My Notes from the 2022 NAEMSP Annual Meeting

 

Before diving into the notes, I would be remiss if I did not take a moment to introduce a driving force in my note taking for well over the last decade (yes, there were things called notebooks with over 40 pages of hand written notes before the past few years of being posted on the internet). Please meet Dr. Peter Stevenson. He was the primary medical director at my place of employment for over 40 years (yes, your read that correctly), and remains as the associate medical director today which brings his total time of service to EMS to 43 years. Dr. Stevenson came to Evansville from Nova Scotia, Dalhousie University to be exact, where he studied under emergency medicine icon Ron Stewart. Dr. Stevenson has been the center continued development for many years and still assists and helps lead us from retirement (alongside our current medical director, Adam Dunstone).

Dr. Stevenson and myself at NAEMSP 2022

 When I am typing away feverishly during NAEMSP or the Eagle's Meeting, he is usually beside me asking the ever present question that is the basis of why we attend: "How do we translate this to the local practice?" Those two meetings have driven our efforts to be more and more evidence-based for over a decade (I think the first Eagle's meeting we attended might have been 2006... not sure). So the truth is, he is the one who has pushed me to do this all of these years. It has been a great thing to go to these meetings and learn from some of the greatest EMS leaders in the world.

So here is the usual disclaimer. These are my raw, slightly looked over, slightly edited notes from the view of a paramedic level practitioner sitting in a large group of emergency physicians and other paramedics. I am sure there are a few missed typos but hopefully I was able to accurately convey numbers and the intent of the presentations. If not, I apologize in advance.

Day 1

 

Levy (Anchorage) - Welcome and NAEMSP President’s Address – “It’s the end of the world as we know it. I feel fine.” Despite all that is going on, pre-registrations for this conference is the highest ever at 973. This is epic. It means people want to be here. If we had withdrawn from holding the conference, all the costs would have still been there. It would have eaten up the operating budget of the NAEMSP for the year. We salute the passion that allows you to support the patients and the caregivers around you. There were a large number of healthcare and firefighter deaths due to COVID. 2056 members in the NAEMSP currently. There has been an acceleration of startups of NAEMSP state chapters. The Colorado NAEMSP, the Ketamine legislation would have done to practice was dramatically mitigated. 27 more EMS fellows were added. 25^th volume of Prehospital Emergency Care was published. New course was developed called Foundations of Medical Oversight. The NAEMSP finished the bylaws update. NAEMSP continues to be instrumental in the legislation regarding controlled substances. The NAEMSP needs funds in the political action committee (call for donations). NAEMSP townhall meetings being held. The PEC has published an airway compendium of position statements (115 authors in 15 articles). This will guide EMS airway management for the foreseeable future. Stryker funded the compendium. A special call out for Greg Mears who is awaiting a liver transplant.

Lt. Quention Curtis (Chicago) – Black Fire Brigade – He was raised in Cabrini Green which was considered the worst housing project in the nation. If you came from that neighborhood, you were known not to have a chance to succeed. 420 youth have been given careers through the Black Fire Brigade and over 4 million dollars of payroll has been created over time. The Lincoln Park neighborhood is seeing a rash of violence daily. There can no longer be a blind eye and we have to make change. Why do blacks not trust EMS? There are communication barriers. Both speak English but the tone of communication is culturally different. One says, “I am on my way to the crib.” The other person says, “The crib? Isn’t that where babies sleep?” It almost started a war. Some kids in these neighborhoods do not believe they will make it to age 18. EMS has to shake that narrative. Diversity is important to fix this. Why do we not speak the language? There is a lack of trust. Trust is huge in the black community. He is a former police officer also. He was talking to some physicians about the Chicago ERs last night. There have been three shootings inside the ERs in Chicago. ER doctors must be aware of what is going on nationally. Stealing is now occurring because marijuana was legalized, and the income stream was taken away. They went from income to nothing overnight. The black Fire Brigade walks youth through the trust and culture to produce successful escape from the neighborhood cycle. We need to participate in helping communities. Last night, two 14-year old’s were shot and killed in Chicago. The Black Fire Brigade is the number one change/employment program in the state of Illinois. Four rescues have been made by youth members. The BFB will go to any city in the world to help develop like programs. The teach how to save lives. The get people to care with basic life saving techniques (CPR, tourniquets, taking action). If you teach them to save a life, they are less likely to take a life. Plus, you learn a lot from these kids. The kids just need direction. They are intelligent, well-coordinated, and social media connected. They just need direction. “No one trusts the police, but everyone trusts the fire department.” We are coming to help because they call. The fire department is not a threat. You call we come. They don’t want everything. They just want to be treated fairly. We find ways to complicate, not to help. Let’s not talk about what you can’t do, let’s talk about what you can. Why are there so many “nos?” We need to get deep into the “yeses.” If everyone does a little, you build a lot. It means a lot to speak on this topic. We all must deal with this at one point or another, so the time has come to do something. Chicago is celebrating the 150^th year of black firefighters in the fire service. The very first paid back firefighters in the world were in Chicago. Spend a day with me and see what the reality out there really is. He was born in it. He knows it. “How can you be so poor and be so happy?” “Wait, we’re poor?” We had government cheese, we played baseball, we made toys out of crates. We were very happy in our own confines. He had 16 siblings. He never knew he was poor because he never wanted for anything. He had family and friends. Then the bad element came, and everything became materialistic. He was happy just having family and friends. Now they want everything, including your blood. The effect of this is becoming worldwide. Two of his sons are Chicago police officers. We have to create hope. We have to give something. We have created homelessness and lawlessness and people don’t believe anymore. Why is this important to us? Everyone in EMS is affected by this. If not in your community today, these problems will be. We get a chance to effectively make change with real conversations. Let’s get behind real programs that give hope and make real change. Just do a little and we will get a lot. The job offers are instant when the youth graduate this program. They drive EMS during the day and go to EMT school at night. Instant employment when done. Employed to go to school. He started with a goal of sending 10 to school. That ended up being 40 for the first class. Now 420 total. Still not a lot of support from local government. We taught these kids how to fish and they are going to eat forever. These kids are making a true change. They are coming to save your life. In interviews, these kids have not been around professionals, so they do not make good eye contact. If you use point systems for hiring, think about things like eye contact, attire, and ability to speak more than one language. These kids do not have those luxuries in their background. They don’t have suits to wear. Adults talk at kids, not to them. Listen and they will tell you what the problems are. We have to take time out to listen. They have been through more than most of us can imagine. One youth went through EMT, firefighter and paramedic school while homeless. He had ten jobs offered immediately. Phase one takes 120 days and they start at $24,000. Salaries can reach up to $72,500 at paramedic. Some have become safety officers at companies with their degrees. Let’s help the future. BFG is willing to help in any community. Ended with a standing ovation.

