It has been nearly a year since I posted notes (or blogged about anything for that matter). I missed Eagle's last year due to some personal health issues and a schedule that got a bit overwhelming. This year, we will start with the 2023 NAEMSP Annual Meeting notes and see how the year goes. These are my notes from the sessions I attended on Thursday and Friday. The half day Saturday notes at the end are courtesy of Brandon Robb from Deaconess Hospital in Evansville (as we were driving 800+ miles to get home and bailed a bit early due to a long drive and a city full of pirates (the Gasparilla Festival) that made getting to and from the hotel a bit interesting. And yes, you heard correctly... Our Clinical Specialist and I (with our spouses) drove a round trip 1,600 miles to attend the annual meeting this year. Why? We have not figured that out yet other than maybe people shouldn't listen to me when I have these bright ideas. But enough for the intro...
As usual, the disclaimer: These are raw notes, taken rapidly. It is always possible that I heard something slightly incorrect or missed a few bits of content. Please forgive grammar errors and concise wording were present.
So here is this years content:
NAEMSP DAY 1 (THURSDAY)
Levy – NAEMSP President – Opening – COVID still around. We
are still learning to live with it. Personnel shortage was looming before the
pandemic. Workforce issues abound. Mental health issues abound. EMS is
hazardous by nature to our personnel. Line of duty deaths are up in number. We
have lost some icon EMS leaders in the last few years. Reflect on how lucky we
were to have known those we have lost. This organization has 30% non-physician
members and it strengthens the organization. Two-thirds of physician members
are board certified. We are in NAEMSP as we enjoy being around each other and
becoming educated. There is significant interest in advocacy. NAEMSP actions
were critical in keeping controlled substances for EMS. Discusses where we are
at with controlled substances legislation and getting the 2017 legislation
implemented. Implementation still not on the radar screen. Medical direction.
Is it a career? Medical directors should be paid. Is EMS an essential service?
Magic 8 ball says “without a doubt”, unless you shake it in certain states. PEC
put out the airway compendium. NAEMSP owns the airway space on EBM. Foundations
of Medical Oversight Course now available online. Social determinants of health
show we need more work equitable access to care. It must be addressed. NAEMSP
has a position statement on equitable workforce development as well. 2022 was
great. 2023 will be better.
Flanary – Wife and Death: Lessons from a Bystander Responder and co-survivor of Sudden Cardiac Arrest – Wife of Dr. Glaucomflecken on social media. “I cant teach you anything about medicine.” She is not in healthcare. She is in communications and marketing. What she can do is show us what the other side looks like. She was there when husband was in medical school and husband got cancer. And again, when it happened a second time. She experienced watching the medical system interact with her husband and visits and doses and everything, She was there when her husband experienced cardiac arrest. She was the only one there. Played 911 call with EMD. Rapid EMD recognition of arrest. About nine minutes of EMD assisted CPR. Standing ovation for nearly 10 minutes of CPR on her husband. Slide show of pictures during and after his recovery. In four days he was home physically and neurologically intact. To her, the 911 dispatcher saved her husbands life. She did not realize he was in arrest, but the dispatcher did, The paramedic stands out for her because he communicated every move to her and kept her well informed. The paramedic went between rooms telling her every detail and explaining what was being done as they worked it on scene. The responders where in massive PPE due to timeframe of COVID. She could not stay in the hospital with him due to COVID restrictions. His ICU nurse was a bridge between her and her husband and the only one who asked her how she was doing. What helped? Frequent updates, Explanation, compassion and words in the moment as well as written information to distribute. What hurt? The healthcare system did not understand that the family is a patient too. Being separated was horrible. Just having no cell phone service where the had her sit at the hospital. Few updates at hospital, no sensory comfort or touch. Then they kicked her out of the
Nakajima – Warming Hands and Warming Hearts in Ukraine: EMS
Side Roads in Humanitarian Aid – She is with NSF (Doctor’s Without Borders).
She packed some handwarmers while in Japan and found them useful in the
Ukraine. Born in the US. Moved back to Japan at age 11. Medical school was
attended in Japan. Emergency medicine is a unique focus in Japan. She joined
NSF. Went to Yale and fell in love with EMS. Did the EMS fellowship in San
Diego and went to Emory EMS. They support her work with NSF. Has been to
Nigeria, Pakistan, Syria, Sudan, Yemen, Syria again, Iraq and then the Ukraine.
NSF is an independent medical humanitarian organization. It takes two billion a
year to fund and be medical “cowboys” who can respond to medical needs quickly.
