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
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
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.
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
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
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.
