarding cardiac arrest. It provides a better survival rate, however, there is no significant increase in neuro intact survival with Epi, however. Does first Epi time matter? Every minute delay in Epi administration decreases survival by 4%. Late Epi (over 10 minutes) decreases survival by at least 18%. 1:1,000 Epi, add 1mg to every 50ml of fluid (5mg in 250ml). 20mcg/ml. Use 120mcg/min. This is 600mcg every 5 minutes. Foundational BLS care must be a strong foundation to start. Uses a 10gtt set, 1 drop per second (6ml/min). This dosing allows us to decrease use of 1:10,000 1mg syringes as well (which are always on shortage). Mitigates timing variability. Producing 14% overall survival and 43% Utstein survival.

 

Meyers and Crowe (ESO) – The End Justifies the Ketamines - A Year-long Review of Uses and Outcomes in 11,291 Patients: Specialties outside of ours have been weighing in on our use of Ketamine. Not a ton out there on prehospital Ketamine. This study looks at EMS data and outcomes on over 2k patients out of 11k looked at. This is a big EMS field. It is a myth that really large dosages are being given (less than 1% of all administrations). No drug is safe without monitoring of the patient. We must monitor oxygenation and hypercarbia. SPO2 and ETCO2 must be monitored. 8% of Ketamine administrations have some hypoxia. There is variation in hypercarbia based on modality. Ranges from 10 to 25%. Above 2mg/kg needs ETCO2 monitoring. A little IPPV goes a long way if issues are noted. Outcomes are a must for determining safety. Out of 128 deaths, 114 were excluded as not related to Ketamine. Most causes of death were overly obvious. 8 could not be excluded as Ketamine but there is also no data to show that Ketamine played a role in the death as well. It is believed that all pian relief and sedation should be monitored, not just Ketamine. Groundbreaking study using actual EMS data.

 

Scheppke (Palm Beach and Broward) – How Good is Ketamine at Terminating Refractory Seizures? GABA switch is the off switch. That is where most seizure drugs work. NMDA receptors are the on switch. If you block the on switch, it becomes an off switch. That is where Ketamine works. 100mg IV in adults, 3mg/kg IM in Peds. 86% of status epilepticus patients had seizures terminated. 8 of 36 patients had an SPO2 less than 90% (most were BEFORE Ketamine). Watch for hypoxia. Hypoxia was easy to correct. One had aspiration BEFORE Ketamine as well. Hypoxia was brief in the cases noted.

 

Colwell (San Francisco) – Getting the Drop on the Overall Amazing Utility of Droperidol, On-scene Inapsine: What is the best drug ever created and why? Some think it’s Swedish Fish and others think it is Ketamine. Is there another way? Droperidol is making a comeback. It is a antipsychotic and antiemetic. It is faster than Haldol on effect. Can use for agitation, headaches and as an antiemetic. Very safe in the literature across multiple specialties of medicine. The black box warning came out 30 years after lots of use. There was no review or study that showed adverse effects. Why is it back? “It’s just that good.” Even works in hyperemesis with cannaboids. Better than Versed. Better than Haldol. Great antiemetic. Has incidence of QT prolongation like Ondansetron. Sedation is the number one side effect. Onset quick and duration is longer, so it is a good drug for prehospital agitation. “Droperidol reigns supreme.”

 

Calhoun (Cincinnati) – What Are the Many Other Potential Uses for TXA in the Field Beside TBI? Does bleeding equal TXA as the treatment every time? Cheap, low risk, must be a panacea? OB Hemorrhage? Small benefit if given quick, but mostly no benefit. GI Hemorrhage? No benefit (HALT-IT trial). Showed some harm. Spontaneous ICH? TICH-2 says no. Nasal Hemorrhage? NoPAC trial says no as well. Why? TXA is beneficial in multisystem hemorrhagic trauma not smaller hemorrhages.

 

Paul Pepe gave an overview on the history and studies regarding TXA, effects, timing and guidelines. TXA is harmful if given late. 2GM upfront in TBI, given IV/IO reduces mortality in TBI.

 

Roach (Ft. Lauderdale) and Winckler (San Antonio) – Rolling Out Low-titer Whole Blood in the Field: Video of a GSW case lacerating an artery. Showed rapid, warmed infusion of blood. Corrected pneumo and whole blood in the field saved patient. Giving blood prehospital is the only solution to hemorrhage. Crystalloids and permissive hypotension are not positive outcome items. Blood reduces incidence of arrest prior to trauma surgery. How do you roll out a ground-based blood program? You need a donor-base of O Negative low-titer blood. You need blood box coolers and a squeeze pump to rapid administer. You need large internal diameter blood tubing. San Antonio has infused over 600 units of blood since 2018. Criteria based administration. Blunt or penetrating trauma with systolic BP of <70 or < 90 with HR>110. ETCO2 <25. Witnessed traumatic arrest is another criterion. There must be a system to get the blood to the patient. There is not enough blood to place on each ambulance. Usually on a Supervisor vehicle. You must build a system of care with all stakeholders involved. Blood supply must be maintained. San Antonio has a zero percent waste rate for blood. It is on unit for 14 days then it goes back to the blood center and is sent to the trauma center for 21 days. It is examined in between. Ft. Lauderdale is having a significant save a month.

 

Colwell (San Francisco) - Defend the Glycocalyx, Why Is Giving Crystalloids in Uncontrollable Hemorrhage So Wrong? It is about the ABCs right? Not really. It is BCA. Airway deaths are small in trauma. All the rest are hemorrhage. ANY crystalloid causes harm. Multiple studies show this. Crystalloids support the death triad of coagulopathy, acidosis, and hypothermia. Should we be giving any crystalloids at all? Literature is slowly moving toward zero. Just like c-collars there is no supportive data for crystalloids. Permissive hypotension is a term with problems. It means hurry up and do nothing. It prioritizes hemostasis over perfusion, but improvement of BP is not the goal of permissive hypotension. Permissive hypotension has little support as well. Limit and minimize ANY crystalloid resuscitation (with the possible exception of head injury). First, do no harm. We need to set a goal of no crystalloids in trauma other than head injury. Great presentation.

 

Levy (Anchorage) – Is It Time to Start Focusing on Mean Arterial Pressure - and How? Quick scenario given. GSW to abdomen. Thready tachycardia. Hypotensive resuscitation Watching the MAP can keep us from blowing the clot. Diastolic pushes the blood most of the time. MAP is more of a way to accurately define shock and tissue perfusion. The machine does this for you with automated BP. Is manual BP really the gold standard? The automated BP mathematically calculates the systolic and diastolic as it really only finds the MAP (opposite of what most believe). MAP is accurate on the automated BP and this is why manual does not match automated systolic and diastolic. (My note: the fact that it figures this in reverse is a revelation compared to what most of us have been told historically).

 

Augustine (Eagles Librarian), Goodloe (Tulsa and OKC), Roach (Ft. Lauderdale) – Best Practices for Field Amputation – And Could EMS Do Them? Some machinery cannot be reversed. Communications on scene must be precision. Communication to hospital must relay need. Communication speeds up responses when it is streamlined. Safety must be a priority. Item causing entrapment must be locked out and tagged out. PPE must be proper as well. Trauma surgeons can be mobilized to the field. They will need emergent transportation to get the surge to the scene. What about tomorrow? What if a surgeon is not available? Time to revisit the process. You cannot make up rules that say EMS cannot do something when a patient is going to die. Know what you are going to do with amputated parts. A regional team approach can be used. A list for the amputation kit can be kept and put together quickly if needed to be picked up at the ER.  Scene management must be listening to those caring for patient and those extricating. Is an LZ needed? Something is needed to contain amputated part and ice to put around it. Procedure must be explained to the patient and adequate sedation/anesthesia must be performed. What if you cannot amputate? Make patient comfortable. Get patient on the phone with their family.

 

Jui (Portland) – Yikes, Crikes! – What Are the Best Practices in Field Cricothyrotomies? Using pre-made kits was expensive and they expire. Now back to scalpel and ET Tube with a 3D printed model of the larynx used for training. All paramedics trained. One training per year. They added a bougie and a tracheal hook as well. Surgical crikes are a viable option.

 

Margolis (U. S. Secret Service) – How Did We Maintain Safety and Training for Law Enforcement During COVID-19? They kept training up and running during COVID. Did internal testing program for COVID. Protectees need protection and they cannot stop doing their job; therefore protectors continue to protect (exactly!). It was a hard year. Campaigning, two conventions, elections, civil disturbances, candidate protection and an inauguration during the last year with COVID. Early focus on education on COVID and countermeasures. Developed a COVID task force made up of instructors. Established screening. Asymptomatic testing twice per month. Used larger areas for training for social distancing. All physical training was moved outdoors. Single groups used the same room over and over. PT was at the end of the day so they could go shower. Testing occurred in car outside of training center gate. Follow up was provided during isolation. Protective medicine is someone that is embedded with those who carry guns. Have a plan for every scenario and know the players.

 

Day 2 - Eagles 6-18-21

 

Molloy (Dublin) and Kahn (San Diego) – Bad Luck of the Irish – How Did Ransomware Crush the Healthcare System and Shouldn’t We Be Ready? Dublin: They are five weeks into a hack attack from a Russian group. Noticed icons missing from desktops. Then they lost networking between hospitals. Lost patient management systems, no ability to do orders. No ability to see labs. They had to physically go to the x-ray machines to view films. Some backup systems were brought in for support. Some systems had to be rebuilt. Payment systems went down. Payroll could not be processed so hospitals instructed banks to pay the same amount they paid the month before. No remote view of films. X-rays were put on CDs and sent by taxi up to six hours away for specialist review. Still not back to normal. Quite frightening. @0 million asked in ransom. Refused to pay. The EMS platforms were not affected from a documentation perspective. Dispatch was not affected. However, ECG transmission and patient data is still down. San Diego: Cyberattack. Scripps Health had all systems go down on May 1, 2021. Hospitals quit taking EMS patients. Nearby hospitals got slammed. Stress to trauma and STEMI systems. Patient volume at already busy hospitals doubled instantly. This was an attack on one hospital, not the EMS system “but it sucked for everyone else.” Patients took a hit on accessibility. Took a month to recover. The hospital had paper documentation backups and some processes ready for this, but the impact was still immense. Radiologists stood at machines and read images live, then write down results on paper and pinned them to the patient. Pen and paper must be ready. Regulatory flexibility will likely be required. The best defense is a good offense. Take cybersecurity very seriously. Update continuity of operations plans. This was an excellent presentation.

 

Ong En Hock (Singapore) – How Did the City Nation Maintain COVID Control? First case in January 2020. Nationwide lockdown. Used old SARS legislation from 15 years prior to initiate lockdown. Used a hammer and dance approach. The “Hammer” was the lockdown, and the “Dance” was the slowing of spread that came after. Currently concerned about the newer Delta variant that originated in India. Seems to be a very different disease with a shorter incubation period and patients remain contagious up to five weeks. Much more contagious as well. Higher susceptibility in children. 40% of population is vaccinated. Hope to be at 80% by August. Workflows changed in the ER. Multidisciplinary research team being used to determine processes.

 

Cabanas (Raleigh), Lowe (Columbus), Scheppke (FL DOH), Persse (Houston),Char (Honolulu) – Public Health is Public Safety – Did EMS Quietly Morph into a Public health and Health Security Leadership Role? The pandemic stretched resources for departments of health. Wake County: EMS came together to assist with vaccination efforts. They assisted with drive through a vaccination site. 8% of the vaccinations in the county were given at this site. Columbus: One of the first cases was a paramedic student, so tracing became important very quickly. Tracking was implemented at a high level. Jacksonville: Department of Health was struggling with testing. EMS was tasked with creating a large testing facility on a football field. 9 vehicle lanes established. Educated quickly on new procedures. National Guard eventually took over that site from EMS, so EMS moved to neighborhood testing sites. EMS did testing at some sporting events as well. This crisis showed the versatility and flexibility of EMS.