The entity came out of rebellion against ICER’s position on neutrality. NSF was
then created. NSF values speaking out on what is seen. NSF works in 74
countries with over 200 programs. They work in disaster, refugee and combat
zones. Sometimes they are activists against issues such as big pharma. They
have their own supply chain (reducing response time to needs). The go places
other organizations do not. There is a lot of fundraising. Multiple projects in
Ukraine. They have a medical train project using rail lines to remove patients
from combat areas. Very successful. Transports multiple patients. Over 2,700
patients transported so far. They simply cross the border alone to meet with
NSF personnel on the inside of the country. She brought operative cash and a
bunch of tourniquets. Her backpack was CBRN gear. So back to the handwarmers...
Visited mobile care project supporting shelters. An older lady approached them
and took them to her room. It was cold with poor insulation. She was given a
couple handwarmers, and then gave out to others. These people had apparently
never seen a handwarmer and they were fascinated by the concept that it kept
them warm for 16 hours. It was a small thing. It was featured in a Japanese
news article. Donations of the handwarmers were received. They are very cheap
to buy in Japan and are very common. The donation of the handwarmers was about
$900. Shipping to Ukraine was over $25k. NSF usually only accepts financial
donations for this very reason, but they embraced this because the relief from
the cold was important to the people in shelters in the Ukraine. Hitachi is
donating 100,000 handwarmers as well but they have their own supply chain and
can get them there. Discussed a shipment of cigarettes that was sent because it
was a donation of care for the heart not the body. She discussed how important
something as a portable hot tub can be to those in refugee status from
disasters. It brings normalcy. Small things make a difference to those we care
for. We are big on identifying what we can do with limited resources. We are
good at the big lifesaving stuff. We must be better at the small things that
give care and smiles. Humanitarianism is paying attention to individual needs,
and it makes a huge difference.
Allied Updates – NREMT/ABEM/NASEMSO – Mackey (NREMT) - NREMT
has removed all barriers to distance education. National discussion on
potentially removing accreditation. Board position was rescinded on removing
accreditation. Working on ALS redesign and continued competency. Sholl
(NASEMSO) – Who is in the workforce? What are the vulnerabilities in the
workforce. Measuring dynamics and changing practices. The Airway EBM Guideline
was a huge project. Working on project with falls in the elderly. Looking more
into use of NEMSIS data. Gausche-Hill (ABEM) – The future of EMS is being a
people centered EMS. 1,057 current EMS Board Certified Physicians. 178 in
latest pass group out of 200+ taking test. New application for managing the board
certification and continuing education. All specialties have went to a five
year cycle. Launching modules for CE and continued evaluation in 2023. Covers
advances, review and knowledge assessment. Process on recertification was
outlined. If a module is failed, the physician has to wait three months to
retake the module.
Brice – PEC Update – Top downloaded article was on
prehospital pain management. There will be eight issues in 2023. New layout for
the publication. Abstract issue available here. PEC is now online only. You can
sign up for new content alerts. There is now a statistical reviewer for
statistical accuracy in articles. Some articles referred to the new
International Journal of Paramedicine.
Oral Abstracts – 1) McMullan – Nasal Ketamine as an Adjunct
to Fentanyl – Pain management is fundamental to EMS. Multi-modal pain control
is appealing. Ketamine and Fentanyl are front-line. Hypothesized that nasal
ketamine would be an effective adjunct to Fentanyl. Paramedics gained consent
for the trial from patients. Cincinnati Fire was the site. Liberal protocol for
application. Randomized trial. Over enrollment in the study was allowed.
Results: 569 screened, 107 received Ketamine. 45% receiving the adjunct
experienced a 2 point improvement in pain which was not significant over
placebo. No serious adverse events. Limitations noted to gender selection and
other routes of administration. While safe, nasal Ketamine offered no benefit
by that route. 2) Burnett - EMS Documentation of Social Determinants of Health
– Observing EMS perspectives of SDOH. Looking at ability to view and
communicate to other areas of healthcare. Looked at triggers such as “hasn’t
eaten” or “can’t afford.” Looked at accessibility to care /food or having to
defer funds to access, mental health, and physical health (for example weakness
and falls in the elderly or things such as substance abuse). Scene descriptions
can be triggers of SDOH elements. EMS documentation reflects common social
topics. 3) CHF and COPD diagnosis using Ultrasound = Previous studies proved
ultrasound teachable to paramedics and usable in the field. Should we
implement? Will improving accuracy of diagnosis improve care and outcome? In
person education provided. Case driven testing. 32 paramedics in study. Significant
improvements in accuracy of diagnosis and management. This was an image-based
study, not a field study on the accuracy/management in scenario testing. 4)
Menegazzi – OHCA increased Mortality Factors - Remle Crowe involved in the
study. OHCA, 350,000 per year. 40% will rearrest. Hypotension, Hypoxia and
Hyperventilation are the H bombs. Used ESO collaborative database. Focused on
hypotension and hypoxia. Mortality data from hospitals. 24.8% experienced by
hypotension and hypoxia. Compared against the group which had neither. Hypoxia
and hypotension after ROSC showed a six fold increase in mortality.