 

Fowler, Levy, Pepe, Krohmer, Stewart, Swor - EMS Medical Direction: The Prequel – Multiple presenters, past presidents of NAEMSP. Stewart – First president. He was elected while he was in the restroom. The NAEMSP was driven by the desire to make EMS a practice of medicine. Paramedics needed advocacy. He practically lived in the streets with his medics in LA. EMS lives in an environment that is much different from that of the ER. The show Emergency was critical. Media matters. Advice to new leaders of the organization: “This is a unique organization. Be careful as to what drive you. We must concentrate on what happens before the crisis. We
do this by being together. We are canaries in the coal mine. EMS will notice it first.” Thoughts on what we should take from this? “This is a great honor to speak. I would say to everyone is that what you have gotten yourself into a great privilege. We need good, solid science and research. We cannot be resistant to change. EMS is the first to touch patients.” Pepe – There was a vacuum for those physicians working alone until they got together to share and lean on each other’s knowledge. Fowler – EMS systems started to emerge in the 1960’s after the development of the interstate roadway systems. The NAEMSP developed the EMS Medical Director’s Handbook and the Medical Director’s course. We must continue to communicate as a tidal wave is coming of data and science. There are still silos of care that do not speak to each other. Swor – PEC was created and has survived the test of the time as the premier EMS Scientific journal. Krohmer – The “White Paper” was really the first time the quality of emergency care was questioned. This led to the National Highway Traffic Safety Act. There was a higher chance of injury driving a car than there was fighting in Vietnam. The led to the levels of EMS certifications and the current structure. There has now been over 50 years of coordination. He is retiring in two weeks from NHTSA. Things will continue to move forward. EMS at the crossroads from NHTSA shined a spotlight on a lot of issues. There was a belief that EMS was just EM moved to the field and therefore an extension. It was a challenge to convince folks that EMS was indeed its own specific area within the house of medicine with its own environment and science. EMS is a team sport, and the medical director is a critical member of that team. Showed an accident slide from the 1960’s. Levy – He asked regarding development of the fellowship program. Pepe answered that the academics and science had to be developed. Krohmer added that we are still stuck with a transportation model for reimbursement rather than medicine. We must change the authorities of CMS. EMS is the intersection of public health, emergency management, public safety, and healthcare. Pepe adds that you must be there as a medical director for your people. Dr. Swor added that Dr. Krohmer has a “blood type of EMS.” Pepe adds we must treat patients as boldly, aggressively, and compassionately as we can. “We are privileged to share the worst moments of people’s lives.” We don’t manage patients; we care for them. My note: Director Krohmer will be greatly missed.

 

Cone, Levy, Wang - EMS Grand Rounds: NAEMSP Prehospital Airway Management Position Statement Compendium – The compendium is an open access document produced through PEC and funded by Stryker. The PEC Podcast has a five-part series on the compendium. There are 15 main articles in the compendium. Airway management has a special place in the history of EMS. Intubation had been reserved for physicians only until it was trained to paramedics. For over 20 years the NAEMSP has published many position papers on this topic.

Airway management is rapidly evolving. The compendium is meant to be a resource that covers a broad spectrum of airway management topics from techniques to quality measurement and education. Use of evidence was crucial. This was focused on cutting edge material. The compendium was approved by independent peer reviewers using the normal PEC process. Manual ventilation is covered in the document. Clinicians must master manual bag-valve-mask ventilation. SGA is covered and capnography is seen as essential for SGA use. DAAM (drug assisted airway management) requires close medical director oversight. Airway management should not interfere with key resuscitation interventions. Trauma airway management should be based on iterative assessment escalating from basic to advanced interventions. Non-invasive ventilation is safe and effective for ALS and BLS providers. Patients with mechanical ventilation must receive appropriate sedation and analgesia. More ventilator use in the field is needed. Surgical airways are acceptable in the prehospital setting with proper training. Pediatric respiratory distress and airway management training and education positions are covered in the compendium. Quality management of pediatric respiratory and airway programs is needed. Pediatric interventions should always be considered difficult.  Novel technologies and techniques are covered as the final article. This compendium took less than a year to produce and is rightly housed in the EMS environment and with the NAEMSP. Video laryngoscopy was not included but will be added. Updates will occur to make sure the compendium is kept current.

 

Clemency, Kupas – Board Certification Update – 1037 current physicians certified by ABEM in the EMS subspecialty. Pass rates are higher in those with fellowship training than practice only. MyEMSCERT has modules for CEU for maintaining the EMS ABEM board certification. Open Book does not mean easy. MyEMSCert being phased in. Based upon keeping current on knowledge. This starts in 2023. You will need to take four modules in five years to maintain. www.abem.org Next fall there will be a webinar on the modules.

 

Cone - PEC Journal Update – Dr. David Cone is the new editor of Prehospital Emergency Care. PEC has been going 25 years, with 112 issues, having 14,446 pages spanning 13 NAEMSP presidents. 10 position papers were published last year. 230,318 downloads of articles in 2021. Implementing decision editors amongst the associate editors. New design and look with a shared look across NAEMSP products. There will be a new internal layout of the journal later this year. There is a new journal coming from the EMS Management Association called the International Journal of Paramedicine. The Airway Compendium was a 2021 effort as well.

 

Mengegazzi Scientific Session #1 – 1) Impact of airway strategy upon ventilation rates in the pragmatic airway resuscitation trial – (Wang): O2 and ventilation needed for resuscitation. Hyperventilation linked to poor outcomes in OHCA. LT vs. ETI on resuscitation rates. 27 agencies from ROC used for data. 3,004 patients. Airway ventilation rate not different between the two airways. Very similar incidence of by hypoventilation and hyperventilation in both airways. 80% of the ventilations met AHA standards. Hypo and hyperventilation not associated with type of airway used. We need to agree on a definition of hyperventilation. 2) A novel method to improve prehospital pediatric CPR Quality (Anders): Simulation based assessment. HPCPR improves outcomes. AHA guidance maintains 15:2 ratio for BLS CPR. This review looks at giving the two breaths, on each, on the upstroke of compression 14 and 15. The normal process was compared with the non-pause style. Higher compression fraction with the non-pause, hiccup style ventilations. Volume of ventilation was slightly less with the hiccup style ventilations. Limited by an artificial environment. There is an unclear gold standard here. Hiccup method did allow for nearly continuous compressions even with ventilations.  3) Caregiver perceptions of including children in alternative disposition systems (Ward): There is an expansion of alternative dispositions for EMS other than the ED. Societal expectations may apply in transporting children to alternative destination. Many of the existing programs for this do not involve children. Virtual focus groups used. There was a belief that EMS was overused. Some of this was driven by healthcare availability and office hours of clinics and pediatricians. There is uncertainty of child caregivers as to what an emergency is defined as. Callers are needing care, not necessarily an ED visit. There is concern over harm with delays, under triage and inability of taxis to get home. They often called 911 due to lack of transportation ability. Availability of car seats was also identified as an issue. Equity was a concern as ride share programs under supply some neighborhoods. Parents want the ultimate decision on disposition. There is not an intrinsic opposition to alternative dispositions by child caregivers, but there are concerns.  4) Impact of Implementing the prehospital treatment guidelines in severe TBI patients with PPV (Gaither): The EPIC Initiative. Funded by NIH. Criteria are O2 sat <90, SBP >90, and ETCO2 <35. Severe head injury had significant improvement in survivability to admission when guidelines were maintained, as well as in overall outcome at discharge. This was not a randomized trial. This was also a bundled care model. Prevent hypoxia. Prevent hyperventilation. Consider BVM even if no ETI. Outcome improvement was not to all major TBI, but mainly severe TBI as a group. There must be strict control of ETCO2.    5) In-Field and Early hospital hypotension in major TBI, correlations and effects on outcome (Rice): This is another EPIC trial. Partially funded by DOD. This is a secondary analysis. Study cohort was 12,582. No hypotension during entire course of EMS and trauma center care had lowest mortality rate of 9.2%. Those that had hypotension during both EMS and trauma center care had the highest mortality rate. The latter group had a 13-fold increase in chance of death than patients with no hypotension. Prevent hypotension in TBI.