 

Augustine (Eagles Librarian), Kaufmann (Indiana State Medical Director), Asaeda (FDNY) and others – Theatrical Performance Critical Reviews - The Eagles 5 Theaters of Past Response and Future Response Planning for EMS: The disease progressed as Dr. Osterholm predicted by wave. Five theaters of operations. 1^st: High COVID numbers. 2^nd: Confidences in vaccine process. 3^rd: Mass vaccination. 4^th: Safe wind down from pandemic ops. 5^th: Fill the voids. FDNY: NYC was overwhelmed while other areas so massive decreases in EMS call volume. 35-40 cardiac arrests daily changed to 200-300 arrests daily for FDNY. 250 contract FEMA ambulances and mutual aid used. Protocols changed to 20 minutes of work and if no ROSC, called without medical control. Patient navigation was used. EMS given the ability to deny transport if flu like symptoms. Engine company responses were limited. Shifts shortened. Physical well-being was a concern for personnel. Paramedic student hospital clinicals were shut down. Florida: Established trust in authorities is shaken in our nation at the moment. Convincing people to trust the vaccine is hard. Videos were made. Social media is both a wonderful and horrible thing at the same time. Effects on pregnancy were a concern. Myths were debunked. The variants are coming, and it will overwhelm the immunity of the current vaccine. There has been a huge spike in vaccine technology. Indiana: A team was created for discussing and putting out resources for EMS to support vaccination efforts. Indiana used the Indianapolis Motor Speedway as a mass vaccine site. San Antonio: The efforts to getting us back to a new normal. Technical decon was used for ambulances. No longer isolating and quarantining if vaccinated or non-symptomatic. Resources were deployed to many areas of operation. We need to plan for mental health recharge and get families on vacation. Hospitals are now full. All the backed-up surgeries are happening now and have roared back into play. Hospitals lost a ton of money, and they are making it up now. Now we must deal with the HR nightmares. What can we mandate? How do we find people? How do we get people time off? Workers comp issues?  How do we continue to screen? Philadelphia: Staffing shortages are bad. Increased efforts to retain and recruit are going. Training has moved to more online and VR/simulation. Mental and physical health has taken a hit in EMS personnel. Telemedicine may become more of an option. Existing supply shortages just got worse. We need a system of mutual aid for supplies. Future designs of ambulances may be changed dramatically. We have to destigmatize mental health issues.

 

Augustine (Eagles Librarian) – What Were Some of the Best Findings from the Past Year’s Eagles’ Surveys? Tales from the bales of Eagles Emails. Do not reinvent what has already been built: SHARE! The last year had 90 discussions NOT related to COVID.  Discussions on termination of resuscitation, turnover of expired persons, management of sepsis and the fact that hospitals need great relations with EMS. Still a wide variation of how EMS is managing sepsis. There is still much friction between hospitals and EMS. CLIA waivers were discussed. The need to do training on recognition of human trafficking (very active issue). Cancer concerns for public safety workers was a discussion item as well.  Stroke scales, spit hoods and ultrasound use by EMS were discussed. Incident rehab was surveyed. New PALS guidelines were reviewed. Decreasing cervical collar use and increased use of alternative destinations in protocols were a topic. Payers need us to get patients to the right place. Choices through 911 need to increase. The unscheduled care strata is growing and is its own layer of care. Sharing best practices is a great practice. Do not create new if you do not need to do so.

 

Asaeda (FDNY), Phlowarz (Long Island), Cabanas (Raleigh) and Myers – Sudden Death Suddenly Appeared - How Profound Were the Increases in Cardiac Arrest Cases Faced by EMS? Asaeda: 4200 calls a day in NYC. 1.5 million calls a year. 1 million transports annually. 2800 EMTs and 1100 Paramedics. Peak of COVID was March 20 through April 11. Normal arrests are in the arena of 30 a day. During peak they were over 200 daily and on April 6^th they ran 305 cardiac arrests. Moved to crew being able to call arrests in the field after 20 minutes of resuscitation.  Late in peak, state allowed a “no resuscitation” to be on ANY arrest with no attempt at resuscitation. They had questions. Fresh ODs? Pregnant women? Everyone? The state said yes. FDNY did not adopt the new state protocol. State was not happy with this decision. Medical Director stood up to the state as it was not the right thing to do. Union supported Medical Director as well. Hospitals continued to accept arrests with ROSC. Numbers dropped to 20% less than normal after peak but are now back to normal. July 1^st NYC opens again, and fireworks will be held on July 4^th. 70% of state has at least one dose of vaccine. They are going to have a parade on July 7^th for essential workers. Maloney: Study shows that COVID probably directly created a large number of cardiac arrests across the nation in 34 cities that were never tested due to arrest/death status. Data showed spikes in cardiac arrests following spikes in positive COVID tests in communities. This is some catastrophic, sobering data.

 

Holman (Washington DC) – Minding the Mind of EMS Professionals, Part I – How Did a Mental Health Well-being Surveillance Tool Work in the District? Research on EMS mental health is lousy and tends to center around PTSD. Decided to do a survey. Looked for PTSD, anxiety, and depression. PHQ-9. GAD-7 and PCL-5 were used. All communication was via the email system. Voluntary and anonymous. 16% participation. 2/3 were working more than 48 hours weekly. Results that were positive: 15.4 PTSD, Anxiety 17.7, Depression 24.1. What stood out was hours worked on PTSD and depression but not on anxiety. Results were 3 to 5 times higher than the general population. Only 5% sought behavioral health care in the last year. These are screening tools and not a diagnosis. Will move forward with a longitudinal survey. Also need to move past pandemic to see if that was part of the issue.

 

Colwell (San Francisco) – Minding the Mind of the EMS Professional, Part II – Creating Safe Harbors for First Responders in the Golden Gate City: What are we doing about mental health in EMS? What are the most trustworthy professions in the US? Number one was firefighters at 80% and EMS at 76% was number two. We are not immune and probably at a higher risk for mental health issues and substance abuse. There is an emotional toll. We provide amazing resources to our patients, but do we deploy amazing resources for our people? How do we care for our caregivers? SF EMS deploys a stress unit. It is 100% peer support. Available to employees AND families. Difference makers? Use peers. Confidentiality. No records. Trusted provider referrals. Provie therapy (public safety people want to know that those they are going to have experience with public safety). Use of team up 30% during pandemic. Most resource use takes an average of 45 minutes. A success story was relayed. One user advised that national and generic hotlines did not help, but internal team did. Use proactive resource development. Break the stigma. Provide Peer Support.

 

Dunne (Detroit) and Scheppke (FL DOH) - Minding the Mind of EMS Professionals, Part III – Why EMS Professionals Were “Beyond Expectations” Heroes During COVID-19: This segment is really about the audience. Detroit: We need to talk about mindset. Working in emergency response in the field is a balance between fear and hope. Fear helps us make better decisions and hope helps us save people and it drives us. Fear ran some of what we did during COVID. We need to control that fear. They used Lieutenants and Captains to respond to manage fear (within all city departments). DFD helped all city departments to safely continue to operate by mitigating fear and delivering hope by defining processes. Those city departments learned that fire and EMS do not give up and we are good at whatever we adopt. We have the mindset. FL DOH: Courage is not the lack of fear. It is the ability to acknowledge and face fear. Some EMS agencies manufactured their own PPE. We have versatility. EMS partnered with companies, health departments and other entities to deliver and give vaccines.

 

Kaufmann (Indiana State EMS Medical Director), Gautreau (San Jose), Viser (CDC) – What Were Some Best Practices in Vaccine Distribution and Confidence Building? San Jose: Medical Directors drive internal vaccine acceptance. Unions can help drive acceptance as well. People declining vaccinations were clustered on certain shifts at certain fire stations. They went and talked about the issue with those shifts. We let them ask questions and gave them answers. Hit 90% within the fire department. CDC: Developed strategies to address questions with known facts. Free vaccine was important. Indiana: We needed more vaccinators. The solution was EMS. Basic EMTs could already do IM Epi. State training was already in place on IMs for EMTs. Worked with Department of Health. Used EMS for mass sites. Individual EMS agencies did homebound Hoosiers by making home visits to administer vaccines.

 

Antevy (GBEMDA) – Nebulizer Use During COVID – What Was the Outcome of a Post-Nebulizer Particulate Counter Study? Different types of aerosols defined. A new mask was evaluated that kept all particles in place. Used 15 test subjects and a and a particle counter to determine efficacy of the device. Did it work? Somewhat yes. It is time to resume nebulization and make efforts to mitigate particles.

 

Pepe (Course Coordinator) – What Were the Important Findings of a Broward County Backyard “High School Science Project?” Accuracy of SARS CoV-2 Antibody (Ab) Tests was in question. 30% of the people that did not turn antibody positive that were PCR positive. Mainly younger individuals. Two sites with drastically different make ups had same results. 1000 more patients will be looked at. What about after vaccination? Do all vaccinated persons have antibodies? With one Pfizer shot: If under age 50, 100% developed antibodies. Over age 50 percentage without antibodies drops with age. With two shots, the age 80 and under were 100%. It drops off again, but not nearly as bad until reaching age 90.

 

Marty (Miami), Jui (Portland) – Iconic ID Identifiers Keep Their Eyes on the Future – Admonitions About Conditions: COVID variant Delta: Delta is the worrisome one. It is more virulent. Discussion on how the vaccines work. The data currently on this is from the UK. UK and Denmark lead the world on genotyping. Effect on the US will parallel the UK in about 3 or 4 months. The Delta variant is far more virulent. The vaccine does not protect fully against the Delta variant. Significantly higher hospitalization rates. Full vaccination is better against Delta than one shot only. What is chance of breakthrough in vaccinated individuals? Somewhat effective. Therapeutics: Monoclonal antibodies, Remdesivir, Decadron and a newer drug coming out on the market. An oral or IV (both) anti-viral may be available soon as well. Antibodies: Most are lasting longer than we thought after infection. Are they the RIGHT antibodies? There is some cross protection from the variants if you have had the disease. COVID myocarditis and vaccine associated myocarditis: Seen in male teenagers within four days of second Pfizer injection. All had elevated Troponin. All were treated and resolved quickly. May show pericarditis indications on 12-lead. COVID related myocarditis is worse than vaccine acquired myocarditis. Some cardiogenic shock seen with myocardial localization of COVID. Athletes studied had 2 to 7% myocarditis with COVID.

 

Visser (CDC) – How Does the CDC Work with You and Me? We had to fully embrace processes for guidance and best practices. Much information during this crisis came directly from physicians on the front line. The Eagles were quick to share CDC guidance into the real world. Visser feels the Eagles served an important role. Specifically mentioned the Homebound Hoosiers program. Interim guidance for post-COVID infections was released this week.

 

Miramontes (San Antonio) – Homing in on the Homeless – The San Antonio Homeless Shelter Clinic: Ran by the San Antonio Fire Department and docs. This is part of the homeless outreach program. Facility houses up to 2000 people each night over 22 acres. Primary care clinic open during the day. After hours there was no on-site care causing it to be a 911 impact site at night. Medic placed there 7p-7a at night. They only use personnel on overtime. Uses a regular ePCR for documentation of encounters. OTCs given, nausea meds are given as well as cough and allergy. Limited antibiotics to bridge to primary care. They do a lot of wound care mainly on feet. Done initially on grant. Transports were decreased by 45%. The medic on-site can also give out taxi vouchers. Increased operational availability of paramedic units. Frees up ER space from minor emergencies as well.

 

Eckstein (Los Angeles) – Is ET3 Going to Work for Us and What Are the Next Steps? Current challenges in EMS are big. We must show value. Budgets are tight. Higher percentage of low acuity calls. Increased response times due to increased utilization. Inappropriate use of 911 and ERs. EMS Super Users. What ET3 has achieved is simply to start the conversation on treat and release and alternative destinations. ET3 may simply be a catalyst. Goals are to provide person centered care and increase EMS efficiency. It also opens the door to expanded types of alternate destinations. Sobering centers may eventually be a part of this as well. It starts us on Telemedicine. Maybe an expansion could be dispatch initiated telemedicine.