Retrospective analysis. Hypoxia is bad. Hypotension is really bad. Both are
really, really, really bad. 5) Jarvis – First Pass Success with Airway Attempts
Made On-Scene versus Enroute – Used ESO dataset. Does where you do an
intubation impact your first pass success? Retrospective study. Also compared
during COVID to before COVID time frames. All success rates were higher in
on-scene interventions for OHCA. Very close on non-arrest. On-scene appears to
have higher potential success rates. 6) Cheetham – A Video based study of
duration and quality of patient handoffs between EMS and a pediatric emergency
department – 164 patients included initially with an eventual total of 156.
About half admitted to the hospital. 38% under 60 seconds. 35% between
61seconds and 89 seconds. Percentage of handoff elements compliance was
reported. High compliance with chief complaint and mechanism of injury.
Interruptions and being asked to repeat were frequent by ED personnel. Relaying
vital sins is very important. ED clinician communication may be detrimental to
useful and safe handoff.
Dorsett - The Role of the EMS Medical Director in Initial
EMS Education – It is easier to learn something on the way in then to change it
after experience. Covered accreditation standards for the role of the medical
director in EMS education. Does the medical director invest in you and your
knowledge? The goal of the medical director must be to get you to the
educational level you need. Excellence is a goal. Life long learning is a goal.
The medical director should show them how medicine changes. The medical
director must figure out how they can be approached by students. Students
should spend time with the medical director in the ER seeing how the MD treats
patients. The medical director should share their space with students including
telling them about errors. The medical director should tell them truths and
show genuine concern for the students.
Cash/Panchal – Who is EMS? Challenges in Describing and
Measuring the EMS Workforce – EMS personnel shortages and agency closures are
numerous. How big is the EMS workforce? It depends on how you are measuring.
Department of labor says around 260,000. NREMT says over 400,000 and NAEMSP
says over one million. Is EMS non-emergent workforce. At least 13% do not do
emergent work. Some in admin roles and not care. How can we measure what we
cannot define? There is no correct workforce data set for EMS. We have people
coming into the EMS workforce and those leaving at any given time. Those
currently in as well. Some entering quit before being certified and some do not
reach competency for certification. 79% graduation rate for EMS programs. 11%
of that number never pass the certification exams. Those leaving retire, go to
a different career, leave but maintain certification, or switch agencies. In 2010, EMS turnover was 7% in one
assessment. In 2021, this was 15-24% (this was private AND public). We need more
population-based studies. They looked at nine states that require maintenance
of National Registry certification. That study showed 18% left. Trying to get
each person to have a unique national EMS ID number. It would tie state
certifications together and we would know entry to leaving and a number of
those working. Increase in the need for EMS in the future. We must have a
definition and means to measure.
Cabanas/Garner - Managing Shortfalls and Growth in EMS – EMS
personnel turnover rates are high. Hospitals experiencing the same thing.
Volume of calls is going up in all environments. Volunteer agencies are
experiencing shortages and sometimes closures. Caregivers are aging out and
retiring. New education completions are decreased. Speaker says it feels like
sharks circling from elected officials. If you get to tell your story of what
is going on, do it and capitalize on it to help support your efforts to improve
the situation. Be on the offense not the defense. Wake county made response
plan changes, started holding calls. Not uncommon for them to be holding up to
30 ambulance calls. Triaged to most acute calls. Delayed responses on low
acuity calls. Used incentive pay plans. Sign on bonuses and referral bonuses
were used. Used holdover bonuses as well. Destination plans were changed to
support the system. Went to tiered system and started using BLS units. Started
using nurse navigation and alternative destinations to the ERs. Started their
own internal paramedic program and started graduating more paramedics with less
cost than the local community college. Take people from the community and train
them internally to do the job. BLS is the right choice for many calls. Dropped
vacancy rate on positions. Nurse navigation and shunting decreased holds on low
acuity calls. The next generation of EMS is going to come directly from the
community. Funding streams have been established to pay for EMT and Paramedic
initial education. Embrace the challenges and turn them into opportunities.