 

McNally – Cardiac Arrest Registry to Enhance Survival: Lessons Learned from over the Past Two Decades from CARES – Executive Director of CARES. CARES covers 51% of the American population. Video shown on what CARES provides to the improvement of EMS system cardiac arrest performance. If you can’t ask how you are doing and look at numbers how can you ever improve your outcomes? The value is to measure and improve from those measurements. AED, bystander CPR and telecommunicator CPR are included in CARES data collection. CARES operates on a “keep it simple” concept. Uses a limited number of data elements. Partners with NAEMSP, NASEMSO, NAEMT, AHA and ARC. You have to have data to move the needle. Allows comparison against national averages on each data element. CARES helps connect the 10 steps of the Resuscitation Academy. Showed a video of video assisted dispatch CPR in Korea. “In God we trust. All others must bring data.” The COVID pandemic has dramatically eroded recent survival gains for OHCA in the United States, even in communities with low COVID mortality rates. There has been a recovery in public AED use, but this is not a complete recovery to pre-COVID survivability rates. EMS agencies that have high termination of field arrest and longer scene times also have high rates of survival. Compression only CPR is not beneficial in in children, in fact there is nearly no difference in survival between compression only and no CPR in infants. CARES data can even be used to show probability of receiving bystander CPR by demographics and geography. CARES will be modernizing software platform in the future. https://mycares.net

 

Streger - Cases in Just Culture: Applying Concept to Reality – Speaker is a lawyer and a paramedic. What happens when to do the right thing for the patient breaks the rules? How do we fix punitive culture? No one goes to work to intentionally screw something up. Aviation vs. Medicine. Aviation is highly regulated and very standardized. Medicine is the opposite. One records everything, while the other area records nothing. One relies on checklists, the other does not. One uses primarily simulation to train, where the other is a see one, do one, teach one model. One controls fatigue, the other acts as if fatigue doesn’t matter. EMS should embrace the culture of aviation. The last major aviation incident was in 2013. Can EMS say this in a single system? There are 250,000 deaths due to medical error in the U. S. each year (that is 700 deaths per day). Read the Checklist Manifesto. There is no magic Just Culture. Just Culture is open, fair and applicable. It must be transparent. We must learn from the event and be non-punitive. We have to prevent errors through designing safe systems. We also have to prevent errors through managing behavioral choices. Expectations must be known and understood. It has to be teachable and reasonable. You have to give examples when you train. Reasonable conduct = lapse, mistake, may not even be an error, uses a reasonable person standard. People do not tolerate being punished for simple mistakes. At risk conduct = poorly calculated risk/benefit. We have to explain the risk vs. benefit. Dangerous conduct = subverting a safety standard, reckless disregard of a known hazard, intentional acts. Gave examples of the types of conduct. Just Culture is NOT outcome based. You cannot look at the outcome. You have to look at what happened, not the outcome to judge it fairly. What are your values? Just culture has to be part of the investigation and we do not do a good job of this. If you have bad data, you will get bad decisions in the end.

 

Stemerman – Data Visualization: Prehospital Centered Design – When you focus on the people that need to see the data you will get the right design. This helps data produce the right outcomes. It has to be people centered, solve the right problem, and understand that everything is a system. The data gets to your brain 60,000 times faster with 90% retention when you view it visually. Visual aids in the classroom increase learning by up to 400%. “Flatten the curve” is a prime example of data visualization. You have to understand your audience. If the reader struggles, the data is useless. If you are designing for everyone, you are designing for no one. Relevant context, requirements, design and then evaluation of the communication are essential. You have to have a problem before you can solve one. How will your visual be viewed? On a big screen or a cell phone? Will it look the same on either? How will your audience most likely view the data? What is the analytic literacy of your audience? Think about how your car relays data to you on the dashboard. It must be able to be viewed quickly and understood and must be relevant. The brain is good at determining length and position but not color or angles. This is why pie charts are horrible at conveying numbers. Bar charts are better. Design with empathy (this looks like it was designed for me. That is because it was). Be simple. Less is more. White space is nice. Prioritize and highlight the information. Use only a few colors, like Red, yellow and green. It must inspire and build skill in the end product.

 

Jarvis – NEMSQA: A National Quality Project, Putting National Quality Measures to Work for Improvement – First point was to illustrate the fact that EMS continues to be measured by response times that have no impact. EMS needs real, outcome driven quality measures. NEMSQA want to endorse existing measures through science and write measures where none exist. NEMSQA started in 2017 after the EMS Compass project was completed. Collaborating with NAEMSP, ACEP, IAFF, NREMT and many, many more. Will be developing and reviewing EMS measures. May adopt measures from other organizations. Will be working to harmonize measures from other organizations where possible. Multiple measures already available (Hypoglycemia, Pediatrics, Seizures, stroke, Trauma, safety and others). Differing from year to year. Looking at number of 911 responses and transports that do not use lights and siren (inverse as the higher number is better). Florida Rural EMS Measurement project, NEMSQA is helping develop FAIR (Feasible, Actionable, Impactful and Relevant) measures. NEMSQA wants to reduce lights and siren use (again, response time measurement causes this in many unnecessary cases). Lights and sirens definitely increase incidence of accident and injury. NEMSQA wants to reduce response to scene with lights and siren to less than 30% and lights and siren in transport to less than 5%. NEMSQA is accepting individual memberships. https://nemsqa.org

 

Mengegazzi Scientific Session #2 – 1) Injury characteristics of chest compressions in a swine model of infant asphyxia cardiac arrest using either 1.5 inch or 1/3 anterior-posterior diameter depth targets (Menegazzi): CPR compressions are not monolithic. Many variances between those performing CPR. Injuries have not been well characterized in the literature. Pigs were used to simulate children. They were ventilated and not hypoxemic. Mechanical chest compressions were used. Lung injury score was used as part of measurement. 36 swine were enrolled in the study simulating infants.  1/3 AP and 1.5-inch depths were compared. ROSC rates higher in the 1/3 AP group. 1/3 AP also increased injury dramatically including cardiac contusion. 1/3 AP produces better pressure and flow.  2)Using natural language processing (NLP) to examine social determinants in pediatric encounters and associations with EMS transport (Briauna): SDOH influence access to healthcare and inequalities of outcomes. ESO data used from 2019. Univariant analysis. 51% male with a relatively diverse racial group. SDOH existence tends to show up frequently in those transported. This was determined by word use in narratives. Self-harm was the most prominent documented SDOH that was associated with transport. There is a large percentage of non-transports in the pediatric patient realm. This is worrisome from a medical and legal issue perspective. Retrospective study.  3) Primary care pediatric physicians’ perceptions of alterative EMS disposition programs (Ward): There has been reluctance to have children included in alternative disposition programs for EMS. Can children be included in successful disposition programs? Identify potential barriers and enablers. Three virtual focus groups were held in 2021. EMS overuse, finances and equity were among the topics. Logistics was a topic as well with challenges in non-EMS transportation. Benefits potentially could be increased quality or care and continuity as well as efficient use of resources. Scheduling of “walk ins” is problematic as most pediatrician serves are always booked (resources are not always available). Patient records may not be accessible. ED revenue loss was a perceived issue as well. All were concerned with whether care would be actually or perceived to be equitable or not. Pediatricians agree EMS is overused and that there would be benefits to integrating care.  4) 10 Disparities in prehospital analgesia administration for trauma patients with long bone fractures (Crowe): Data shows that pain is undertreated by EMS and does contain bias. Focused on long bone fractures. Hypothesis was that there would be disparities based on several factors. 2019 data was used. Any analgesic by any route was assessed. 15,150 patients included in the study. 45% received analgesia. There is a decrease in analgesia administration by increasing age. No difference between male and female. Racial disparities were noted. For each 10 years of age, analgesia use decreases by 8%. Less than half of patients with long bone fractures received analgesia. Equity measures are needed. 5) Twenty Years after the EMS Research Agenda – Trends in EMS publications and research funding (Goldberg): Almost two decades ago an EMS research agenda was published. Research was needed to improve focus and increased financial support was needed for the research. Publications and rate or publications continue to rise. Research is increasing in OHCA, sepsis and safety while decreasing in areas such as airway management. NIH funded grants for EMS research have increased in number and amount of funding. Limitations? Quantity does not equal quality (how much is translatable to practice?). Future directions of research. It has tripled but needs to be evaluated for content, quality, and implementation capability.