 

Lowe (Columbus) – Things They Did Not Teach Me in My EM Training: Handed a pandemic right after becoming medical director. Fire Chief announces retirement. Medical director got COVID. Civil unrest started 8 hours into a new fire chief. These things are lessons in crisis management. We have routine emergencies and stuff that here was no plan for. There was real time problem solving daily. Crisis Management is authenticity, visibility, priorities, situational intelligence, and awareness, focus but do not over focus, and manage expectations. “Your First 100 days in a New Executive Job” recommended book.

 

Gautreau (San Jose) - Reflections on the Grass Roots Role of the Medical Director: Five things: 1) He hates the statement that “nurses are a higher level of care.” He states, “Nurses are not a HIGHER level of care than paramedics; they are a DIFFERENT level of care than paramedics.” 2) Have humility – He is still humbled when a paramedic may know a subject better than him. Understand that you must keep learning. His expectations are that his paramedics can recognize STEMI patterns as well as resident physicians. Paramedics must be masters of the refusal. It can kill if mismanaged. 3) Know a little about their job – You must understand what the paramedics job is like. Paramedics also need to know about downstream care so they can explain the future to the patient. 4) Do not bullshit the medical director – You cannot explain away facts. He can fix knowledge gaps. You cannot fix lying. 5) Maybe a little less judgement - If they “don’t look right” they are not right. Do what needs to be done and do not make excuses. Do not judge addicts. Give them chances.

 

Gilmore (St. Louis), Krohmer (National Office of EMS) – Protecting Our People with Optimal Personal Protective Equipment Purchasing: Many organizations have standards that apply to PPE. This will give you a headache.  Rely on an expert when possible. Make sure your expert knows the standards too!

 

Goodloe (Tulsa and OKC) – Why is Preparation for Natural Disasters More than Just a Priority? High yield content sharing. Keep it simple. Make not as usual operations as close to usual as possible. Do not always count on the resources you usually count on. When you cannot do the usual how do you still get to those who need you the most with some uniformity. Define a severe weather event in advance. Get input from stakeholders. General Order #1 – Limit Wheels Rolling (cancel what is not needed). #2 Limit how far the wheels roll (limit how far you will go during the event). General Order #3 – Do not risk life for death (do not over work codes and transport). General Order #4 – Do not make a fixed problem move. General Order #5 – Stay available to make a difference (limit non-emergent transfers, Omega, Alpha and Bravo responses). Remember the sun does rise. Work diligently and know capabilities and save more people.

 

Eckstein (Los Angeles) – What are the 2021 Ways to Manage Callers to 9-1-1 with Limited English Proficiency? Why important? CPR instructions make a difference. You must be able to give CPR instructions to 911 callers. Previous dispatch system was evaluated. Changed to a home-grown system for system applicability and comfort. Before and after measurements on the language issue. Huge improvement when a focus was placed on this function. T-CPR went from 28% to 69% under the new system. Using a language line produces longer time intervals to recognition of cardiac arrest and action.

 

Banerjee (Polk County) and Crowe (ESO) – Implementing the Espanol Escala de Carrera: Stroke disparities in the Hispanic population. The root causes are delays in medical intervention. Why the delays? Many Spanish speakers do not know the signs of stroke. FAST does not work in Spanish. AHORA (now in Spanish) – see photo. Outreach was performed using the new tool and anacronym. Partnered with large hospital systems and placed in protocols. Magnets were made for refrigerators.

 

Dunne (Detroit) – A Non-invasive Device for Stroke Assessment: LVO or no LVO?What if we just use a device rather than a scale? Device is $140 and disposable. It is a very sensitive array of accelerometers. It measures pulses of blood flow through the brain. It was assessed in a stroke center. It works with a smartphone through Bluetooth. It asks about symptoms. It produces a score that advises chance of LVO. It is in prehospital validation. The app will eventually advise closest stroke center with capability. Looks to be a pretty useful tool. This is an ECG equivalent for stroke patients. It will provide consistency and is easy to use.

 

Dunne (Detroit) – Evolution and Expansion of the Medical Director’s Role in Detroit: Medical Director Role Creep. A lot of things happened during the pandemic. It was not role creep; it was more like a waterfall. Two physicians in city government. One in the health department and the EMS medical director. Helped police and multiple city agencies figure out what to do during pandemic.

 

Asaeda (FDNY) – How Did COVID Change NYC and the FDNY? Timeline of events presented. March 1, 2020, was the first NYC confirmed case. Limited responding personnel on scene. Converting shifts to limit numbers at work. No choice of patient hospital. Closest destination always unless specialty care (trauma, stroke). Did 20 minutes on all arrests, then called if no ROSC. No hospital diversions allowed. State authorized no transport for flu like symptoms. Ensured availability of counseling services. Emotional strain on personnel was high. Six EMTs and one firefighter died of COVID.

 

Eagles Lightning Questions – 1) Colorado and Ketamine: The legislation passed on limiting Ketamine in Colorado. Public perception on this is way off fact. They banned the use of the term Excited Delirium. What do we do? Many conditions warrant sedation, and the term Excited Delirium is not widely used to much. They should not be legislating the practice of medicine. We must focus on caring for patients when they need us the most. The term has been misinterpreted and we just need to take care of patients and let others argue the semantics. Terms change and are debated all the time. Asaeda, “I don’t care what we call it. We just need to get involved and treat it.” Be proactive and teach legislators in other states the truth about Ketamine (state EMS offices usually must stay politically neutral). A national level bill was introduced earlier this week, but it is not publicly available yet. This bill is supposedly like the Colorado bill. Stay in your lane is a valid response to government on this but we must also say what can we do better? We should have consistent monitoring of these patients. Many of the issues blamed on Ketamine are actually lack of patient monitoring. IV dosing can produce apnea if pushed too fast. “It doesn’t matter what you use to sedate, if you don’t monitor you are going to have a bad outcome.” Training of LE to not compress the chest of patients during holds is paramount. 2) What is being used for scene recording? One on-scene video mechanism being used is an I-pad with the file dropped into a HIPAA compliant drop box. Some monitors do have audio recording capability. 3) In cardiac arrest termination it seems we still use duration of arrest as an indicator, are we moving to physiologic parameters, ETCO2 and ultrasound? High end performing systems have TOR criteria that are more physiologic. Systems need to change this. With automated CPR we can work quality arrests longer. We do not know for sure the physiologic end points yet. We are still evolving. ECMO may change a lot of this. Lactate and potassium may also be TOR criteria. “Yes, we are bringing more technology into this.” It is cardio-cerebral resuscitation (that is the goal, and we need to look there more). 4) With PPE, medication, and supply shortages, is there an effort to get a robust stockpile? The government is looking very aggressively at this as we are nowhere near being out of the forest. Current stockpiles are being built out. The raw materials come from outside the US and raw materials are a good part of the problem. It takes years to build up manufacturing capabilities. Out of the country manufacturers may not be meeting standards for a working product. Give yourself credit for what you are doing now. Build up local preparedness. Do not depend on others. Do not waste PPE. Use it when needed. Preserve resources. 5) Getting new people in the business is hard. COVID made it worse. What can we do to get more people into EMS and incentivize them to stay? Attrition rates are increasing. Alternative staffing concepts may be needed. Recruit. Show them the cool parts too. San Antonio has a program called “A Hero Like Her,” targets young ladies to explore the EMS career field. Steal ideas that work from others. If we need something badly enough as a society, we pay for it. “An EMT cannot afford to live in the Bay area.” Recognition is important as well. No one thing is the magic answer. Turnover is costly. Burnout is driven by job resources and job demand. Pay and benefits are important but not near as important as knowing that you are cared about. They need feedback and the need to know you care about them and what they do and how good they are. Assure good QI follow up (non-punitive). Simulation labs help you tell if the paramedic can really function and allows you to help them instead of getting rid of them. Local credentialing

processes help you keep people. Some medical directors feel they do not do well at credentialing. We lose too many medics to engine companies (increase in pay) which also has an associated skill decrease (again the need for credentialing). 6) Rate compliance on telephonic CPR is dismal. Has anyone successfully fixed this? There is a multipronged approach that has been used with dispatchers to understand high performance CPR. It takes time and direct work. Hours will be spent in training. Use No-No-Go. Starting T-CPR is better than not starting. Dispatchers should not let the caller stop CPR until it is confirmed that rescuers are on the chest, or the patient wakes up. 7) Has anyone had issues with EMTs or Paramedics on medical marijuana? Will an insurance carrier sign off on this? One agency ran it by HR attorneys, and they said it can be banned. Is it a fitness for duty issue? Probably, whether legal or not. One provider simply looks for impairment. FDNY has a zero-tolerance policy on the issue. DC also does not allow anyone to test positive. 8) Suggestion for next year is a focus on teaching proper restraint on medical calls by LE. Design the training with a medical focus.

That wraps it up for the 2021 meeting notes. After taking notes for many years, I hope to continue to do so for several years to come. I sincerely hope each reader can put these reports to use. If you have never been to this meeting, I hope that you will consider going in person. South Florida is the new nest for the Eagles group. The next event is planned for June 2022.

My Notes from the 2021 NAEMSP (Virtual) Annual Meeting

I picked the header picture based upon what should have been. In years past, during the first
two weeks of January, I have typically been flying to San Diego, Bonita Springs, Austin or even Tucson for this event. This year the only flying to be done was my fingers across a keyboard (but I am not sure that would have been any different rather I was in some distant locale or sitting in my office. I will say that trying to do this annual exercise of note taking while not actually being in the room lacks some distinct ambiance and certainly leaves something to be preferred in networking with others.

That being said, here is the normal disclaimer: I am 100% sure that a few spelling and grammatical errors will be found. Please remember that these are raw, rapidly taken notes with a few pictures thrown in. The point here is to disseminate the great work being done by NAEMSP that I feel should be one of our top sources for change in EMS. Without any further delay, the notes:

Day One:

NAEMSP Welcome & Opening Remarks (David Tan): Welcome to the 2021 National Meeting of the NAEMSP. Speaker has noticed the extreme dedication of EMS during the events of this past year. 2022 will be a fabulous reunion when we can all meet again in person in San Diego. We had great plans for 2020 but those plans were hijacked by COVID. What did NAEMSP do in 2020? Townhall meetings were held on COVID with sample protocols and best practices. NAEMSP worked to assure that EMS emergency medications were included in the act to allow better access during COVID. NAEMSP continues to engage stakeholders in advocacy and the NAEMSP political action committee. The 2021 NAEMSP textbook was updated. Quality medical oversight is an essential facet of prehospital emergency care. NAEMSP position papers and the width and depth of the organization continues to solve problems.

