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

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

Day 1 - Eagles 6-17-21

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

 

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

 

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

 

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

 

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

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Day 2 - Eagles 6-18-21

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

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