 

Day 2

 

Abo – Surfside Collapse: A month Lasting a Lifetime – Played dispatch tapes from the structure collapse at Surfside. Been Abo is with Florida Task Forces 1 and 6. Showed video of staging of emergency vehicles lined up for quite a long distance. Structure collapse reviewed. Garage was one level below ground. Building essentially came straight down into garage without much side-to-side debris. Garage had knee deep water in the non-collapse area. The rescue team was trying to reach a lady in and apartment from the second floor from the basement. She stopped talking after a few hours. Smoke is now building at top of the building that is remaining. They were pulled out due to the fire and efforts were paused. Once back in the still continued to try to talk with her without response. Air conditioners were still on edge of roof that could fall at any time. It was determined that she had passed away. Tremendous impact with those trying to rescue her. “The wind was knocked out of our guys.” She died but she wasn’t alone. She died but at least she knew someone was trying to get her. It is believed she died from asphyxia. Air quality was an issue during efforts. They attempted to collect as many pictures, toys and personal items that might bring people solace as they could. Describes accessing where the girl was from another direction during recovery and seeing the hole they had made and where their tools had been. They then realized from where they had been it would have probably taken 48 hours to actually reach her during the rescue. This was a very hard psychological event on all and the people lost will never be forgotten. “We are not paid for what we do but for what we are prepared to do.”

 

Holley - Variability in Manual Ventilation Performance by EMS First Responders: Its Patient Impact and Airflow Physiology – Study evaluated the use of the SOTAIR device as part of the study. Evaluates the proper use of the BVM and the ability to deliver breaths within proper parameters. 47 providers were randomly divided into two groups, one with a flow limiting device and the other without. Metronome was used. Results were compared to manual ventilators (Revel and Puritan Bennett). ALS and BLS providers were utilized and BVM technique, length of experience and hand size were noted. There was wide variability to remain in range. “To put it quite bluntly, they sucked.” This is why we continue to struggle with how to use a BVM. Use of the SOTAIR device did tend to limit both pressures and flow and compensate for provider skill. None of the other measured characteristics mattered. We have to control pressures and flow to stay in therapeutic range of artificial ventilations. 22% improvement in tidal volume and reduction in PIP with the device added to the BVM. Extended manual ventilation is not optimal. The technology exists to reduce barotrauma, underventilation and overventilation with a small device to prevent the complications of BVM use. This device could even be used for short term replacement of a ventilator during ventilator rationing.

 

Rosenbaum – Post-resuscitive Care to Improve OHCA Survival – They want to improve ROSC and gain more survival to discharge. Looking at a systematic approach to post-resuscitation care. They use CARES as their cardiac arrest registry. Systems have many components, AED programs, resuscitation academies, DA-CPR, vector changes, Esmolol. But survival numbers still lagged. The lag was accompanied an implementation of mechanical CPR devices. Focused on improving survival back to previous levels. Looked for patterns. Got input from field supervisors that were on scene during arrests. Concentrated on what happened in the first five minutes of ROSC. Did great on working the arrest on the scene, but there was a focus on getting off scene as soon as ROSC was gained rather than affecting stabilization of the patient. Some re-arrested. Also focused on identifying post ROSC patients needing PCI. Made a mnemonic to push post ROSC care. Stabilize, airway, vitals (look for your post arrest good BP to drop quickly), assure vascular access, external cooling, Amiodarone, Levophed, LUCAS (restrictions placed on use), Internal cooling (4-degree Celsius fluid), follow-up vitals, EKG (12-lead). Rolled out in early 2019. Field supervisors were trained first and were given a post-resuscitation role of running the post-ROSC checklist. Pressor use in appropriate situations reached 90% and BP post ROSC became better. Goal was reached except for one slump during spring of 2020 due to COVID. CPC 1and 2 survival was improved as well and correlates to the process implementation. More CPC1 status in 2021. Opioid epidemic has confounded the arrest data. Percentage of VF arrests has decreased by half. Team approach is important. Stay to stabilize. Frequent vitals. Assure airway, assure vascular access, and do a 12-lead before you depart. Address potential deterioration early. There is no single thing to fix. It is a bundle of appropriate care. “It’s like making a craft cocktail. Sometimes it only takes the addition of one ingredient to make an undrinkable drink into something good. Right now, the drink is good, so I do not want to mess with it.”

 

Breyre/Hanson - Allowing Natural Death: Hospice and Palliative Care in EMS – The focus changes to aggressive symptom control rather than fixing the problem which is oppositional to the traditional EMS focus. Hospice is an insurance status that is based upon a daily payment to care for the dying patient’s care. They get staff, stuff, and services. This includes home or center care, drugs and needed services. Patients who have palliative care, live longer, have better quality of life and have lower costs. Case presented where the POST/POLST form cannot be found.

History of CPR covered in correlation to DNR and POST. DNR was first used in 1974 following the development of CP in the 1960’s. POLST was first used in Oregon in 1994. All 50 states now have a POST/POLST type form. Consider the use of an “Allow Natural Death” status on POST/POLST forms. Do not ask “Do you want everything done?” and ask, “Would you like to allow a natural death?” Advanced Directives are legal documents while POST/POLST forms are medical orders. Some areas are allowing verbal DNRs from reliable family members. Define what your system will and will not do in policy. Teach communication skills for these situations. Process flow how code status will be verified. Case study presented where patient asks EMS to turn off an LVAD. Existential Crisis is defined as a point where the patient may come to a point of convergence with issues on anxiety, finances, depression, lack of symptom control and other variables. Patients and patient families in palliative care call 911 when in existential crisis. There is an App called VitalTalk Tips that scripts difficult conversations. Internet resources covered. Another case study on stage 4 lung cancer. Calls 911 due to existential crisis. Patient refuses transport but wants pain relief from EMS. Can EMS use morphine dose equivalents to help control pain with what EMS carries? Morphine dose equivalents reviewed. Oral hydromorphone is five times stronger than oral morphine. EMS needs palliative care skills, knowledge of pain control and when NOT to use Narcan, access of PICC lines, and training in how to work with hospice care workers. Case study on community paramedic arriving on scene to provide episodic palliative care (drastic reduction in number transported to the ER). The EMS Medical Director must have an active role. There must be accessible online medical control. Ketamine could be an alternative to opioid use. Offline medical control must be scripted. EMS must have communication skills aligned with palliative care and bereavement. EMS burnout must be prevented by making EMS empowered rather than traumatized. Dispatch must have hospice/palliative care solutions and pathways. Community paramedicine could do hospice referrals, care for the actively dying patient and direct collaboration with hospice agencies. A philosophic shift must occur with EMS. It is a privilege to be a part of a patient’s final wishes for comfort.

 

Menegazzi Scientific Sessions – 1) Hyperoxia and Outcome before and after implementation of the prehospital TBI guidelines (Spaite): Part of the EPIC study. Impact of the TBI guidelines. HF O2 by NRB on every TBI or intubated with 100% O2. Does this give too much oxygen? Should we change the approach? Evidence of Hyperoxia damage all comes from ICU studies, not prehospital. SIREN network is now using hyperbaric oxygenation on TBI. The truth is unknown. We do know hypoxia in TBI kills. 100% SPO2 does not mean they are Hyperoxic. The unadjusted sweet spot in decreasing mortality was between 97-98% by SPO2. The slight increase in mortality at 100% is not statistically significant. Risk adjustment shows 100% is safe. This study is observational and not controlled. This doesn’t prove HFO2 improves outcome, it simply hints that it decreases mortality dramatically. 97-98% seems perfect with a slight uptick in mortality at 100%. Hyperoxygenation was associated with decrease in mortality. Aggressively treat all TBI patients with supplemental oxygen. The question is going to be how soon can we get these patients to hyperbaric chambers? 2) Comparing 24-hour survival among prehospital airway management techniques for trauma patients (Pickus): Funded by DOD. ETI is the gold standard, but SGAs are gaining ground in trauma management. One study showed increase in mortality with SGAs but the data was incomplete, and the SGAs were used after failed intubation attempts. Multicenter trial utilized. ISS was 9 or greater. Prime outcome was 24-hour mortality. 1,641 patients. 717 of the 1,641 died. We know there is no difference in survival in cardiac arrest between ETI and SGA. This study showed that mortality was no difference in trauma patients with SGA vs. ETI. 3) Association between Ketamine dosing and outcomes for patients with traumatic injuries (Crowe): Ketamine is a useful drug for EMS treatment of agitation and those needing sedation. Does dosing affect outcomes? 2018-2019 ESO data used. Used NAEMSP position paper as the baseline for proper dosing. About 5,000 patients. Only 5% had doses above standard. Patient population had a median age of 27 (young). Cardiac arrest was extremely rare. This was a retrospective review of data. Higher doses saw decrease in LOC and some incidence of occasional hypotension. 4) A retrospective, single-agency analysis of ambulance crashes occurring in a 3-year period – Association with driver demographics and telematics measured safe driving score (Stevens): 4,500 ambulance crashes reported annually I the United States. Driver demographics and aggressive driving are established risk factors for general motor vehicle crashes. Allina Health EMS installed Telematics for monitoring in 2017. Data used from 2017 through part of 2020. What is the incidence rate between