James/Levy – EMS Legal Updates – 2022 was a growth year for
EMS legal cases. In 2022 50% of cases were regarding interactions where the
other 50% were in regards to outcomes. Transports to urgent cares can be a
higher risk. Regulatory agents are not quite ready to deal with treat and
release. Not transporting and treating on scene is something insurance
companies are having to improve their grasp of how to manage. Concierge
services such as starting IVs on performers at concert venues are not
mainstream and fall into a high risk pool that is probably not covered by
insurance. Personnel are most likely not covered. Medicare and Medicaid billing
fraud cases are increasing. Assure that if doing treat and release that it is
legal to perform. There are EMS personnel involved in “IV wellness” services.
These are rarely covered by insurance and many are illegal.
NAEMSP DAY 2 (FRIDAY)
Burnett/Mllder – Eliminating EMS Divert During a Pandemic: The Twin Cities Experience – Two geographically different areas with different numbers of hospitals. Defined as East and West Metro areas. Divert is a single facility localized tool to allow a facility to decompress. When more than one facility is on divert it becomes non-effective. Statewide diversion notification system was in place. October 2021
Slattery – We Are Not an Island! Hospital Area Command: A
Novel Approach to Supporting Hospitals with Fire/EMS Assets Immediately After a
Mass Shooting Incident – What would happen in your hospital with inbound multiple patients from a
shooting at a football field? His hospital implemented Hospital Area Command.
The process creates a toolbox for these type events. Covered mass Las Vegas
shooting from 2017. Discussed egress of patients. Showed how patients exited
venue. Hospitals were over ran especially non-trauma centers. Most arrived by
Uber or private vehicle. Ambulance bays packed with cars delivering patients.
Patients were laying in the floors of ED waiting rooms. 864 injured, 422 shot.
60 killed. 16 hospitals received patients. When this happened, all hospitals
were already near capacity. What can be done? Fire Department assets can now be
dispatched to the hospitals to assist with triage, treatment, and movement of
patients. Activation of this process is for patient number more than 25 and a
company level officer responds with personnel. Fire personnel are authorized to
do anything within their scope of practice.
Fire companies able to request equipment/supplies from the facility.
Fire command works with charge nurse. Seven-minute training program. Simulation
has been performed as well. Fire command and charge nurse must be shoulder to
shoulder. These two must not triage or treat, they must focus on the command
function and providing needs. Active shooter kits can actually support
functions at EDs as well. Fire personnel can handle initial triage and
treatment at hospitals. Used surveys after simulation. Hospital Area Command is
a simple force modifier. “One team, one fight.”
Farah/Haamid – Overcoming Barriers to Recruitment and
Retention of a Diverse EMS Workforce – Issue has been addressed in several
studies. Most of the authors of the studies are on stage or in the audience.
Staffing is recruiting, selection, retention and culture. Panel speaker talks
about CHAMP program. It is a career help program in community schools to
support middle school students seeking a healthcare student path. It focuses on
equity. Provides mentorship and financial management courses. Children need to
know that they can become an EMT, paramedic or a firefighter. Kids need to see
us before they lead us. Another panel speaker states that we need to be allies
to those who want to enter the EMS workforce. Remove barriers. Success comes
from cohorts of diverse individuals. Used an audio book in one case for EMT
class due to lower reading levels (100% pass rate on National Registry). How do
you start? Start with community organizations. We have to create environments
where people are comfortable being who they are and then they stay. This is
inclusion. We must realize and address bias. Bias training should be utilized. Learning
is the key to changing. We all came into EMS to help people. This includes
those coming into the career field.
Crowe/Stemerman – EMS Data Analysis to Visualization – We
have more EMS data available than ever before. How you present data is
important. If you want to change something you have to make the data visually
appealing and understandable. Data, sorted, arranged, presented visually,
explained with a story can stimulate change. Don’t start with the data. Start
with the problem. Discussed PDSA process for change. What makes a good QI Aim?
It must matter and not be a rare event. The standard of care for the aim must
be known. NEMSQA is a great place to start. You need an operational definition
to assure we are comparing apples to apples. The data stream must fit the
operational definition of the data population you are looking for. Types of
variation must be noted. Is variation common cause or special cause. We need to
use data to work toward commitment. Colors make a difference in visualizing
data. Older generations get fatigued by dark backgrounds and do not turn back
to the visualization as much as younger generations. Used stroke data to walk
through a process of visualizing the proper data. Storytelling with data is
important. Needs consistency, transparency, clarity sustainability.
Smith – Can’t he just sleep it off? Novel Transport Triage
for Intoxicated Patients – Alcohol intoxication is common. Can be significant
but often uncomplicated. They are a source of frustration for EMS personnel.