NAEMSP Keynote Address: Compassion in Action - Resilient Leadership in Uncertain Times (Chetan Kharod, MD – Department of Defense): Speaker is a leader in first response resiliency. Tells the story of being a mid-level residence. Took care of a patient he shall call Mrs. H. Patient had pneumonia. Facility was busy. Patient needed respiratory support, antibiotics and breathing treatments. He checked on her between patients and found her weeping. He walked in and asked what she was needed. He sat down, because if you sit down, they know you are there. She asked for something so that she would never wake up again. He told her he could not. He wiped her head and told her they would help her. He was chastised for sitting with her. The next morning, he remembered he said he would check on her. He went back to hospital and checked on her and found she now considered him to be her doctor (she was telling the attending she wanted to see him). She smiled. The physician who chastised him later apologized as he realized this was proper care. “My life is My Message” was quoted. Is compassion a weak or a strong choice? Veneer theory or biologic basis for kindness? Is Lord of the Flies inevitable for Man? He submits… absolutely not! Animals live together as do humans. Survival is possible together. In being alone is great danger. When you see bad behavior or anger, use the phrase, “Just like me,” as in, “Just like me, that person may be in a hurry.” There are perils in social isolation. We are all part of something greater. In EMS, we are aware that we are a part of something greater. We get it. We are dialed in that humans are more important than hardware. Take an item you have. How did you get it? It represents a chain of interdependence. We are incredibly interconnected. There is connectedness whether you note it or not. Self-cultivation is different from being selfish or self-interested. To care for others we have to care for ourselves. You cannot fill the cup of others if yours is empty. Ripple effect affects us. Ripples help transform us for population impact of those in need. Mrs. H was a drop that created a ripple that is still with him today. The ripple continues because it is shared. Leaders set the tone. Leaders have the superpower of emotional contagion. We must be aware of the power we have. Kindness is contagious. It is as simple as holding a door open. Recipients of kindness are more likely to carry on the kindness. One act becomes five, becomes twenty-five becomes one hundred and twenty-five. Do not confuse faith that you will prevail with the discipline to confront the most brutal facts of your current reality. Quotes the Stockdale Paradox. “As we seek, so shall we

find.” The speaker is a Scoutmaster as well. He talks to scouts about the boiling water story. If the challenges of life are boiling water we have three approaches. We can be carrots and become soft and squishy in the boiling water. Or we can be eggs and harden up in the boiling water. Or we can become coffee and turn into something wonderful in the boiling water. Coffee is like smelling hope. Become coffee. Hope is a key. He treated Mrs. H with hope. He told her she would have help getting through her medical issue. Superman was a symbol of hope. Leaders are a symbol of hope. Leadership in uncertain times: Pre-plan, stay sharp, maintain perspective, stay connected, be present, have and give hope and be compassionate. Compassion is strength. Progress is more important than perfection. We will not be perfect every day. Resiliency = individual + team + system. Combine today’s action with tomorrow’s hope. “It is not enough to be compassionate; we must act.” Our life is our message. He talked about his first military deployment and wondering when it would normalize. Wishing for it to go back to normal does make it happen fast. Be with the ones you are beside. Put a hand on a shoulder. Discuss things that were hard. It is OK to have a bad day. Acknowledge limitations.

NAEMSP Navigating Drug Shortages, Improving Patient Safety, and Reducing Waste (Clayton Kazan – LA Fire Department): December of 2015, the pharmacy notified the fire department that they would not supply controlled substances any longer. Board of pharmacy was taking action against medical director’s personal licenses. The whole process had to change. He covered the existing process which was intense and complicated. Multiple form processes. Could take up to ten days for restock. Some patients were not getting Morphine because medics were conserving due to length of time to replace. Only the worst pain was being treated. This led to overstocking. In contrast, pharmacies use electronic records, auto-dispensing and stock rotation to prevent waste. Fire stations were not allowed to have dispensing systems by law. The law was changed. Pyxis machines were placed as a solution. The DEA regulations caused confusion with who and where needed licensing. The fire department did all that was needed to be compliant. Dr. Craig Manifold was crucial in working with the Access to Emergency Medication Act of 2017. Covered the system of how the monitor the distribution machines. They have remote monitoring of the stations as well. One machine per battalion. All restocks are compared against the EPCR. Biometric ID is required by both members of the crew for restock. Waste is double signed. Now at 3.5 years and over 20,000 transactions there have only been three vials of Morphine missing. Utilization with patients has increased as now there is no fear of delayed resupply. This caused them to look at other medications. Epi went on shortage. Found EMS was a low priority on distribution when receiving meds from hospitals. They were moving to using Epi as a push dose pressor which increased supply need. They centralized ordering for Epi. Stations started reporting stock and expiration dates. Reduced Epi usage on arrest patients (no benefit beyond 3mg). EPCR data was used to determine needed PAR stocking levels. Ordered through hospital but formed relationships with distributors and manufacturers. End result? They maintained stock when many were out. The epiphany: It showed them how to navigate other shortages. They started to look at all medication stock in the same way. Stations have four-month stock of predicted utilization (California is rated as the worst state for disasters by FEMA). Monthly distribution is utilized. Expired meds are returned. Waste has been drastically reduced which saved a lot of money. They were spending $900,000 annually and wasting $300,000. Now it is at $700,000 with waste at around $100,000. What about drug safety? EMS is a major healthcare organization. They no longer take preloads out of the box. This should not happen. They are boxed for protection from light. Regulatory requirements on storing medications matter. Medication is a core part of the EMS mission. Pharmacists must be a part of your processes. Medical directors are not necessarily trained on what a pharmacist does for a living. Pharmacy training really does not mention EMS. Cross education is a must. There is much return on investment on improving the education and the process. Better compliance, access and security are a result. EZ IO needles are treated as drugs in stock control. Drug shortages are managed. Waste and costs are managed. They would love to share their process with others.

NAEMSP Peer Review for the Medical Literature: How to Help Our Journal (PEC) Grow and Thrive (David Cone, MD) –Editor in chief is changing for the first time in twenty-five years. Why are peer reviews needed? Assess intrinsic value and assesses controversial opinion. It should detect poor study design, flaws of logic, bad science, math errors and erroneous or overstated conclusions. Three options: accept without review, reject without review or send out for peer review. Two thirds of articles go out for peer review. Reviewers are selected by screeners (generally 3 or 4). May also use a specialized reviewer. Manuscripts are blinded. Most do not reveal the authors to the reviewers. Journal publication schedules are tight. If you commit to a review, get it in on time. How to read: Read it three times. One study recommends four hours for review. Use a peer review template. Initial impressions? Does the paper pass the “so what?” test? Conflicts of interest? Look at each section. Mark up the manuscript. Don’t write the review yet. Determine which references to review. Is it clear why the study was done? Is the study question clearly stated? Reproducible? Techniques understandable? Setting explained? Are the statistics reasonable? What analytic methods were used? Do data and results match the methods. Are the results in context? Is the relevance and importance made clear without being over-stated? Does the paper wander off topic? Are limitations missing or under-stated? Figures and tables helpful or fluff? References up to date? Are important references meeting? Grammar, spelling, syntax good? Originality? Validity must be assessed. Discussed the importance of the three readings. Start writing the review. Write a review for the editor and one for the authors. Tell the editor what you really think. Include specific concern comments. What happens next? Editor considers reviews and makes a disposition decision. Decision letters are sent to the authors with either specific or consensus reviews. The editor may be called for advice. Revisions may be handled by the editor. May be re-sent to reviewers. May use new reviewers for revision reviews. Examine the published article against your review.

NAEMSP Building a Relationship with the Medics: The Medical Director Belongs in the Field (Jason Pickett, MD, FACEP and Selena Xie, President Austin EMS Association – Austin, TX) - Building a relationship with the medics and the workforce is a must. Will discuss perils and pitfalls. The medical director is often seen as scary. This is true of the ER physician as well. Even the smallest comments can be taken as tearing them down instead of support. This view can set the medical director and the relationship up for failure. They must get to know the medical director and feel comfortable asking questions. The medics need to know the medical director knows what they are talking about. There is a real need for the physician medical director to build street cred. The medical director must inspire them to do what is needed and they must know why it is important. Otherwise, they will find ways not to do it. If you add to their burdens they must know why. You must be in their environment or you will be perceived of not understanding their world. Caregivers must believe in medical practice changes and a

great relationship helps that adoption. Nothing sabotages future initiatives like a failed initiative. The medical director must identify and understand pitfalls in implementing a new procedure. The medical director needs to gain an intimate understanding of special operations. That understanding is not gained outside of the environment. Equipment is no good without know how. Being out there gives the physician a knowledge of the austere environment where EMS lives. Being out there allows for bedside teaching. We want to instill physician mindset in paramedics in the field and that is done at the bedside. The medical director must create excitement about the care and about changes. When they ask you a question they are thinking about the medicine. Medical errors and near misses must have frank conversations that foster learning, not fear. Process improvement must have a medical director component and involvement and for this to occur, the physician must understand the technique and the environment. Documentation alone cannot cover everything that occurs on an emergency scene. Previous observation helps fill in those gaps. The medical director is a brand, and you have to build that brand. Being aloof from the medics is a bad thing and you will be scene negatively. The physician speaker prefers to be addressed by first name by the paramedics. The rank of physician serves as a barrier to interaction and transparency in the situation. Messaging can be used as well between the medical director and the workforce. Joint messaging between the MD, the caregivers and the EMS organization has proven very beneficial. A pitfall of increased involvement is familiarity. Familiarity may also breed problems with objective review. You must be aware of bias. The medical director should not blur the lines of operational vs. medical authority. We all have to stay in our lanes. Good medicine is sometimes bad tactics. Pick your battles wisely. You will see things that need to be addressed. Pick the ones that are yours as a medical director own. “If you’re an asshole, it does more harm than good.” Field time is fun. It can get you back to your roots as a medical director. Medics feel excitement and pride at seeing their medical director in the field. Great presentation.

NAEMSP Learning in Place: Overcoming the Obsolescence of Our Initial Education (Scott Bourn, PhD): A few questions? Ponder this. Look at your own practice. Have you had a patient with a disease you never heard of? A toxin? Asked advice about something you did not know existed? Then you are confused just like others on occasion. Speaker had to learn how to be a clinical resource. Initial education only prepared him for the field, not being a resource. Everything he needed to know WAS NOT learned in Kindergarten. Knowledge expires the day after graduation. That is dismaying but true. Why? The world changes. Our role in the world changes. We are really good at some stuff and not really good at other things. We gravitate toward what we are good at. Data influences what we need to know and modify. Data drives personalization. After initial education we have to utilize data to leverage our function. We have to cultivate a new attitude when change is required. We must know that we don’t know everything we need to know. “Mastery begins with humility.” We have to learn from failure. When bad things happen make it an obligation to teach and create to keep the bad thing from happening again. We can run from failure or embrace it and use it to grow. Seek and understand the data. Learn leadership and know the data from the clinical practice you lead. Know the data and know it very well. We must analyze the actionable area between literature and operational data. We must build on our strengths. Recognize opportunities to serve where you are strong. Things we are really good at are things were learned faster. Stick to your strengths. Don’t stay in your lane, it is too comfortable. We do not perform at true potential when we are bored. Seek certification to truly know something. Getting out of your lane broadens your impact. You can grow by going back to school or other routes of self-education and immersion. Continual education is hard work. Sometimes it is obvious that we have to learn more very fast to survive in the role we have joined. Remember, what we do is a privilege. Keep refreshing your expiration date.

NAEMSP Community Response and Drone Technology to Improve Outcomes from Rural and remote Cardiac Arrest: The Future is Now! (Cheskes, MD and Snobelen, Paramedic Services Specialist): Public Access Defib has a tremendous impact on survival. There is a solution to get these programs to rural and remote operations. Every second counts in cardiac arrest survival. Urban response times are short. Bystander CPR rates are around 40%. Many places are less than 20%. An AED can still make a big difference. They are simple and easy to use. Many times, an AED is not applied in the public. Patients will say they were lucky because someone did CPR and there was an AED. This outcome should not be luck. Some places are difficult to get to, in fact most of America is this way. Drones can affect this. We have to connect those willing to the patient and the tools. The PulsePoint application serves to connect those willing to CPR with the arrest patient and in many cases an AED. Peel Regional Paramedic Services created a volunteer unit that reports to paramedic services. They are given a response kit. The kit has an AED and associated supplies for cardiac arrest. After the arrest they follow up with the bystander. They also capture the rhythms off the AED. Another option is the drone program. This is considered private access AED. There are many uses for drones. There has been an increase in medical usage drones. They are using Beyond Visual Line of Sight drones. They believe 90% AED arrival in a rural setting of between 10 and 11 minutes is feasible. The program has reached national media attention in Canada. Video was shown of a simulated response. In most cases the drone arrived faster than the ambulance by about three minutes in simulation. Some feasibility flights covered nearly 9km. Surveys showed that the rural populace knew what a drone was but were not familiar with the AED. Delivering an AED without instructions on how and when to use does not meet the goal. AED drops practiced from the drone. Used Facetime App to deliver instructions (smartphone attached to the AED). Some simulations now up to 50km. Illumination added to the AED for night drops. They keep testing new things.