variables? Single agency study. Retrospective observational study. Covers 75 Type III ambulances. What is a severe crash? What is a severe injury? Needs definition. Females had higher rates of crash. More number of miles driven correlates with less incidents. This correlates to more over the road vs. urban driving. Younger drivers had more incidents of crashing. 1/3 of crashes caused injury. If lights and siren used, injury rate is higher. Female gender, ages 18-24 and tenure of less than 3 years all associated with higher crash rates. The more you drive, the better you are. Drivers with more incidence of monitoring issues had higher prevalence of crashes. There will be crashes. Telematics are not good enough. Video is not good enough. You need both! Example (my note), Road Safety and Lytx Drivecam combined. Further research is needed. Most of all, we need to understand that hurrying to scenes does not matter. We know that the majority of crashes occur while the ambulance is going straight at normal speeds. 5) Prevalence and characteristics of low acuity pediatric calls in an urban EMS system (Ward): These are not qualitative results in this study. How common are pediatric low acuity calls? Literature is inconclusive. How is acuity defined? Observational analysis by chart review. 9/2020-9/2021 data used. Low acuity definition used centered around stable vitals and lack of invasive interventions by EMS or ED. Also had to be discharged home with no return visit within five days. Gender was equal split. Majority of patients were black or Hispanic and the majority were on public insurance (Medicaid). 33% of EMS pediatric calls were deemed to be low acuity. Age 1 was the most predictable factor for low acuity transport. This could be a low estimate in total number. MVC peds victims are more likely to be low acuity. These could be candidates for alternative dispositions.

 

Mann - The Power of NEMSIS: Transforming Data into Action and Vision – What is the NEMSIS value-proposition? NEMSIS is standardized data collection across the nation. NEMSIS collects data directly from state registry sites. Idaho and Delaware are the only V3 holdouts on data. There are over 134 million ambulance transports in NEMSIS. Several data findings: When Uber enters a city there is a 7% decrease in per capita ambulance use rate (43 states and 766 cities included in data run). Does EMS response time in MVC reduce mortality (2.2 million activations in 2,265 counties). MVC mortality does increase with ambulance response time. COVID symptoms in EMS transports has been being tracked in NEMSIS. Community overdose surveillance has been being utilized. Opioid deaths skyrocketed during the first wave of the pandemic. NEMSIS EMS data closely correlates with CDC data on COVID. There is an EMS Agency Performance Dashboard of NEMSIS data. There is also an EMS Agency Data Quality Dashboard as well. NEMSIS data is being used by the CDC and the CMS ET3 project. NEMSIS has a accustom configuration section that could be utilized for future research. They are working to connect NEMSIS with other sources of data as well so that even patient outcomes may someday be included. Now moving to Version 3.5.0. NEMSIS wants the data used to measure provider practice. They would love to offer more dashboards.

 

Wilson - Combining Technology and Community to Improve Patient Care in Cardiac Arrest and More: The GoodSAM Experience – Crowdsourcing cardiac arrest events for public response. GoodSAM alerts off duty responders to cases needing CPR.

Where you have cardiac arrest affects survival. GoodSAM used across the world. Uses a phone application. Largest AED registry. Showed a video showcasing survival with use of the system. The system is moving into support for elderly falls as well. Can allow communications with patients as well and can include a video consultation. Can send video and location to call taker. Video can be forwarded. Video capability can be linked from drones as well. It has the ability to transcribe and translate in 104 languages. Can be used to remote triage responses to the patient. Scene safety can be better assessed by video. System has been studied and shown to be effective. With video, compression quality can be assessed and guided as well. Performed a video locating and assessment as a demonstration in the presentation room. Fast and efficient. This takes advantage of technology to build community.

 

Crowe/Pepe - EBM vs. EBM: Why we need both evidence-based and experience-based medicine (and new strategies for resuscitation research) - This has been talked about for several years that both types of EBM are needed. Speaker references the Chicago airport AED studies. Keep the fact that all of those patients in the study survived. In 1982, PASG and IV fluids were the gold standard for shock. Evidence proved otherwise. Lives were saved because current data showed the prevalent therapy was detrimental. Some stuff goes good in the lab but not in the field. So many factors compromise cardiac arrest clinical trials. Everything with cardiac arrest is interwoven. 2011 showed that ITD by itself did not improve outcomes, ruled no significant difference. BUT, ITD combined with ACD CPR devices, improved survival dramatically. There are so many uncontrollable or limited control factors during arrest management that it is hard to measure what has a valuable effect. “An intervention is not simply good or bad.” Interventions need to be looked at through various lenses. “Only a Sith deals in absolutes.” You have to use an intervention correctly to get it to work. Randomized control trials are not the only way to do things. Implementing a cardiac arrest bundle to optimize care and then measure the results. Look at neuroprotective CPR. What if you mix ITD, ACD CPR and gradually raise the head? It is a bundled approach that is producing great numbers. This even works for non-shockable rhythms. External validation helps. In practice, excellent ETCO2 values were seen with neuroprotective CPR in the field. In conclusion, the dead shall be raised.

 

Seaman/Stone - A Working Code is a Working Fire – Fire service has an emphasis on life and property save. Dr. Eugene Nagel was one of the first to notice that the fire service was already positioned to be the very first responder. Fire says, “Everybody goes home,” so why not say “Every patient goes home.” Fire service suppression is somewhat segregated from EMS even within many fire departments, but EMS first response is still the most common call. There is a culture of “the big one” in the fire service, but “the big one” has medical meaning as well. There is definite value of more persons on scene during critical medical incidents. Nominal number of people on scene to impact a positive outcome in a cardiac arrest event? Seven was the critical number which supports high performance CPR and all arrest functions. Cardiac disease is still the number one killer in the United States. Best practices include rapid dispatch, T-CPR, and HP-CPR. Goals should be 100% delivery of HP-CPR, 75% application of T-CPR and an AED applied within 6 minutes 5% of the time, we can attain 50% survival in VF patients. A win-win must be painted for the volunteer fire service. Working OHCA makes for more lifesaving opportunities. Each response equals a chance to practice response evolutions. Appeal to the universal role of the fire department in service. Why not have a cardiac arrest duty crew? Go to the stations and congratulate fire crews involved in saves. Celebrate the wins. Push HP-CPR in the firs service. Run to the unit as fast for OHCA as is normal for a fire.