EMS transporting to the ED can be reconsidered. Screening factors can be
identified can identify patients that can be left with a responsible party.
Case study presented. 25 year old intermittently cooperative and intoxicated
with normal vitals. Able to stand and walk. Minimally compliant. Trying to
refuse service. What are our options? 1) Force her to go and sedate her against
her will, 2) Try and convince her t go by telling her she could die, 3) Call
the police and try to get her arrested for drunk in public, or 4) Call and get
a detainment order (at least 45 minutes), or let her refuse and leave her
there. Alcohol is readily absorbed and distributed through the body. Takes
about 60 minutes to be absorbed. CNS depressant at above 200mg/dl (CNS
stimulant under that amount). Chance of emesis increases above 200mg/dl.
Metabolized at about one drink per hour. Above 0.2 is worrisome, and above 0.40
is dangerous. 800,000 ED visits each year and about half are discharged without
significant care. Often uncooperative and difficult to deal with. Can they
refuse care? Do they need medical clearance for jail? How drunk is too drunk? If
we do something against their will, can we be sued? What happens in the ED?
They metabolize to freedom in the hallway, usually unmonitored. Can
uncomplicated intoxication be triaged to somewhere other than the ED? Back to
the case: Her friend walks up and asks, can I just take her home? A checklist
can be used to triage between a sobering center and the ED. 718 patients in
study. 0.25 was usual BA for the sobering center. Inability to ambulate was
primary reason many went to the ED. Showed minimal adverse reactions for those
going to the sobering center. Another study showed that 39 out of 99
intoxicated individuals can be safely treated by transport to a sobering
center. In San Francisco, the ED and EMS can send to the sobering center. Only
4% of patients were sent form sobering center to ED. High risk would be any
significant trauma, suicidal thoughts, co-ingestants, any alcohol ingestion in
last hours, any combative behavior, use of Taser, or any inability to walk or
stand. Chronic alcoholics are at high risk for illness and/or injury. Goal was
to identify intoxicated patients that do not require transport to an ED.
Options for diversion were 1) police for incarceration or transport, 2)
non-emergent transport to a shelter or detox center, 3) Responsible friends or
family that will stay with them. If uncomfortable, transport to ED. If they
want to go to ED, they go to ED. All minors go to ED. Any abnormal vital sign,
they go to ER. Recurrent vomiting is transported to ED. Pregnant goes to ED. If psychiatric component
recognized they also go to the ED. If
0.4 or above they go to ED. 11% diverted in Arlington, VA. No bad
outcomes noted on QA follow up. “To alcohol... the cause and solution of all
life’s problems.”
Flint - Pediatric Psychiatric and Behavioral Emergencies in
Transport – Only usually see upticks in these transport correlating to return
to school times. However, during COVID shutdown there was an uptick. Types of
patients: stable with episode of aggression, stable with no aggression, going
for in-patient, History of aggression with risk factors of more aggression, and
patients with active aggression. Remember that agitation is a state of
behavioral dyscontrol. It is a multifactorial sign of distress. Patient and
crew safety: prepare video and make safe, remove things that hang around necks
of crew members, cover head and have hair back on crew members, remove patient
shoes and maintain control of personal items, bock exits during cot moves, give
sensory items for autism, give meds early if indications of aggression. They
use CMCCT Behavioral Health Observation Tool for patient evaluation. Determine
use of de-escalation techniques, sedation or not doing transport. Predefine
what medications will be used. Base meds on what is going on using an evaluation
tool. Different meds for agitation/aggression versus delirium with agitation.
If there is substance abuse or withdrawal, requires more specific sedatory
management by type of overdose. What to do with high-risk transports? 1 on 1
security or ongoing aggression is a big red flag. There needs to be a pre-plan
of pre-meds and rescue meds before and during transport. There must also be a
contingency plan if status changes in transport. Pre-transport huddle with transport crew and
facility staff. Where will you go if something goes wrong in transport. They
try not to use restraints but rely on medications. Crew has the ability to deny
the transport based on safety. Most of this information is modifiable for first
response agencies. Use local resources to define your plan. Safety first. Give
meds early. Currently studying Ketamine, Dexmedetomidine, and psychiatric
crisis.
Antevy/Colwell/Crowe/Pepe/Maloney – Minding the Mind in EMS
(A Multi-Level Inventory for Addressing Mental Well-Being, Resilience and Support
for Front-Line Responders) – Develop programs for your own teams. The sickest
patients never make it to the hospital. The burden of seeing that falls to EMS.