NAEMSP Development of a Sustainable Payment Model for Alternative Destinations (Medero, MD, Smith, MPA and Kasper): Large service area in Albuquerque. Three acute Care hospital ED’s. Do we really need to go to the emergency department with our patients? Greater than 50% of calls are low acuity. ED overcrowding leads delays in receiving care. Goal is to meet IHI Triple Aim (my note: as it should be for all EMS agencies). Use of ETHAN for telemedicine was assessed. Data showing time and cost savings using alternative destinations. Legal review must be a component. What is the capacity for care of the alternative destination? It must be able to address the patient’s needs. Assess what is needed to move forward and act. Using Uber Health as well. No billing/reimbursement path exists today. Financial modeling was used to determine financial impact. Payer sources wanted to see proof of concept before agreeing to participate. Patients were surveyed as to whether they would utilize an alternative destination during a 911 call. Many patients said yes. Many said they would prefer an urgent care over the ED. The payer mix in the survey matched what was seen in normal EMS transport. The cost of using Uber Health to go to ED instead of ambulance to ED was about a savings of $3,400 per patient. State laws differ on the availability to deliver alternative destination care. There is no direct billing code for this service with many payer sources in NM. Many are on managed care plans. There were a lot of challenges in billing and coding restraints. Meetings and research were prolific. There were challenges with physician billing for the telemedicine piece as well. Luckily, everyone wants to see this program work.

NAEMSP Oral Abstracts (1 – 6):

1.‎ Bougie-Assisted Endotracheal Intubation in the Pragmatic Airway Resuscitation Trial: Airway is an important role in resuscitation. Intubation is difficult with pitfalls. The bougie is a semi-rigid tool for airway insertion. Associated with greater first pass success. Post-hoc analysis of PART on ETI patients. Bougie use was paramedic discretion. Analyzed success and survival at 72 hours. N=1,227 patients. First pass success was not significantly different with or without bougie. Intubation was faster without bougie. No difference in 72 hour survival between both groups. Overall survival was lower in the bougie group. Not a randomized trial. Baseline ETI success rate in the overall trial was low. Findings neither support or refute bougie use. ROC study.

‎2.‎ Effect of Airway Strategy Upon Chest Compression Quality in the Pragmatic Airway Resuscitation Trial: High quality CPR improves arrest outcomes. Airway management may alter chest compression quality. Supraglottic airways may not conflict with compressions. PART study data was used. Better outcomes with supraglottic airways than with intubation. Used CPR waveform analysis from the ECG monitor for compression delays and compression quality. Interruption was defined as a pause for longer than 3 seconds. Examined differences in cases with pauses and with multiple airway attempts. N=1,996. Duration of resuscitation was 3 minutes longer with ETI. Duration and number of interruptions were similar between airway devices, but durations were longer with ETI. Interruptions were shorter with BVM only airway management. This study supports other studies. ROC study. Airway management can influence chest compressions. Airway DOES matter in cardiac arrest. Supraglottic airway use has shorter compression interruptions.

‎3.‎ Measuring the Overuse of Helicopter Air Ambulances for Transport of Trauma Patients: Why does helicopter transport matter? Costly. Risk: 3.62 accidents per 100,00 hours of flight time in 2018. We know that for short distances ground transport is better. For long distances, air transport is better. Strong benefit of air to trauma outcomes. Retrospective analysis using ESO data. Trauma activation criteria used in the study. N=5,984 transported by helicopter EMS. Median age = 44. Over 69% of patients were male. 57% of those transported did not meet trauma center activation. 52% were rural. 17% were super-rural. REMS used for acuity measurement. Over half had no documented trauma activation criteria. Urban setting transports presented no time savings.

‎4.‎ Incidence and Factors Associated with Post-intubation Cardiac Arrest in the Prehospital Setting: Case study presented on the topic. Patient arrested during intubation. Associated factors identified and are multiple. Include obesity, Succinylcholine and others. N=37 patients. All had cardiac arrest within 20 minutes of intubation. COPD was a common factor. Hypotension was also noted as a common factor. 45.9% had IV fluids prior to intubation. 19 received neuromuscular blockade. ROSC was 54.1%. Hypoxemia and hypotension, shock index and RSI were all factors. Important to note that over 50% were normotensive. Dosages were standard for RSI medications. There is no comparison group and small sample size. One EMS organization was used. PICA is due to multiple factors. Resuscitate before you intubate. More studies needed.

‎5.‎ Applying a Set of Termination of Resuscitation Criteria to Pediatric Out-of-hospital Cardiac Arrest: OHCA in children incidence is low. Survival has improved but rate is still low and neuro outcomes need improvement. TOR criteria is primarily prevalent in adult patients and rare for Peds. Adult studies have shown TOR criteria is applicable to adult patients. pTOR criteria is needed. Retrospective observational study. Study looked at 0-17 age patients. pTOR criteria was applied looking at minimum scene times, amount of Epi and ETCO2 readings. If minimum scene time increased from 10 to 20 minutes PPV was increased to 92.9% with better sensitivity and specificity. Medical pTOR criteria performed far better than Trauma pTOR. ROSC was a proxy for survival in the study. Overall outcomes were not assessed.

‎6.‎ Bougie through i-gel® Technique for Endotracheal Intubation on Cadavers: Technique of insertion discussed. Procedure taught in cadaver lab. Can be used as a blind intubation technique. Hypothesis was that first pass success of this technique would be 70%. Complicated airway was simulated with a cervical collar. 51 paramedics participated in the trial. Combined first pass success was 69%. 73% with bougie. Technique is slow due to multiple steps. Further research needed. Technique has similar success rate to other methods.

NAEMSP ON DEMAND SESSION – 10 Ways to Die on a Farm: Medical Control Considerations for EMS Medical Directors (Ashley Huff, MD): The farm is the deadliest workplace. 1) Grain bin accidents. In last 50 years over 900 cases of grain engulfment have been reported with a fatality rate of 62%. In 2010, there were 26 fatalities. Grain bridges (caps) collapse and surround and suffocate the farm worker by surrounding the chest. Anticipate crush injury and inhalation of grain dust. Special training needed for rescue. 2)There are also explosions in grain elevators. 3) Auger entrapment: Augers trap farmers and children who live and work on the farm. They cause significant horrific injuries. These are prolonged extrications with need for tourniquets and junctional tourniquets. Amputation may be needed. 4) Power Take Offs: Covers are taken off to speed up use or for maintenance. Clothing is then caught and pulls victim in. Normal reaction time is not enough to escape. Victim is spun around the PTO. 5) Tractor Rollovers: 1,700 died in tractor accidents between 2003 and 2013. The most common type was a rollover. This is a high fatality incident. Crush injuries and spinal cord injuries are common. Rollover protection systems are needed. 6) Front Loaders: Usually injuries are due to this vehicle being used for purposes that it was not intended for. Again, crush and spinal injuries common. 7) Sewage Slurry Pits: It is manure pit in or near livestock pins. Churning the manure creates toxic gasses like Hydrogen Sulfide and Methane. Inhalation can result in immediate collapse and this is highly fatal. When more than one person is down in a farm accident be highly suspicious of this. There are usually two victims before anyone realizes what is going on. 8) Chemical Spills: Anhydrous Ammonia causes bronchospasm and pulmonary toxicity. Large ETT and early tracheostomy may help with sloughed mucosa. 9) Livestock Attacks: Cows are most common during calving season. Veterinarians are commonly attacked. Crush injuries are most common due to trampling. Occurs with horses as well. 108 fatalities from cows between 2003 and 2007. 10) ATVs: Used commonly in agriculture. In 2013 alone there were 99,600 ATV-related emergency department treated injuries in the US. 25% were under 16 years of age. There were 13,043 ATV-related fatalities between 1982 and 2013. Most did not wear safety gear. Few had received any instruction on operation. Most drove them less than one day a week. Destinations: Not all EDs are equal. Rural EDs may transfer to trauma centers. Think about transfer times.

NAEMSP ON DEMAND SESSION – Top Articles of 2020 (Clemency, DO): Articles of importance from 2020 that may have impact on EMS for years to come.

1. Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion - Whole blood was a pipe dream to most a few years ago. Since then, it has become more prevalent in the prehospital environment. Must be capable to have conversations about things that are being proposed. This was published in Prehospital and Disaster medicine and is on the financial implications. Looked at administrations in a few systems. 46% of administrations of whole blood were for non-trauma conditions. What is unique in this article is the math. It is always hard in EMS to balance impact with cost. It is rare to find attempts at calculation. Five calculations were used in this article: A) Projected EMS runs per whole blood administration = Average EMS runs per month / Average Whole blood administrations per month. B) TOTAL COSTS = Fixed costs + Variable Costsyear1 + Variable Costsyear2 + Variable Costsyearx. C) Average Costs = Total Costs / Total Administrations. D) Projected lives saved annually = Annual total whole blood administrations / Number Needed to Treat to save a life. E) Average cost of a life saved = Total Costs / Total projected lives save. Using these calculations, you could in theory insert any medication or procedure and determine cost per life saved (my note: like Naloxone? ITD? Lucas?). Used a demand forecast as well looking toward more use in future years. By year ten it was projected that he average cost of whole blood to save a life would be around $5,100. They used a monitor/defib and associated disposables was used for comparison at $1,700 per life saved over ten years. He notes that blood transfusion does not need to be as good as a monitor to still have benefit, but it does put the costs into perspective. The question is, what other things are we doing in EMS that would not pass this test? “What wouldn’t cut the mustard?”

2. Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement – This is a PEC article and contains a joint position statement from ACS, ACEP, NAEMSP, NASEMSO and NAEMT. At the end of the article, there are quite a few more organizations who signed off at the end including the American Academy of Pediatrics. The speaker encourages anyone using or thinking about using Ketamine in their system to dive into this position statement. Discusses indications but the document weighs heavily towards trauma. The speaker likes the fact that the statement used terms like “preferable” and “excellent” regarding Ketamine. The dosing section starts with admission that here is no standard dosing guideline available. The position statement uses dosages for Analgesia of 0.1-0.3 mg/kg (max 30mg) IV every 20 minutes PRN for a max of three doses (weight based) or 20 mg slow IV/IO push over 1 minute repeat every 20 minutes (non-weight based). For acute agitation or excited delirium: 3-5 mg/kg IM or 1-2 mg/kg IV. Side affects covered. Rapid IV bolus can cause transient apnea. Normal side effects covered as well. ETCO2 monitoring should be used. Emergence reactions believed to be rare and can be handled with benzodiazepines. Pre-medicating with benzodiazepines is not recommended. Most side effects are transient. Over sedation is usually seen in combination with benzodiazepines. Ketamine was once considered bad in head trauma, but no longer. It has minimal effect on ICP and no adverse effect on CPP or neuro outcomes. The speaker does not care for the use of the term “unreality” in the article but cannot think of a better term either.

3. Review Article: Prevalence of Burnout in Paramedics: A systematic Review of Prevalence Studies – This is a review of five articles. Three instruments from four countries with low response rates. Most are single center studies. Key findings were that burnout is evidently present in paramedics, but exact prevalence is not clear, measurement tools make the prevalence more unclear, and more research into interventions is needed. Patient related stressors were the smallest impact! Personal and work related were the highest. The speaker thinks this is indeed the key finding and they missed it. Personal life issues and work-related stressors (my note: culture?) are more impactful on burnout. He stated there are four other associated articles worth reading on this: Paramedics in Pandemics: Protecting the Mental Wellness of Those Behind the Lines, then The Impact of Working Overtime or Multiple Jobs in Emergency Medical Services (a PEC article), Should Public Safety Workers be Allowed to Nap While on Duty? and Ambulatory Blood Pressure Monitoring among Emergency medical Services Night Shift Workers.