 

Burns/Butsch/Kaufman – When Reality Differs from Theory: Our Experience with Alternative Destinations and the ET3 Program – Combined fire rescue service who is an ET3 provider. Medicare estimates that 16% of 911 patients could go to alternative destinations. Telemedicine capability already existed using a smartphone. 42 AD transports. Of those, there were 5 re-transports within 24 hours, many of these were from the AD to the ED. The goal of ET3 was to divert patients away from the emergency rooms. Their system used a dedicated transport destination officer during the first part of 2021 (this resulted in a large number to the ADs at first). They do not determine Medicare eligibility at the time of care and ET3 use. 78% of the Medicare bills were paid. AD transport program did not meet the agencies expectations. Who has to make this work? The people who are going to use it. If they don’t use it, it will not work. They rolled out another program at almost the same time called “direct to triage.” It was easier to use the DTT process than it was to do the ET3 AD process. Crews followed the path of least resistance. 16 ET3 telehealth visits with 2 recalls in the first 72 hours. Only 5 were paid. Also using the ET3 telehealth process for high-risk refusals. Maryland requires the telehealth physicians to be base station physicians. There are inconsistencies in care options between the urgent cares and AD acceptance of the patient is subjective. There have been some AD closures due to staffing. So, what now? Bolster through marketing? Bolster through policy? Add a priority 3 gatekeeper? No change? What they feel they really need is sobering centers and behavioral health stabilization centers (those are the patients tying up resources). ET3 so far is not a magic bullet.

 

Abo/Davis - Too Hot, Too Cold, Too Legit to Quit: Updated Realm of Thermal Emergencies – Wilderness medicine overlaps with other environments. Heat stroke is a real thing, and it really does kills. Hurry up load and go is still being pushed when action needs to be taken immediately on scene. Either the environment is hot, or we are making a hot environment. It is easy to create our own hyperthermia. Our body has ways to compensate but sometimes we do not allow it to do so. Covered disaster situations and discussed several situations where environmental emergencies impacted first responders or even killed those affected by the disasters.  Get rid of the stuff that says they stop sweating and use an evidence-based guideline. Hot plus altered mental status equals heat stroke. In areas of high humidity, if you are wet, you stay wet and you will transition straight to heat stroke with no evidence of sweating cessation. High school sports are areas where heat stroke is common. Use TACO (Tarp Assisted Cooling Oscillation). Think of things in gradients and not absolutes of a spectrum. Rapid cooling on scene is more important than rapid transport. A shopping cart with a tarp in it can be used to provide TACO. Transitions presentations to cold emergencies. Gave several examples of hypothermia patients. Hypothermia happens in places like Florida as well. Hypothermia also occurs in urban environment. How do we care for cold patients? They need calories and insulation, and they can generate their own heat. When they are unable to shiver, they can no longer generate their own heat, that is when we need to help them. Essentially, we need to make them a burrito and keep them from getting colder. Use a burrito wrap. Hypothermic patients can look dead. CPR is a good idea for patients that are probably dead because they are cold. Care, movement, and prevention of heat loss does need to occur while CPR is in progress so we may need to stop CPR intermittently to accomplish these goals (this is at odds with our normal desire for MICPR). Defibrillation? Multiple opinions and guidelines. Time? A 65-year-old female was successfully resuscitated after 8 hours of arrest management when hypothermic. Suggest use of HOPE score to determine viability. If you don’t do anything, the chance of survival is 0%. ECMO may be needed. Take home points. Hot and AMS equals heat stroke. Delayed transport not delayed care. Not dead until warm and dead. Consider prolonged CPR. Both conditions can occur in any environment. Go to an appropriate care facility that can handle these cases (does your destination have rewarming capability?). TACO for hyperthermia, Burrito for hypothermia.

 

Kupas - Lights and Sirens use in EMS: Above All Do No Harm - Many systems reducing number of transports using lights and siren without any negative impact on patients. Vehicle colors and reflectivity matter as much as lights and siren to visibility. Unique schemes on individual ambulances may be dangerous. High visibility broken patterns on a light color should be used. Use high visibility outer wear when exiting vehicles on roadways at night. Vehicle coloring is more important than lighting. Lights and siren are useful for requesting the right of way, blocking the right of way, and cutting through traffic to reach destinations. Light glare can be an issue in seeing people standing around the vehicle. We assume that lights and siren are more effective than they actually are in reality. 33 feet is the maximum stopping effectiveness distance at 55 miles per hour. Lights and siren use can increase myocardial ischemia in the patient. Most studies show that the savings of using lights and siren transport is minimal and not impactful to outcome. Is the patient going to benefit from a 3-minute shorter transport time? Do they run patients to the cath lab? No, they walk with the stretcher. EMD can be used to reduce lights and siren response (we have known this to 1983). Less than 50% of responses should be lights and siren. 8 minutes and 59 seconds is not a valid measurement that affects outcomes. Some EMS systems are now responding to motor vehicle accidents without lights and sirens.  Lights and siren use not indicated not appropriate for fire standbys, medical alarms, all BLS call determinants and MVCs for unknown injuries. Some systems now suggesting 25-minute response times for low acuity calls. Quiet deliberateness is a sign of competence, not noisy bravado.  Lights and siren usage requires a whole lot of responsibility. Cardiac arrests for the most part should only be transported post-ROSC (my note: possible exception of persistent VF?).

 

Day 3

 

Lt. Curtis/Garner/Page/Owusa-Ansah/Tripp - EMS Pipeline Career Pathway Programs: Improving Diversity in Our EMS Workforce – How do we get more people interested in a career in EMS and create more career opportunities? Garner states that they designed a camp and had a waiting list to go. They also started an EMS club. Engaged school systems as well and started doing EMT classes in high schools. Created a defined pathways program to get them into community colleges paramedic programs. They end up with an associate degree with nearly no out of pocket costs. The pipeline is helping them achieve those goals. Pittsburgh has a similar program based on the start of Freedom House Ambulance. Mayor came to graduation. Trying to get City of Pittsburgh involved. St. Paul and Minneapolis both have pathways going back to 2009. Started with grants. They were paid to go to EMT class. Both programs have turned out nearly 460 students together. Had to find homes for some. They taught them to cook. They also had to get some into healthy living and better physical condition for the job. Used income form BLS transports to fund the next program and created a financing cycle. Great successes coming out of program as some have become lawyers and doctors. Chicago has put 420 kids through school, 10 of them have been homeless. Gets them doing something productive. They have 10 in paramedic school now with five more already completed. Have taken some kids out of gangs. It is self-funded with no grants. They bought an event building and rentals from events fund the program. They don’t look for students, the students come to them. There is a waiting list, and they take them in order of sign-up. It is a zero-tolerance program for professionalism, being on time and doing the job. They help them learn how to survive. One program teaches them to start and manage a bank account.

 

Stemerman - Can EMS Play a Role in Addressing Social Determinants of Health? – Social determinants of EMS affect every part of our daily life. Complex circumstances in which we are born, grow, work, live, age and a wider set of sources. Things like housing, healthcare availability, economics, food, education and social context. Neighborhood and physical environment as well. Presented a case study on a patient she ad interacted with several times as a paramedic. Police refused to take patient to a homeless shelter. EMS got permission to take to homeless shelter. They would not take a walk in without a referral. EMS could not refer. This got her interested in how to affect this. Ended up taking him to the hospital. Patient feels defeated. Paramedic feels defeated. Patient just says, “I am sick of this. I might just kill someone so that I can go to jail and get a meal and have a roof over my head.” United States does not do well on healthcare outcomes

based on cost. Stress affects generations and communities. National average of the segregation score is 12.6. Chicago is above 44. This correlates to life expectancy, food availability and other areas. Lack of transportation makes a person 2.6 times more likely to go to an emergency room. In EMS, these things translate to frequent users, mental health, substance abuse and preventable hospitalizations. Electronic health records can capture social determinants of health. Free text of the narrative does not help track SDoH or other data elements. These need to be data elements so that text analysis does not need to be used. Text mining is difficult, but it is one way of finding the data. Showed an example of text mining. San Diego built a community information change using 211 and community paramedics. It allows all of the agencies that can impact SDoH to communicate and follow up. This caused a 26% reduction in transports of homeless and a 44% improvement in referrals. Screen for SDoH, use paramedics in the community and have a digital platform to align with agencies to impact the situations. This requires training. Define documentation needs. Coordinate locally. Find or build the technology platform to support the project. Community paramedics draw it all together. This environment is where paramedics live daily. SDoH got rocked by the pandemic. Everything is crazy. Even parks and playgrounds where/are shut down. Jobs have become unsafe. Kids have been impacted and may be incurring generational trauma. The chronic stress level is high. This will be a traumatic decade. Food shortages and inflation are prevalent.