This makes CISD very important. EMS workers are twice as likely to doe of
suicide that the public. Peer recognition and support is usually received
better than formal mental health utilization. We have to reach out after
something bad happens. Peer support is early reliable and non-invasive. Peer
support or CISD teams need to be alerted based on types of calls. Helping
resupply and clean along with a snack or water go a long way. The process is to
let the provider know they are safe. What we do before we get to scenes may be
more important than what we do on scene. Preparing to look people in the eye is
hard. If we do pre-game, the game goes much better. We must mind the mind of
the individuals on scene. Research being done on how agency practices affect
burnout. It may come down to job demand versus job resources. Do we use
constructive feedback. Respectful cultures have the most positive impact on
preventing burnout. Team members must be reminded that services are available.
Exposure to critical incidents must be documented.
Gallagher/Wright – Are You Ready to Lead a New Team? The
Multidisciplinary EMS of the Future is Coming – Where are you with your system
and where are you going? Initial EMS model concept was to respond to calls and
transport to hospitals. Now there are alternative destinations, treat and
release and MIH programs. MIH? Telemedicine? Social Workers? Behavioral Health?
Addiction medicine? EMS practitioners? Alternative Destinations? And what about
Nurse Triage? EMS is healthcare not just transport. Healthcare must be led by
physicians. Should all levels of leadership in EMS be a physician? If not,
where is the line? Non-physician partners deliver admin roles, education, and
credentialing. The larger question is physician integration into leadership.
Can the medical director role fall to a mid-level practitioner? We do progress
so we must have conversations. There are multiple providers doing types of
alternative care. Medstar Tx, Austin, Washington University EMS, Wake County,
LA County Fire just to name a few. EMS is rapidly changing from load and go to
a holistic healthcare system. Unprepared physicians are increasingly being
asked to lead multidisciplinary teams. Current EMS physicians must embrace the
change before someone else does. Leadership versus clinical (or both?). You
have to strive to be the leader your team needs.
Bourn/Myers – Lessons Learned from the National Ketamine
Situation (Spoiler Alert: They Had Nothing to do with Ketamine) – Not going to
talk about the clinical dosing and stuff about Ketamine. We are going to talk
about the response to the Ketamine issue. EMS is a public practice of medicine.
As a consequence, we have to be in the public square all of the time. Some
things must be “never” events. We have to be the voice of reason. Statements
regarding Ketamine complications made it to media without context. Many efforts
to restrict Ketamine use. Was Ketamine safe? Yes it was. Multi-organization
endorsement of Ketamine use even without weight-based dosing. The American
Society of Anesthesiologists states that Ketamine should not be given outside
of a healthcare setting with adequate training (EMS is a healthcare setting
with training). Everyone thought the public now understood that Ketamine issues
were localized and not a wide problem. They thought everyone knew it was done
under medical direction. The public thought EMS had body cams and wanted body
cam footage of Ketamine incidents. What is the lesson if a similar thig happens
again? How do we react to large public events? There must be consistent
stakeholder education from local to national levels. Crisis communications
relies on relationships. Do we have comparable cases? Are policies and
guidelines clear? Are we monitoring the right measures? Ask, could this happen
here? We need to have transparency and communicate before we are asked. Do we
do what is in question? How often? Rate of complications? Do clinicians have
adequate information to meet their practice needs? Are initial and ongoing
education aligned with clinical expectations (both locally and nationally). We
must embrace patient safety, population health and community expectations and
education. Our greatest chance of error is during transitions (such as between
EMS and ED or police and ED). Transitions must be practiced.
Burton/Baker/Nabavi – Update on Nationwide Implementation of
ET3 and Nurse Navigation – ET3 is emergency triage, treat and transfer. GMR
started a nurse navigation program with DCEMS in 2018. This shunted them from
emergency ambulance use to appropriate care for operational efficiencies. Nurse
navigation expands access to appropriate care with correct level of
transportation. The same service takes care of the patient but through a
different means and partnerships. Nurse navigation is a transformational model
for EMS. Nurse navigation allows for true appropriate destinations and
appropriate level of care (telehealth, urgent care, etc.). Nurse Navigation
utilizes 2-1-1 and Lyft. ET3 is utilized on 911 calls with an ambulance on
scene. It can provide telemedicine with treat and release or transportation to
an alternative destination that is appropriate. ET3 is now available to all EMS
providers. High Risk refusal is now being utilized as well using Telemedicine.