4. Paramedic-Delivered Fibrinolysis in the Treatment of ST-Elevation Myocardial Infarction: Comparison of a Physician-Authorized versus Autonomous Paramedic Approach – New Zealand location before and after study. Historically this system had ECG transmission failure in about a third of the cases when seeking orders for Fibrinolytics. Paramedics in New Zealand are trained differently than in the United States. Procedure and exclusion checklists were the same in both groups. In the autonomous group, the machine had to have an MI alert, confirming paramedic interpretation, normal QRS or RBBB, and HR of under 130. Drug regimens were the same in both groups. Patients in both groups were similar. There may be Hawthorne effect in this study. Saved eight minutes from 12-lead to needle in the autonomous group. The Hawthorne effect may be that they managed to do 12-leads more quickly in the autonomous group as these were two separate study periods. No greater issues noted with autonomous function. Also look at the PEC article Point-of-Care Troponin Testing during Ambulance Transport to Detect Acute Myocardial Infarction. There may be a synergy between these two interventions.

5. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest (JAMA) – “Cardiac Arrests are like golf balls – they should be played where they lie.” This is a reanalysis of ROC data from ten study sites including almost 200 EMS agencies. Overall survival to hospital discharge AND survival with favorable neurological outcomes were favored in the on-scene resuscitation group. Even the ones who had intra-arrest transport that survived still had prehospital ROSC so it is doubtful that hospital interventions offered any particular benefit over what occurred prehospital. Agencies who worked more arrests on scene had better survivability than those who transported during the arrest. There were some variances with some sights that were statistically insignificant. “Friends don’t let friends transport patients in cardiac arrest to the hospital.” If you do have to transport these in your system, do it later than sooner.

Day Two:

NAEMSP ON DEMAND SESSION High Flow Diesel Fixes Everything and Other Lies They Told Us in Paramedic School (Johanna Innes, MD – Buffalo, NY): Prehospital EMS providers are experts at making quick decisions with limited information. Load and go is a decision that is made quickly on every unstable call. EMS notes quick triggers to rapid movement. Many education systems push to get the patient to the ambulance as quickly as possible. The interior of the truck is well lit, has the maximum supplies and less people from the scene asking questions and trying to direct what EMS does. Rapid movement to the unit can lead to missed opportunities to prevent or manage cardiac arrest. Can you do a good assessment, get assessment/history findings and decide what to treat if you are rapidly moving the patient? Education is still saying that providers should dilute their attention and skills to move the patient. In critical trauma this is true. The patient needs blood or the steel of a surgeon’s blade to survive. The CDC guidelines are clear where trauma is concerned, and EMS excels at this. This helps mitigate trauma life threats. However, in cardiac arrest we know this is best worked without moving the patient. CPR is far less effective in a moving vehicle or when the patient is moving. Staying where you are in cardiac arrest leads to better outcomes. They have seen this in Buffalo and in other systems. Some places have not been ready to do so in the peri-arrest patient though. Pittsburgh was an early adopter of a stay and stabilize in place model. Implemented a “crashing patient” care bundle. It comprises of: No movement, physiological monitoring, aggressive BLS/ALS airway management, aggressive respiratory distress/failure management, early IV/IO access, aggressive IVF/pressors, maximal medication therapy. Agencies that stay and stabilize are seeing improved outcomes. Post contact cardiac arrest was cut by half. Buffalo: Post arrival respiratory and cardiac arrest (PARCA) accounted for 10% of witnessed arrest. Arrest was typically occurring between scene and the back of the ambulance. Stop moving critically ill patient to the ambulance before we perform critical interventions. There is a correlation between unstable vital signs and EMS witnessed arrest. Most had some or all of the following: pulse less than 60, respiratory rate less than 10, SBP less than 90mmHg and/or a GCS less than 14. If moved before obtaining these, how do you know? Equipment must go to patient side. 70% may have respiratory distress. Data is based on recognition of arrest after movement. When does it occur? Pennsylvania reduced on scene care to protocol based on paramedic assessment without criteria. How do we fix this? The book Thinking Fast and Slow was mentioned (my note: this book is mentioned a lot and is a must read for all EMS providers). We must use system 2 thinking and use deliberation and logic rather than “go” which is system 1 thinking. Education is a barrier. Every paramedic school has a medical director and must ensure that this is being taught. We also have to educate the public as to why we do not just pick up and run to the hospital. They trained their caregivers to explain the reason why we are not moving at the eight-minute point in the arrest. Sometimes we are yelled at to go by other public safety personnel. This has to be trained out by mutual knowledge and engagement/involvement. We also must resist the urge to go to the unit due to light, better environment and more equipment. Bring the equipment into the scene. Drugs go into the scene. We also tend to run with high acuity low frequency calls (my note: this is why Handtevy teaches not to move peds arrest early). We need to start by fixing this in paramedic school and follow up in CME. Barriers need to be addressed. Provide care bundles in protocols before leaving scene. Leave the monitor on and do not disconnect during movement. Build this all into protocols/guidelines. Use direct medical director involvement. Decide how to study the “after period” following the change.

NAEMSP Infectious Disease outbreaks and COVID-19: Implications for EMS (Milana Boukham Trounce, MD): Professor at Stanford. Has been teaching on this topic for 10 years and has written on this topic. How does this information apply to EMS and preparedness for other bio threats. COVID: EMS providers are at high risk. Mortality risk is several times higher than nurses and physicians after age adjusted comparison. We learned a lot about testing with COVID. Vaccines are now in play and are 95% effective. EMS providers are justifiably first in line for the vaccine. Covered vaccine trial statistics. Primarily anaphylaxis is the main side effect being noted. Time is always our enemy in an outbreak. Infectious diseases have killed more people in history than any other events. When the 1917-1918 Spanish Flu hit, life expectancy dropped to 40 years old as it hit the young. There has been a rise in both natural and intentional biological threats. This changes how we understand risks. Natural drivers: biological hazards follow air travel, urban settings, higher population, encroachment on animal habitats which causes viral jumps to humans. Many diseases are moving north from tropical zones. 30% increase in outbreaks. Numerous Ebola outbreaks since 1976. Accidental/deliberate drivers: advancements in biotechnology, some things eradicated have been brought back. Infectious diseases can be altered to make them more lethal. There are some scary academic studies on this topic. Viruses are hypermutable and can render vaccines and drugs useless. Medical surge capacity is limited including EMS. Without vaccines we turn to quarantine and isolation. All control of pandemic disease is focused on interrupting transmission. This includes a lot of engineering controls in workplaces as well as PPE. Interrupting transmission is important whether airborne or touch. Use antimicrobial surfaces, optimize temperature and humidity, optimize ventilation, filtration and air flow, and UV light. It can be as simple as opening a window. EMS vehicles? Open back of unit between runs, vent fan, patient isolation covers, PPE. Ford has developed internal software for police vehicles that directs the heater to drive temperature up and kill viruses and bacteria. UV light is effective. UV light can cause cancer and cataracts. There is a new light being researched that does no human harm (UV-C). Copper kills SARS-CoV-2 in under 4 hours. To recap, there is a continuing pandemic disease emergence that comes from several causes as noted.

NAEMSP Operational Medical and Public Health Intelligence: Why Now? (Amado Baez, MD): Principles of medical intelligence. Speaker travels the world doing protective medicine. This year he has added a mask to his gun and radio. Experiences from the G20 summit. Medical threat assessment occurs to sum up actions and conditions that can threaten a mission at hand. The intelligence cycle: Data collection, processing, analysis and production, dissemination, feedback, and then planning and direction. A threat matrix helps determine threat based on many factors by risk level, type, and environment. Tactical meteorology is used as well as weather affects assets in medicine. Aircraft landing zones and transport decisions should be considered and determined. Many of the documents used are adopted from law enforcement or military usages. Just because there is an “H” on the roof does not mean the building is structurally sound enough to support a helicopter. Use open-source assets like Google Maps/Earth for mapping and marking plans. They use opposing force simulation to determine vulnerabilities. Other pieces of intel for special event management is entry points, water sources, video, gas detection birds and things that test and monitor the environment. Syndromic surveillance can be passive or active. Reporting system would be considered passive-delayed. An active real time method would be taking temperatures. There is an Epidemiology Intelligence Fusion Center in the Dominican Republic. It infuses data and brains from many organizations’ military, public and private. Watches trends and probabilistic models. They created dashboards for readiness and COVID isolation centers. Must have national policy but local data and management. They identified zone level data in Santa Domingo. In 10 days they were able to break the cycle and change the curve for the Dominican Republic.

NAEMSP ALS to BLS Downgrades: Tools and Data to Assist in the Safety of BLS Transports after ALS Dispatch (Stone, MD – Butsch, MA): Will cover the advantages and pitfalls of tiered BLS/ALS system responses and downgrades. Will discuss a downgrade checklist. They hope they can help other systems develop tools for this as well. Montgomery County Maryland model. 1.1 million people with 500 square miles. Fire based system. 72,000 transports per year. Primarily use BLS ambulances with paramedics in other vehicles. Allows ALS to return to service when not needed. Downgrades use an evaluation tool for patient safety. Downgrade is independent without medical control contact. 25-40% of ALS dispatches are downgraded (25-35 calls daily). QI focused on downgrades. ALS downgrades can create cumulative risk. These are a form of handoff. Each one may be a sliver of risk that adds up. Where does ALS make the most difference? Paramedic knowledge value is harder to study than interventions. Discussed OPALS study on effectiveness of ALS. This is not about leaving them at home, it is about lowering level of transport. The paramedic brain is more valuable than the paramedic hands. There must be a standard approach to downgrades. Some require OLMS for this to occur, this system does not. The best systems operate off standing orders. Sometimes, being with the patient is ALS. There were some inclusion criteria in a study on mistriage for downgrades. The numbers in that study were encouraging. What is the pre-transport risk probability? Created a downgrade process, checklist and tracking system. Multiple factors utilized including what occurred prior to arrival. It looks for high risk complaints and at the assessment. Is relief of human suffering with analgesia needed? Several factors must be managed in ALS downgrades: lack of engagement, pre-judging, inadequate assessment, failure to recognize, insufficient BLS communication and incomplete documentation. There must be visual contact with the patient. The ALS Provider makes the decision on the downgrade. Must have full assessment and complete medical history. Use a handoff mnemonic. It is a mutual and informed downgrade decision. ALS providers may deviate from the form having to be “all negative” as over triage is a concern as well. Must be able to defend position on downgrade. Uses FirstWatch to provide surveillance on this process. There has been no increase in ALS scene time. 79.9% appropriate downgrades in the pilot. Full process put in place in November of 2020. Engage the patient at the ALS level. Assure full assessment. Communicate with the BLS crew. Complete the checklist. BLS crews have protection if the downgrade tool is not righteous.


NAEMSP Just Culture and Error Prevention (Streger, JD, Paramedic – Levy, DO): Bringing just culture to EMS systems. Medical errors are uncomfortable experience. Legal issues, being labeled by peers and potentially harming someone. Human beings are prone to making errors. The single biggest impediment to error prevention in medicine is that we punish people for making mistakes. Reduce opportunity for error. Capture errors before a bad outcome occurs. Allow for recovery from consequences when a patient is hurt. Facilitate crews to make good decisions. Organizations are responsible for the systems they design and that they work as intended. People are accountable for the quality of the care, acting and notifying of errors and issues. Just culture IS NOT blameless. Just Culture IS NOT a punitive culture. There is accountability for actions, but unintentional mistakes should not be punished. When an error occurs, we need to understand why. Most medical errors are related to a system component. We must get to the root cause of an error. Training? Cognitive coaching? Controls? Behaviors do not exist in a vacuum. Behaviors are part of a bigger puzzle. Simple mistake, at-risk, or reckless? Punishment does not end the occurrence of mistakes. We want to get persons to cease error prone activities. A simple mistake does not involve making a choice. Simple mistakes are usually unconscious errors. Corrective actions should correct not punish. Errors and near misses are opportunities to learn. Just Culture is not based on outcome, it is based on risk. At-risk behavior involves a decision with no intent to do harm or be unsafe. This is miscalculated risk. Retraining and remediation is used. Reckless behavior is the red flag. There is an unjustifiable reason for harm or breaking a rule. These cannot be tolerated. This should be a disciplinary referral. Understanding behaviors is essential to Just Culture. Good Just Culture systems use an algorithm or decision tree for assessment of the event. Must define system issues versus behaviors and how the behavior was classified. We must assess what others in the same position would do as well. Would another paramedic have made the same mistake with the same tools and situation? We need a culture of learning and shared accountability. Eliminate fear of repercussion in reporting. Just Culture needs a healthy QI program as well.