 

Nichols - Building a Diverse and Inclusive EMS Agency – New Orleans EMS diversity program. Speaker is the medical director. Even though every EMS system is a service, every agency is a business. We need to rebuild joy out of this two-year disaster of COVID. People that are happy are motivated and want to come to work. Covers’ Maslow’s Hierarchy of Need as the Hierarchy of Employee Engagement. Looked at the points of change management. Diversity and inclusion are part of employee engagement. Workplace diversity increases patient trust and satisfaction in healthcare. How do we change? Do not use quotas for diversity. Never select solely because they fall into a class or have a certain identity. The goal is to change policies, practices, and behaviors, NOT people and their beliefs. Everyone has a right to their bodies and their beliefs. These are ground rules. Create a climate of change with urgency. It is about patient care. When patients find someone, they can connect with, there is a moment of self-disclosure, and they build trust, and this augments care. People need to trust the uniform. Cultural competence is important. Cultural competency is a life-long journey. Form a powerful coalition. Who wants/needs to work on it? This cannot be just administrators; it needs people on the ground with influence. Create a vision for change. Engage and enable. Communicate the vision.  People need to know why. Empower action. Create quick wins. Decorate for holidays. Little things matter. Use employee spotlights. Upgrade uniforms. Have a social media presence. Build on the change so that it is sustainable. Lastly, make it stick. Make sure policies align with practices. Reassess efforts and modify. Give feedback. Build allies and expand the supportive team. Continue to promote the new workplace culture. The NOLA FD also building diversity advocates. Take leadership all the way.

 

Cowe/Cyr/Hutchins – Current State of Diversity Research in EMS – Case study on perception using a riddle. The riddle: A father and son are headed back home from a sporting event. They hit a semi-head on. The father is shipped to the adult trauma center where he undergoes care. The son is shipped to the closest pediatric trauma center. The surgeon walks in and looks at the son and says, “I cannot operate on him as this is my son.” How can this be? Most cannot immediately solve the riddle as they make the assumption that the surgeon is a man. The surgeon could be the mom. The surgeon could be the divorced father. The surgeon could be the male partner of the other father. Workforce should be representative of the population served. Inequities exist. Increase diversity in applicants but hire the best person for the job. Looked at EMS workforce statistics by gender and race. Discussed work experience of black EMS work experiences form an interview study. Participants drove the interview. General stress, relationships with patients and experiences with white colleagues. They also discussed a critical moment of acceptance of trust building within the team. Some did not feel supported by their partners. Others had partners directly support them. Another interview session talked about how some things do not occur because of their race. Some responders had actually been barred from entering houses because of race. Huge call is currently out there for training and education on diversity and identity. Discussions on discussing identity on the job and the impact of discussing this at work. These discussions are situation dependent. There is worry on being stereotyped. They educated fellow employees on their identity. A desire was present to simply be identified as an EMS clinician first and foremost with their identity being second. They make both pals and generate prejudice. EMS uses dark humor in the moment. This can be beneficial or problematic. Positive environments can be developed. Support increases communication in the workplace and development of positive relationships. Improves communication with patients as well. Formal research is limited. Clinicians are talking about their experiences in this area.

 

James/Levy/Streger – EMS Practice, Insurance Claims Trends, Legal Pitfalls, and Legislative Interactions – This year has been interesting as community paramedicine is changing where lines are drawn, and insurance doesn’t know how to handle this. Large uptick in treat and release and alternative destinations. Largest area of exposure for medical directors is from employees. Second is over outcomes of care. Many are lack of follow up on treat and release or alternative destinations. There is pushback from patients with bad outcomes whether it is causal or not. COVID situations are some of these. Subdural hematomas should not go to a detox center. Failure to transport is still an issue with refusals and litigation. Medical Director insurance costs are rising. EMS is not contemplating the exposure of treat/release and alternative destinations. Claims not cases is an early barometer. Treat and Release is paramedic initiated so it is not a refusal. Causation will be hard to determine. An occurrence is different from a claim which is different from a case/suit. Local grants of immunity and crisis standards of care may be cited but may not be protection. ET3 does not have built in patient follow-up. Liability of ET3 type programs must be addressed. Staffing is critical so the bar has dropped on what providers are willing to tolerate. Patient drops are still prevalent. Patient drop cases are common and huge. Patient drops are a low hanging fruit that providers should work to eliminate. Traditional EMS professional liability insurance is not prepared for the costs and number of claims that are being generated. General liability and professional liability cases are increasing. Costs and risks are based on prior cases. When you enter into something new, the risk has not been assessed by this method. There is an uptick of nursing home liability cases. Declaratory Judgement cases are common in the insurance world. There will have to be declaratory judgements on treat and release and alternative destination cases. Medical directors need to assure they are covered for this. Criminal liability is increasing as well. Boundary issues, narcotics, fraud, and abuse are increasing. Medication errors can be seen as criminal. Manslaughter is defined as recklessly causing the death of another person. Reckless = a conscious disregard with a substantial and unjustifiable risk that death would be caused. Manslaughter DOES NOT require intent. This is like criminal homicide (requires a gross deviation from a standard). Politics and perception often drive criminal cases. Outcome of the patient also drives the potential for criminal charges. This is a very subjective issue. Criminal risk in Med errors, MVAs, Elopement, Restraint use and positional asphyxia and failure to provide care/transport. Have flags in your organization to watch for and manage these things. There is a lot to work on currently.

 

Lyng - Inquiries from the Interweb: Questions and Discussions on EMS Physician Social Media Sites – Physicians use social media. Upward trend on social media research. Social media dumpster fires happen due to unregulated group membership and/or no oversight or moderation. Ad hominem attacks are common on social media. Social Media Treasure Troves have regulated membership, careful oversight, and moderated content. Social Media allows for networking, access to resources, information sharing and rapid access to expert opinion. So what are some of the common topics in the “EMS Docs” Facebook group? Assessing crews for fit for duty, credentialing, and de-credentialing as well as restricting practice, contracts/salaries and responsibilities, drugs used for DAAM, OHCA management questions, devices, and death discussions such as time of death determination and who does it. Some operational areas discussed were use of force, staffing, do crews do legal blood draws for LE. Lights and siren stuff like organ transplants, Omega and Alpha calls, and do you audit lights and siren use. Destination determination has been dusted off and has come back into recent conversations. EMTALA comes into discussions as well. 911 calls to hospital ER waiting rooms have been a topic discussed. Wall hold time. What happens when the patient does not want to stay on the wall hold and wants to go elsewhere? If the crew is involved in an incident that injures the crew or damages the unit; do they continue the run if able? Another topic with frequent questions is regarding the adoption of technology like EPCR software, CPR monitoring, high flow nasal cannulas, protocol software. There are asks for various protocols. Don’t reinvent the wheel just tweak it to meet your needs. Remember that anything on social media is not private and everything is discoverable. Watch for making HIPAA violations on social media. Only use groups that are well regulated and moderated.