Typical televisit response time is 3 minutes. Typical visit duration is 10
minutes. Average successful treatment in place without transport is 60% of
telemedicine contacts. Now working with
60 geographical areas. Telemedicine is not medical control for EMS, it is a
medical visit for the patient. Case study presented on a 14 year old with ADHD
and ODD which was a 911 call for aggressive behavior. EMS makes contact and
starts telemedicine. Normally this would be a telemedicine visit. Found patient
off meds for two days. Medication was on shortage. They worked to find a
pharmacy that had the medication. Telemedicine issued a new prescription so the
medication could be obtained. Patients rate the experiences with these services
very highly. These programs extend care and improves access to getting needs
met. ET3 helps decompress emergency departments. Some high-risk refusal
patients agree to transport after talking to a physician on telemedicine.
NAEMSP DAY 3 (SATURDAY) Courtesy of Brandon Robb (in all
fairness his notes are more prolific than mine!)
Al Lulla – Takeaways from the new Brain Trauma Foundation
TBI Guidelines - The Brain Trauma Foundation has done 20 years of in hospital
and out of hospital research and has been doing great work in the formation of
guidelines. The Department of Defense
has played an important role in the funding and support of these programs. Case Study Presentation: a 3 y/o boy is the
backseat unrestrained passenger. Is your
EMS system ready to take care of this child in a manner that gives them the
greatest chance of survival? Are you
doing focused QA / QI? TBI is a young
person’s disease! Do you have
pre-hospital protocols geared directly in reflection to current TBI
science? The science is overall not yet
intertwined with prehospital protocols currently in use. The EPIC data studies
appreciate that the new guidelines work as notated in JAMA’s “Association of
Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment
Guidelines with Patient Survival Following traumatic Brain Injury.” In 2002,
the 1st guidelines were published for TBI. As everyone remembers, this focused on airway
and “hyperventilation” which is now known not to be a best practice. The 3rd edition will be issued in
short succession. This new guideline
appreciates the three big criticalities (Airway, Breathing, and Circulation)
all being managed in parallel. 122 studies were reviewed. The consensus was Hypoxia, Hypotension, and
Hyperventilation (THE “H” BOMBS) are the BIG KILLERS. The presence of one of these H Bombs, even
briefly, presents a two-fold increase in mortality. Any of these in combination, mortality goes
up exponentially. How do we manage
them? First, we must monitor them. If you are doing q15 vitals, you are not
getting the full picture. Continuous monitoring
is of upmost importance. You cannot
perform an intervention to something you don’t otherwise know. “If you can’t measure it, you can’t improve
it.” - Lord Kelvin. Aggressive resuscitation needs to be conducted when a
variation exists. Reassessments must
take place during and after resuscitation. TBI needs to start being addressed
the way we treat cardiac arrest care, in a pit crew fashion prehospital. Data
does not support the utilization of TBI prophylactic treatments in the
pre-hospital setting, including steroids and Mannitol. Additionally, data does not support the
utilization of TXA in the isolated TBI.
(My note: this does NOT represent a contraindication to TXA utilization
in the multisystem trauma patient). What is the common thought of such TBI
patients in the pre-hospital and Emergency Department settings? Normally it is the belief that these patients
are not going to do well in the end-result.
This is just NOT TRUE. The end results are not finally known until
months later, and a bias should be banished.
A subdural bleed progression of CT on day 1, 5, and 15 are presented
which shows gross improvement. It was
appreciated that the pre-hospital care providers don’t get to see these results
quite frequently. Simple protocols and guidelines don’t necessarily mean
easy. It is not always the hitting of
the “EASY BUTTON.” Key Updates: Blood pressure targets are uniformly
increased. Stronger emphasis is placed
on oxygen supplementation on ALL TBI patients. Continuous capnography and avoidance of
CO2<35 mmHg. Further, as previously
discussed, continuous monitoring is a must, followed by good documentation. GCS is no longer considered as part of the
decision tree in airway management. Assessment:
Hypotension: SBP <100mmHg (not 90). “While no specific data exists for hard
cut-off values, optimal adult specific SBPs following TBI are dependent on a
variety of factors and should be targeted to 110 mmHg or greater, as lower
values are associated with worse outcomes.
Optimal targets may be higher.”
(Strength of recommendation: STRONG). Treatment: “Intravenous fluids
should be administered in the prehospital setting to treat hypotension and/or
limit hypotension to the shortest duration possible. Hypotensive patients should be treated with isotonic
fluids and/or blood products (if indicated and available) in the prehospital
setting.” (Strength of Recommendation:
Strong). Assessment: Hypoxia: <90% SPO2
“While no specific data exists for hard
cutoff values, optimal oxygenation saturation levels following TBI are
dependent on a variety of factors and should be treated to 90% or greater, as
low values are associated with worst outcome. Optimal targets may be higher.” Treatment:
“All patients with suspected severe TBI should be placed on continuous oxygen
supplementation via nasal cannula or face mask in the prehospital setting in
order to minimize secondary insults related to hypoxia.” (Strength of Evidence: Strong). An airway
should be established, by the most appropriate means available, in the patients
who have signs of severe TBI, and the inability to maintain an adequate airway,
or if hypoxemia is not corrected by supplemental oxygen. GCS is no longer appreciated as value in this
evaluation. Assessment: Ventilation should be assessed in the prehospital
setting for all patients with altered level of consciousness with conscious
capnography to maintain ETCO2 levels between 35 and 45mmHg. (Strength of Recommendation is Strong).