NAEMSP Medical Legal Liability Update (Streger, JD, Paramedic – Levy, DO – James, MGA): What’s in the claims pipeline? Did the shadow of COVID make lawyers climb under a rock? Claims mix is business as usual. Normally medical director can be excluded but it is expensive. First direct hands-on care issue with a medical director. All cases followed protocols. Most are from bad outcomes. Some related to COVID. Claims are coming in but the judicial system has slowed dramatically. Next year there will be a big spike in published cases after all are heard. COVID has been like building a bicycle while careening down a hill. Things changed quite frequently. Yesterday’s information was tomorrow’s bad information. This caused legal issues. Immunity laws changed. Scopes changed. Both of those helped. COVID caused almost an ET3 model to happen. Many medical directors are often included in wrongful termination suits, but they end up being dismissed. Just because you have immunity does not mean you will not be sued, and you will have to prove immunity. This is a bit sobering to many. Is there exposure in flexing the system? Most COVID related claims will most likely go away as it is felt that juries will not be sympathetic. Many of the changes in EMS systems due to COVID were needed anyway… alternative destinations, telemedicine, cessation of resuscitation. The biggest problem in these cases is that EMS systems did not explain it to the public. COVID has also been an opportunity for frivolous law suits as well. COVID has been draining to healthcare providers and this is causing PPE questioning and dissatisfaction in other areas. It is a result of COVID fatigue. Beware normalization of deviance. Claims are starting to occur for free-standing IV services, mobile IV services or event IV services. This includes vitamin additives and other non-EMS transport IV services. This is now an insurance exclusion for medical directors. Has become a big problem. Normalization of deviance from standards that removes us from what we should be doing causes big issues. Always contact insurer as to whether something is covered for medical direction services.

NAEMSP Pearls for Management of the Pregnant or Peri-partum Patient (Karin Fox, MD – Texas Children’s Hospital, Baylor University): To improve population health for women we must focus on all facets of healthcare. EMS is a part of this. Has initiated a maternal transport program (three years ago). Maternal Level of Care designation. Focus on maternal mortality. The U. S. is leading advanced nations in maternal mortality. Hemorrhage is the number one cause of mortality. There is not a lot of public knowledge in this area. Same for providers. Set up the system so it is easy to be successful. Good handoffs. Ensure continuity of care. Maternal designations are being placed like trauma centers. Level IV is the highest acuity center. Lower levels of care need to be educated as to when to refer and transport out. Transport or not transport? Deliver where they are or transport to the maternal center. OB
Nurse on team. The best incubator is a stable mother. Are they in labor? What stage? What is travel time (look at time NOT distance)? 49% of counties in the U. S. have no OB GYN

physicians or maternal services. Top five issues for referral: Hemorrhage, cardiovascular events, Infection (including COVID), preeclampsia, and overdose. Maternal-Fetal Conflict: sometimes the focus is on the infant’s well-being and not the mother. The mother is the focus of the maternal team as the mom is the best incubator and protection for the baby. Worried about maternal heart rates over 120. Pre-oxygenation before intubation is critical in maternal care. Edema is not uncommon in pregnant women. Increased tidal volume. Slight respiratory alkalosis. Gastric emptying is delayed. Coagulation factors increase. Asthma, cardiac arrest, overdose, hypothermia, diabetes and many other things are treated the same as normal. Maternal patients should not be transported absolutely flat due to IVC occlusion (can be an issue with CPR as well). Easy care: IV access, transport tilted to left, mag sulfate present, oxygen, monitor and maintain homeostasis (watch for vital sign changes). Gestational hypertension, preeclampsia and eclampsia are all issues that need managed. If doing CPR, transport for emergent c-section. There is no reason not to try this in the appropriate setting. COVID precautions are important now. The speaker does not support with holding intubation in COVID or suspected COVID patients in maternal settings. They need to come intubated if needed. There will be increasing demand for EMS services to support transport for these patients.

NAEMSP Vasopressor Intravenous Push to Enhance Resuscitation (VIPER) Study Final Outcomes: The Final Piece of the Triad (Olvera, BA, NRP): When are push dose pressors needed? How does Ketamine interact in this setting? 80 systolic is the threshold for arrest. The window is about five minutes to prevent arrest. End tidal at 24 is about the same threshold. When those two elements occur together arrest is eminent. What about ketamine? Patient’s should not stop breathing and Ketamine is good for that. It also raises BP. It does cause hypersalivation and can cause laryngospasm if pushed too fast. Etomidate causes less desaturation and less hypotension than Ketamine in RSI. So what about push dose pressors? Arrest in peri-intubation is not common. They use Phenylephrine and Vasopressin in their practice. Most literature shows push dose pressors work but do not improve safety or outcome. Push dose pressor use can rapidly bridge the gap and prevent crashing patient arrest. Study had to have a systolic less than 90 and ETCO2 of less than 25. Must be used within 15 minutes before or after intubation. Statistics on study covered rapidly. Both vasopressors raised BP. Both also had relapse hypotension within 20 minutes. Occurrence of Peri RSI Arrest decreased. People who were in the dead graph before PDP use were now just coming in hypotensive. PDP corrects hypotension and decreases incidence of peri RSI arrest.

NAEMSP Oral Abstracts (7-12):

7. Comparing OHCA Treatment and Outcomes of Males and Females: Previous studies have been contradictory. Some studies have shown females have a lower survival rates. 120,306 arrests as a start point. 2011 to 2015. N=65,241 with required study data. 36% were female. Males had 11% more shockable rhythm on initial contact. Males 3.25 higher survival to discharge. Males received defibrillation 13% more often than females. Incidence of receiving Epi was higher in males also. Time to CPR start and first defibrillation was higher in females. Time to first ROSC was slightly higher in females as well. Duration of arrest efforts was shorter in females. The study showed that females were less likely to arrest in public which could explain a longer time to discovery. Further research needed.

8. International Multi-Center Controlled Interventional Trial to Increase OHCA Survival by Implementation of a ‎Dispatcher-Assisted CPR Package (Pan-Asian Resuscitation Outcomes Study Phase 2)‎: Study presenter from Singapore. Bystander CPR and survival rates are low in the Asian pacific. Differences between a basic and a comprehensive dispatch CPR package were measured. Multi-national study. Primary outcome was measured as survival to discharge or 30 days. Comparison was between counties that implemented the comprehensive package and those who did not. Comprehensive package sites had better outcomes. This presentation moved very fast and it was difficult to digest the data as to the differences. Wide variations in sample sizes between countries.

9. Community Disparities in Out-of-Hospital Cardiac Arrest Care and Outcomes in Texas: Minority neighborhoods have lower rates of bystander CPR. The disparity is at a national level but did it exist in Texas? N=18,488 in study. Low high school graduation rates were associated with lower bystander CPR and survival. Employment status was not an indicator. Teas did have minority neighborhood disparities. Must be a quality improvement effort to train these communities in Texas.

‎10. Real-time Feedback Devices Associated with Improved Outcomes in Cardiac Arrest: Do real-time feedback devices in CPR improve outcomes? There is little research on manual CPR with feedback devices. N=978. Retrospective study from 2012 to 2018. Looked at 30-day survival. Under 18 and trauma was excluded. No differences in bystander CPR or shockable rhythms. Utstein outcome criteria used as well. ROSC improved by 13% with feedback devices. Across all rhythms, neuro intact survival improved by over 5%. CPR compression rate was corrected and slowed slightly. Compression depth was increased with a feedback device. Release velocity was improved as well. Do not drive blind, use a CPR feedback device.

‎11. Priorities for Prehospital Evidence-Based Guideline Development: A Modified Delphi Analysis: Gaps exist between EMS care and evidence-based care. What are the gaps? Surveys were used 2019-2020. Open ended questions were used to identify clinical and operational gaps. Identified gaps were rated by members of the Prehospital Guidelines Consortium. 65 clinical and 58 operational gaps were identified. Three top clinical gaps: Airway management in adults and peds, carte of Peds, and management of behavioral health emergencies. Three top Operational gaps: Define and measure impact of EMS outcomes, Practitioner wellness, and practitioner safety. They did not comment on research gaps but guideline gaps with research. Study was before COVID so no pandemic influence.

12. Feasibility and Psychometric Validity of Spanish Language Basic and Advanced EMS Certification Exams: Diverse and disparate models of EMS exist in Latin America. Culture and context are important in EMS certification exams. Some use National Registry translated exams. Subject matter experts reviewed the exams. Psychometric evaluation performed. Nine countries were evaluated. 12% of items were removed following the psychometric evaluation.

Day Three:

NAEMSP ETCO2 in EMS: Questioning the Status Quo (Latimer, MD – Bulger, Research Coordinator – Counts PhD): Seattle Medic One has created a database of ETCO2 waveform files. What do we think we know? Low ETCO2 not able to be resuscitated? ETCO2 during BVM utilizable? ROSC heralded by increase in ETCO2? Case study presented on VF arrest patient. CO2 is a byproduct of metabolism. “CO2 is the smoke from the flames of metabolism” – Ray Fowler, MD. Several accepted usages: ET placement, ET dislodgement recognition, confirming quality of CPR, detecting OHCA and ROSC, component of TOR criteria. ETCO2 is to ventilation and perfusion as ECG is to cardiac rhythm. ETCO2 must be considered a vital sign. Seattle Medic One Airway registry includes the ETCO2 data. LP15 draws power from the ETCO2 module during defib charging creating null values at times. They perform a lot of data mining and algorithmic analysis of the waveforms. 4.5 years of data with 1,278 intubations. Does ETCO2 predict ROSC? Yes. Smaller BVMs provide better ventilation in cardiac arrest. ETCO2 is a predictor of outcome in Cardiac arrest. ETCO2 capable of predicting hemorrhagic shock. ETCO2 appears to be able to predict pending OHCA as well. More research is required. ETCO2 is clinically relevant in prehospital care.

NAEMSP Re-Thinking Systems of Care for Time Sensitive Emergencies (Gunderson, EMT-P): STEMI, OHCA, CVA. Systems are designed to improve outcomes. Systems develop organically over time in communities. There must be processes of bystander and self-care prior to EMS arrival. We cannot ignore time from symptom start to EMS activation. It does not do any good to place a coronary artery stent and the patient then not fill their anticoagulant prescription. All facets of care are a part of driving ultimate outcomes. Is there a system level entity to even work with a system improvement champion? Who is accountable? Are destinations specified? Are there patient registries? Is there an aggregation of efforts to improve these outcomes? Other time sensitive conditions can be addressed. Customize the management entity (RETSCO) to be a catchment area and involve all stakeholders. Facilities must coordinate with EMS together and NOT independently (my note: so true!). Involve government and dispatch as well. Be careful of bias. Competition can create preexisting bias. A stand alone not-for-profit RETSCO may be good, but costly. Each time sensitive condition should have its’ own committee within the RETSCO. There can be a cross-condition committee to strengthen areas of commonality like immediate transfer of patients to specialty centers. Leadership is important in a RETSCO. ED physicians are perfect leaders for a RETSCO as they have broad application of care. Many systems have a lack of external accountability on time sensitive condition performance. Therefore, a RETSCO may again be a favorable model. Create transparency and create accountabilities that overshadow barriers. Strive to use formal clinical registries.