 

Abo – Medically Directed Rescue – Case study of amputation of leg after being trapped in iron work on a bridge. Morphine and a wire saw were used to perform the procedure. Do we save the life or the limb? Rescue can be very technical. Dr. Abo believes the golden hour is dead. Does prehospital time affect mortality? Medically directed rescue is more important than time. Extrication is a medical procedure. Damage control extrication also aims to improve outcome. There is robust data that shows treatment on scene is preferential to rapid transport. Trauma, as a field, has been reluctant to understand where this is true in injury as well. Covered studies where response times do not affect outcomes. There is NO ASSOCIATION between EMS intervals (response or scene times) among injured patients with physiologic abnormality in the field. Scene times DO NOT make a difference in 30-day mortality. The speaker covered studies that support these concepts. Trauma systems, research and education affect mortality, not scene times of EMS. Tourniquets (the artist formerly known as harmful) are now universal. MAST/PASG suits are gone. IV fluids don’t help. Neither do short scene times. Blood transfusions do help. Is the question “how are we going to get the patient out?” or “how are we going to care for the patient?” Providing care affects mortality. People who ae trained in the EMS and/or rescue environment need to be the ones doing the procedures in the environment (as opposed to the surgeon in scrubs and crocs). Case study of an arm caught in a forklift mechanism (example of amputation not possible due to access). Assess skin temperature by touch when you cannot access with SPO2. Patient was treated on scene through a long extrication process. Patient condition was supported and kept stable. Ultimately, they got him out without amputating but it took eight hours. Patient was not bleeding out. Time was not important because the patient was managed. It’s not only about getting them out, but about supporting while getting them out, slow and steady. Patient kept his arm. Access AND care. Great care anywhere. Instead of “how are we going to get the guy off the rebar?” how about “are we giving him pain medication?” Short case study of patient on rebar. We must expand and grow what our crews are doing. Use medically directed rescue, not just rescue.

 

Kupas – Training EMS Practitioners in the Skill of Breaking Bad News – Tips related on doing a program to do this. It is a skill. Why teach this skill? We increase survival when we stay on scene in the vast majority of cases. Those with low rates of field arrest termination also have low survival rates. Telling of a death is difficult. For survivors, this moment is remembered forever. We do competencies on many skills but not on communication skills. Simulate this communication. There is dead and mostly dead and good EMS providers know the difference. There should be TOR (termination of resuscitation) guidelines. Survivors are usually satisfied with field terminations and how they are handled. Death in EMS is difficult. We see sudden/unexpected and gradual/expected. EMS providers need to understand grief and these discussions must go well. Grief is culturally and demographically diverse. Grief lasts 6 to 12 months and improves in 6 to 8 weeks. Prolonged grief can occur with pediatrics, suicide, denial and other factors. There can be violent responses. Sometimes there is demonstrative behavior or extreme calmness. Guilt can be

present. Sometimes transport is indicated for safety as opposed to field TOR when family is upset or disposed to violence. Survivor guilt is common. EMS providers should relieve guilt during the notification. Do not acta s if they should have done something more or different. Should family be present during the resuscitation? If the family wants to be there, yes. They want to spend time with the deceased. Survivors also have questions that should be answered if possible. “Would you like to be with him/her when we stop? Would you like to hold their hand?” Do not push this but allow if they desire. Mneumonic: (not in order, it’s a bundle): GRIEV-ING. Avoid jargon. Give them a way to connect later if they need to so that they may ask questions. Do not walk in with the thought that you are going to perform a field termination. Walk in ready to work. Use a Filed TOR workflow. Use formal pronouncement. Clean up the scene (taking into account medicolegal death investigation requirements). Service should consider a generic sympathy card. Do not have the crews sign cards if you do them, use a generic signatory using the name of the agency. Write a curriculum on this and teach it as applicable for your agency. Use case discussions and standardized patients for practice. Have ready statements like “I can’t imagine how difficult this is for you” or “I know you are feeling overwhelmed right now.” DON NOT say you understand or compare to your own experience. Do not refer to “the body” or “the corpse.” Do not discuss God’s will. Do not tell them to be strong. Do not tell them they will get over it. Death notification is a skill that needs practice. This process also helps the EMS team deal with this exposure. Do this well.

 

Seifarth/Terry – New Approaches for Verifying Initial and Continuing Competency for EMS Practitioners – NREMT providing presentation. ALS Exam redesign update: Moving toward replacing the paramedic psychomotor exam with the student minimum competencies. CAT will remain for paramedic, but computer based will remain for AEMT. AEMT will also have psychomotor removed for student minimum competencies. Both will have a performance exam. The performance exam will occur on the same day as the cognitive testing. Clinical judgement will be assessed. There will be more scenario-based evaluation. The test will use enhanced technology. This is all technology currently used by other professions that have been validated. This will begin late in 2023 (full implementation). This redesign is happening through an expert panel in collaboration with CoAEMSP and NASEMSO. The psychomotor exam materials will still be available but no longer required.  All is preliminary but currently on track. NREMT is communicating this as they have developments. Continued competency update: Uses 2019 scope of practice model. Need to assure both base and new knowledge. Must assure skills competencies. Must verify special role knowledge as well as what you need to know for your agency. There should be a progression toward mastery and development. Where is the line? NREMT suggests that the line is at knowing the base and new stuff but stopping before special role knowledge. The goal is to get as complete of a picture of competency as possible. Exploring crossover value between IBSC certifications. https://nremt.org/Document/ALS-Redesign

 

Braithwaite/Lindbeck/Shah – The Latest Prehospital Pain Management Evidence-based Guideline – Used a technical expert panel. Revision to a previous guideline. Covered process for developing guideline. Recommendations, the big picture as everyone should read the paper: all of the recommendations are for moderate to

severe pain only (5 to 10) as there is no available research on minor pain. This is a toolbox concept. Uses the SHARE decision making model. Certainty of evidence was the best possible given the research. With Ketamine either Morphine or Fentanyl is acceptable. Not enough information for a good recommendation on Nitrous Oxide. The recommendations are detailed, and the guideline should be read. This guideline is limited by the evidence available. Pediatric cut off for the guideline is 18 years of age. Real-world implementation: There was a lot of discussion regarding costs. Cost of IV APAP used as an example ($250 a dose is not generally acceptable although some are now reporting dramatic drops in pricing). If the patient is going to wait for pain relief when you get to the emergency department, you had better consider giving them something. We should be more proactive about managing pediatric pain (intranasal Fentanyl is easy). Use the guidelines as they are suggested to be, as a toolbox, not a reason to replace something. Good plans will contain multiple analgesic options.

 

Guyette - Top NAEMSP Position Statements 2021 – 1) EMS Curriculum Should Educate Beyond a Technical Scope of Practice. 2) Recommended Essential Equipment for BLS and ALS Ambulances 2020: A Joint Position Statement. 3) Position Statement: The Role of the EMS Physician Assistant and Nurse Practitioner in EMS Systems. This supports maintaining physician lead but welcome them into the fold. 4) Clinical Care and Restraint of Agitated or Combative Patients by EMS Practitioners. Must have a protocol and assessment is key. De-escalation should be attempted first. Must be based on indications to restraint. Monitoring is essential. 5) Ketamine Use in Prehospital and Hospital Treatment of the Acute Trauma Patient: A Joint Position Statement. NAEMSP, ACS-COT, NASEMSO, NAEMT and ACEP all agreed on this position. 6) Position Statement: Mass Gathering Medical Care. Defined as over 1,000 people in attendance. 7) Role of EMS in Disaster Response: Must be led by local agencies. ICS must be used. 8) Appropriate Use of Air Medical Services Utilization and Integration. Many influencing factors. 9) Physician Oversight of Air-based EMS: A Joint Position Paper. Unique area requiring expertise and acclimation.

 

Levy - Closing Remarks – 2022 NAEMSP Annual Meeting – Next year: JW Marriott Tampa, FL, January 23-28, 2023.

So, that is it for the NAEMSP Annual Meeting for 2022. Hope you found them valuable and can use them to translate the data, findings and information into outcoming changing practice for what we do in EMS.

Till next time...

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