Spaite – How much is Too Much O2? Should EMS Limit Oxygen Delivery in Non-Hypoxic
TBI Patients? - 90% emerged passively from decades of small studies using the
convenient dichotomy. EPIC data strongly
suggests that SPO2 less than 90% doubles mortality rates. The past has unfortunately just been “bad
science” in that no clinical trials have tested 90% as a true threshold and,
every study presumes that 90% is the “cut point.” Dichotomizing small populations with a
predetermined value is not the same as identifying a true threshold. What is a
true physiological threshold? A clinically meaningful cut point. Correlates
with a marked change in physiological response and patient outcome when the
value drops below a specific level. An EPIC adjusted mortality review
appreciated the threshold to be 96 to 97%.
In the traumatic brain injury should hypoxia be defined as the mid high
90s? In any case it is not 89%! Unadjusted and adjusted mortality at 89% is
more than double that of 97 to 100%. If hyperoxia causes no harm, is the upper threshold
a moot point? If giving too much O2 is of no concern then all TBI patients
should be given high flow oxygen because, it helps prevent hypoxia, it is
inexpensive, and is easy to apply non-invasively via non-rebreather. Does the
approach of aggressively preventing hypoxia give too much oxygen? Should we
titrate oxygen? Should we forgo the non-rebreather? Should we use a nasal
cannula? Should we turn down the flow and aim for 96% to 97% O2 saturation? There is a lot we don't know. The evidence
for the detrimental effects of oxygen came from ICU studies in which patients
were hyper oxygenated for hours or even days.
NOT the prehospital setting. The flip side is that there is substantial
evidence to support that hyper oxygenation may be beneficial in TBI. In fact,
SIREN Network is randomizing hyperbaric!!!
“HOBIT: Hyperbaric Oxygenation Brain Injury Treatment Trial” Despite this, the concerns about hyperoxia
have led some EMS systems to ignore the guidelines and limit the amount of
oxygen given in TBI. SPO2 is NOT the same as pO2! Hyperoxia equivalates to a pO2 >110 mmHg. In the field, pO2 is not measured, and SPO2
is relied upon. 100% SPO2 is a very poor
surrogate to hyperoxia. So the question
is, when patients have an SPO2 of 100%, are they hyperoxic? The problem is, any pO2 level of 100-760mmHg
displays as 100% SPO2. So to reflect on the question, is hyperoxia bad? The
spo2 mortality analysis before implementation is provocative. Dramatic
improvements in mortality between 80% and 97% are appreciated. Furthermore, a distinct-appearing mortality
uptick between 98% and 100% is in the unadjusted data. This mortality uptick does not exist in the
adjusted data in which cases with other mortality factors (hypotension, etc.)
were eliminated. This uptick correlated to
other non-related factors. At the end of the day what do we really know about
oxygenation in the early management of TBI? Hypoxia is really bad. Hypoxic
events are really common. We have to look at and weigh the risks and benefits.
Indirect evidence of a theoretical risk of brief hyperoxia versus established
evidence that hypoxia is disastrous. The bottom line, tweaking oxygen delivery
to prevent hyper oxygenation removes the protection of preoxygenation in the
high risk prehospital environment. In summary, hypoxia associated mortality
decreases until SPO2 is in the 96 to 97% range. The current definition of
hypoxia in the guidelines is far too low for optimizing clinical outcomes. The
concept of a hypoxia threshold less than 100% appears to be moot, and growing
evidence of lack of harm with hyperoxia in the early management of TBI appears
strong. Finally, protection from hypoxia is much better in the hyperoxygenated
patient. The hypoxia threshold in the
TBI patient should be 100%.
Thanks again Brandon for covering part of that last day.
And with that, the notes from this years NAEMSP Annual
Meeting (from the sessions attended) are presented. I hope you find them useful.
Please feel free to share the link to these notes to those who might benefit.
Thank you for reading.
And just for the fun of it, we finally stopped at a Buc-ee's in Georgia. I needed coffee...