NAEMSP Pseudo PEA: “To PEA or NOT To PEA” (March, MD – Kitch, MD): There are sub types of pseudo-PEA. Will discuss application of ETCO2 in PEA. Compared PEA to the differences in fine and coarse VF. True PEA is no pulse and no MAP (AKA, EMD). False PEA has no pulse, but the MAP is greater than 60 (Body habitus, aortic dissection, PVD, increased systemic vascular resistance). Pseudo PEA has no palpable pulse and MAP is between 60 and zero. ETCO2 between 20-30 (less than 10 common) may be in pseudo-PEA (check BP and consider CPR – 1mg Epi). Ultrasound can be used in PEA to determine cardiac wall movement (contractility). Today ultrasound probes can connect to a smartphone App. If there is PEA with cardiac wall movement, there is a 400% greater chance of achieving ROSC with arrest efforts. Paramedics with only one hour training were very good at using ultrasound for this specific purpose. Kitch believes that this was once a device looking for an application, but the application is now here. POCUS is important in arrest management in the prehospital environment. If the heart is squeezing, efforts are aimed at increasing output. Use Norepinephine or push dose Epi. If you find a treatable cause on POCUS then treat if able. If not, that is the point of transport.

NAEMSP Stories from the Frontlines: Advancing Prehospital Care in Low-resource Environments (Abo, MD – Becker, MD): Stories and experiences for working in international environments. How do you fund work in these areas? Sometimes it is self-sponsored. It could be sponsored by an agency as a philanthropic effort or for exchange or publication. Non-governmental organizations may sponsor delivery of care in these areas as well. There may be a goal such as decreasing fetal/maternal mortality in an area. Research funding could be used also. Care should attempt to be sustainable after the trip. Are you creating a system or augmenting an existing system? Creating is big, augmenting can be small and focused or large like transitioning EMS from BLS to ALS. What are your objectives and your delivery models? Perform a needs assessment. The importance of this cannot be overstated. Watch for conflicts of objectives; needs assessments help with this. Vehicles are a small component of the system but a critical component and may of these systems have very aged vehicles. Oversight should have appropriate credentials. Is there any substance to the individual(s) providing oversight and education? Are you even allowed to work in that country or locality? Are you even allowed to be there? Oversight must have local vetting. Local benefits are the prime directive. You need to vet the locals out as your future partners also. You want to do the right thing and not be overcome. Promote local ownership of the project/care. They need to take it and go further. Promote sustainability. Create train-the-trainers. Sustainability must be economic, environmental, human capital, psychosocial and educational. If you drop things off, are they sustainable? Can they even charge a device? Can vehicles be serviced? Must have cultural sensitivity as to what, why and how. Who are the stakeholders? Local clinicians, local admins, politicians and regional leaders, philanthropists/funders, and domestic expectations. This is not cookie cutter. Every location is different. “If you have seen one EMS system… you have seen one EMS system.” No two are alike. GREAT SESSION.

NAEMSP Pediatric Termination of Resuscitation by EMS: Creating a Compassionate and Useful Protocol (Anders, MD – Johnson, MSN, RN): This is on pediatric TOR. TOR has a timeline covering positions from 1992 to the present. Most TOR criteria exclude pediatrics. The etiologies of pediatric arrest are different from adult arrests. Why peds TOR? Reduce resource use for futile care, reduce high risk transport, avoid giving false hope and improve outcomes. If we are going to stay on scene and work arrests, we must always have a plan for end of care when futile. There is very little literature to drive this. Children with witnessed arrest, VF or PEA have better chances of survival. Adult TOR criteria may not be suitable for children. Several trauma TOR consensus documents exist. PTOR has steps to establish. Considered resource use. Post-mortem care must be an operational consideration. Care must include social support for family members and release of ambulance back to service. We also need to make this emotionally safe for our EMS caregivers. We don’t know what we don’t know. Identify stakeholders. Listen and hold focus groups. Identified variations in scene handling in different areas. Medical examiner arrival on scene varied widely in Maryland. They heard consistently that pediatric death was a heavy emotional burden. Created an offline tool for PTOR. Defined medical futility. Allowed for use of EMS judgement and assessed operational feasibility. PTOR: Must have 15X2 cycles of CPR, asystole, ETCO2 less than 15 and judgement of EMS and law enforcement on scene. Rollout through identified and trained pediatric champions. Trained hospital personnel at base stations. Educational update of 8 minutes to all state personnel. There is new literature all of the time that can lead to revision of PTOR. May need to exclude drowning victims from PTOR. Performed education to EMS on breaking bad news and emotional resilience and wellness. Create pediatric champions to be point persons. Support local clinicians in these efforts.


NAEMSP When a Child Dies: Formalizing the Bereavement Process in EMS (Antevy, MD): Dr. Antevy is the creator of the Handtevy Pediatric system. Covered a case study where a father accidentally ran over his son. Crews arriving were prepared to treat the child but not the grieving father. The Captain had the hardest discussion of his life with the father. If peds cardiac arrest is 10% survivable and 90% death, where should our training be? We should increase training on how to help those left behind. The arrest life cycle in healthcare providers. The last quadrant is “closure.” It contains “we did everything right,” but the family needs to hear what we did. If there is no closure, the resuscitation never ends. “I was never trained to do this.” “We wanted to show mom and dad that we did something.” Not seeing what is done is NOT good for the family. The family needs closeness in those moments, not exclusion. “It’s

easier to leave the scene.” It is hard to stay. Staying is emotional. Leaving is fear of the situation. Staying is love and compassion. “I wasn’t sure what to say.” Always hard but cannot be taught. This is low hanging fruit. There is a huge gap with bereavement in EMS. We must understand what the parents need, and we need EMS medical director leadership in this area. TOR guidelines help protect for the liability of not transporting. Discussion of cases and liability. Liability is indeed limited. Focus on what matters. Played video from Dr. Kupas where parents were concerned with child being baptized before termination of arrest. On scene medical director baptized the infant prior to arrest termination. He followed up with a certificate of baptism which helped the family with closure. “THAT my friends is compassion. That is what we need to learn from.” Communication with families must be improved. Parents recommendations: Be honest, repeat it, resources available for grieving, need other family members present and privacy, a key member of staff to stay, walk them to wear they need to go, time with deceased child. They also want follow up care to see how they are. They also need information on what happens next. Recommends work of Dr. Mary Fallat. The parents want to remember, and they want you to as well. We have to own helping them. One system has educational dinners for grieving parents and supporters. Parents want to know how the child died and the details of the resuscitation. We have to tell them. COPE training available. Compassionate Options for Pediatric EMS. Look at www.emergencyresilience.com . Send a sympathy card. We must practice vicarious bereavement. Played video of Sandy Hook elementary reaction of the President.

NAEMSP A Focus on Clinical Decision Making: Lessons Learned from a Regional RSI Credentialing Program (Dorsett, MD – Galton, MD): Interventions come with the potential of harm and benefit. We deal with both populations and individuals. RSI is a high-risk procedure. Literature offers no clear picture of the risk versus benefit. Overall, literature does not support prehospital PHI. Experience of the individual doing the procedure is a confounding factor. Extended experience equals better outcome, and this can be confirmed by a credentialing process. The system of the presenters uses tiered response of credentialed individuals to deliver RSI. How do you get there to provide objective credentialing? Who is eligible? They must be comfortable in the system. Must be in direct patient care. No less than 10 field intubations. Used a written exam as part of the process. Provided education that is online, interactive and then small group. Uses scenarios in training. Small group training is physician led. At this point they are still potential candidates. They then progress to high fidelity simulation (with physicians present). Did they move straight to intubation or progress through protecting the airway towards intubation appropriately? Once approved as a RSI provider, all RSI situations are debriefed. This occurs through a survey. In most cases RSI is deferred. If they progress through airway control and management, there is improvement in the patient which causes RSI to not be performed. Focus on the outcome not just the airway. Airway control is about making the right decision. In the presenter’s system, all RSI patients receive follow up to determine outcome. Post review includes physician concurrence on need for RSI. Decrease peri-intubation hypoxia.

NAEMSP Conference-wide Interactive Session:

1. Oxygen supply in long transports can be an issue. Issues in high flow oxygen during transport. Also issues with discharging to homes and no oxygen at home on arrival.

2. COVID vaccination rollout: Issues in getting frontline personnel to accept the vaccine. Firefighters seem to be more reluctant to receive in some areas. Some systems report vaccinating over 400 per day. Some incidences of redness at injection site appearing eight days after injection. Online sign up for vaccine problematic in some areas. Online registration may exclude many elderly persons. Vaccine sites may want to be ready for persons in wheelchairs (accessibility). Do not waste doses left over in vials (find someone to give it to).

3. When will COVID start to taper down? “Every bet we have made we have been wrong.”

4. Trauma system time measurements: Field scene times are not the delay in trauma. Is anyone measuring door to scalpel in trauma? Abu Dhabi has set a 20-minute goal.

NAEMSP 2021 Awards Ceremony, Business Meeting and Closing Remarks:

On demand NAEMSP lectures will be available to NAEMSP conference attendees for the entire year.

Brent Meyers as past president and other outgoing committee members were recognized.

Committee leads were recognized. 369 individuals have been inducted as Fellows of the Academy of EMS. 59 more added this year. Chuck Norris video played congratulating inductees as “Chuck Norris approved.”

Stryker EMS Medical Director Fellowship Award winner: Michael Lauria, MD, NRP (note he is a paramedic as well).

NAEMSP President’s Awards: Toni Gross, MD for the creation of the virtual conference. Ryan Jacobsen, MD for skillful management of the Standards and Clinical Practice Committee.

Friends of EMS Award: Jon Krohmer, MD for dedication to NAEMSP and EMS efforts and advocacy at the federal level. Video played from Randolph Mantooth (Johnny Gage from Emergency!), congratulating him and thanking all for everything they do.

Keith Neeley Outstanding Contribution to NAEMSP Award: Maia Dorsett, MD. Congratulations video from Debra Messing from “Will and Grace.” Awarded for dedication and course creation.

Ronald D. Stewart Award: Considered a life-time achievement award and is the NAEMSP’s highest award. Awarded to Craig Manifold, MD (posthumous). Congratulations video from Ronald D. Stewart. Accepted by his children and wife via video. He told his daughter that he never worked a day in his life because he enjoyed what he did.

Dr. Tan recognized the NAEMSP staff and his wife.

Research Abstract Presentations Awards: Remle Crowe on comparison of sedation agents. Timothy Burns on predicting COVID positive patients. Benjamin Leung for Machine learning rules for drone AED delivery. Matthew Harris on Peds TOR. Bonnie Snyder for small BVM usage in cardiac arrest. Henry Wang on airway strategy and chest compression quality.

Dr. Redlener recognized the best quality improvement projects: Rick Allgood (Indianapolis Fire) on completed documentation project. William Leggio (Austin) on matching EMS cases to hospital records. Bryan Wilson, MD (Bethlem, PA) on reducing lights and siren use to the hospital (dramatic reduction of usage).

Annual Business Meeting:

Dr. David Tan Recognized NAEMSP officers and incoming officers.

Thank you to the largest sponsors: Global Medical Response and GM On-Star.

Dr. Tan gave thanks for his time as President of the NAEMSP. Dr. David Tan then awarded with the past president’s pin by incoming President Dr. Michael Levy.

Closing comments by Dr. Michael Levy, incoming president:

Dr. Levy thanked Dr. Tan for his leadership. Dr. Levy’s goals for his presidency: increase NAEMSP membership, increase improvements in EMS science, increase and make collaboration easier, continue inspiration (find the Isaac Newtons and McGyver’s), reach out and let people know that the leaders are accessible, increase relevance to non-members and international colleagues. He wants to drive this through the committees. There is need to be extreme, inspirational and motivational. Looking forward to the 2022 meeting in San Diego. January 10-15, 2022.


That is the whole of my notes from NAEMSP this year. For those who want to progress your career in EMS and use the data to better impact your communities, I highly suggest joining NAEMSP as a professional member (you do not have to be a physician). This organization is amazing. This annual meeting (even though virtual) has so much information that I have not touched yet like a virtual exhibit hall, more on demand sessions and 170 scientific poster presentations.

Next year, hopefully the plague will be gone and we can all attend NAEMSP in person in San Diego.