Thursday, February 2, 2023

My Notes from the 2023 NAEMSP Annual Meeting - Tampa


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

hospital due to COVID. She sat on a bench outside and waited for someone to pick her up. She did not need to hear the grim statistics on OHCA. Hospital appeared in many cases to be “tolerating” her questions. Things were said like: “I wish you would have actually seen him collapse so we knew a good arrest time,” in a situation like this, questions like that can come off as blame or fault. A hug or a warm blanket would have brought at least some comfort. Instead, it seemed sterile and exclusionary. Aftershocks? ICD placement brought more stress. Coordinating care was difficult. Healthcare is siloed and making appointments happen is hard to sort. Prior authorizations and insurance were never helpful. Crisis mode finally subsided but it left her feeling like it was harder to communicate with the world. She lost her words. She wrote an article on this for the journal of cardiac failure. She went to a quiet place. Types of words that helped: What did I here? Why did this happen? Will they be OK? What do I do? What do I need to do next? She used the Lay-Responder Resource Guide. They need to know what happened. They need validation of feelings. Words that provided a label: Names have power. Once you can name it you can tell people about it. We cannot ignore the forgotten patient. Explain. Name and Validate. Don’t forget the co-survivors. He went to sleep and woke up in an ICU with no underwear. She lived every moment of it. Co-survivors are partners, responders, caregivers and bystanders. Healthcare is designed to care for diseases not people. It is a poor design. Create systems to relieve suffering, not add to the pile. Life is perilous and fragile. Not being able to get a prescription refilled or a needed device creates a futile feeling that is horrible. Before you a healthcare professional, you are a human, and you witness more in a day than most people do in a lifetime.

 

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

had 355 periods of diversion in one month. This was not just COVID as EMS staffing issues were becoming prevalent. If three hospitals go on divert, all hospitals are forced off divert. This was happening often so it became a question of why even divert? One trauma center was going on divert and being forced off every day. The diversion rate was totally disassociated from the number of COVID admissions. What do you do? Collect data and define problem. Make sure everyone agrees there is a problem. Leverage the law. Get support from clinical subject matter experts. Frame the argument in terms of harm/benefit to patients. Use regulatory boards to advise what will be done. In their case there was no statutory support for diversion, and it was made clear that EMS could override divert status when in best interest of the patient. They also received a statement that diversion was not in the best interest of the patient and hospitals should stop using diversion as a tool. The state trauma advisory committee weighed in and supported the thought that diversions should be eliminated. The term “abolish” was used frequently. Ambulance diversion was eliminated in January of 2022. Other systems followed suit within the state. PDSA cycles were used to follow progress and improve issue. EDs ended up boarding more patients, but time to getting into a bid showed no change. Boarding issue was not caused by not diverting but by staffing shortage. EMS turnaround times went up slightly (15 to 18 minutes). Hospital stay time was the same overall.

 

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.” https://youtu.be/ec0wKXHmgsI - HAC Training Video and https://me-qr.com/mobile/pdf/12126738 - HAC Policy.

 

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...




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