Tuesday, June 18, 2024

A Stormy Eagles XXV - My Notes from the 2024 Eagles Meeting

I will state that this was probably the most interesting travel I have had to an Eagles meeting.
Storms in Southern Florida wreaked havoc with getting flights into Ft. Lauderdale. After many hours of sitting in Atlanta we made it to Ft. Lauderdale at sunset... and promptly landed in about eight inches of water (which was interesting to say the least).

 

I won’t delay the real reason you came here... the notes. So, the disclaimer: These are raw snapshots from each rapid-fire presentation. I have checked spelling within the limits of the software, but the product will not be without error. There will be typos and I will fix in the blog as I find or am made aware of them. It happens. Pretty sure i missed taking notes on one lecture at the end of day one.

 

So here you go... the notes from Eagles XXV from the Hard Rock Seminole conference center.

 

Day One

 

Opening -Pepe – Eagles Moderator – Several presenters unable to arrive due to the severe storms and flooding the last few days.

 

Chief Russo – Welcomed all to Florida for the 25th Gathering of Eagles meeting.

 

The Pentagon Papers: The Five Most Important Papers of the Past Year – Slovis – Nashville – 1) Single dose Epi – Is one and done the answer? The more Epi you give, the more likely you are to get ROSC but NOT better favorable outcome. No improvement in neurological outcome. In shockable rhythms, Epi did not matter. If there is bystander CPR, single dose Epi has better neuro outcomes.  2) Switch AL Pads? A lot out there on DSD. Maybe we just need to change location of defib pads. Vector change needs to happen after two to three shocks. In recurrent VF, no statistical difference in pad placement outcomes. DSD is vastly better in refractory VF. Better than just vector change or staying with AL placement. At least do AP placement or DSD.   3) Epi, When in VF? Never give Epi prior to second VF. Published in Circulation. New article says after third shock. No antiarrhythmic until after third shock as well. 4) Adenosine with Modified Valsalva. Everyone should be using modified Valsalva at this point as it is the treatment of choice. What about adding Adenosine with the modified Valsalva? Gave during initial part of Valsalva. When done, almost doubles conversion rate. 5) Can age alone be predictive of neuro injury? Just do it. 5) One in six of patients that had neuro injury were from asymptomatic head impact. Assume badness in elderly head trauma.

 

Cinco De Trauma - Five Most Important Trauma Publications of the Year – Colwell – San Francisco – 1) Prehospital Vital Signs Matter. Prehospital Shock Index predicts 24-hour mortality in trauma patients with normal shock index upon ED arrival. Abnormal Prehospital shock index means higher 24-hour mortality. Vitals must be obtained to be able to matter. EMS still doing a bd job of getting a BP in kids. IV Fluids in Trauma. Data from the two largest European trauma registries. Variability still exists in fluid being given. Trending towards reduced use of fluid and less mortality. Perhaps leaning toward elimination of fluids in trauma and lean toward blood products only. We should tolerate low BP if not concerned about major head trauma. #) Blood in the Field. Study looked at penetrating trauma. 11% mortality increase for each minute in delay to blood administration. Wonderful alternative to fluids. 4) TXA. One study with lower dose TX had no difference (did not use 2gm). 5) Geriatric falls. Integrating fall prevention strategies with EMS visits resulted in 37% decrease in repeat calls. Done through follow up visit for prevention assessment and finding cause of fall. 6) Ketamine. Found not to be inferior to Morphine for pain control. Study supported Ketamine for pain control. He stated that he added a sixth point.

 

Advocacy: Let My People go! – Terry – ACEP – EMS and Hospital System Overload is still an issue. ER Boarding is still a problem. This is a systems problem. Why? Access to care is exactly what we do. “Wall time” is the same as “boarding time.” Hospital-wide efficiencies are a must. We must insist that the hospitals work with EMS to fix this decades old issue. There are stories of patients being admitted to the ICU from the waiting room. Case study of a female patient who stayed on the ambulance cot for 90 minutes that had an intracranial hemorrhage. She had to be transferred and ended up being a fatality. “When Minutes Count for EMS Patients Act” is being supported by ACEP. ACEP has also drafted a response to the new healthcare safety OSHA regulations. Also supporting payment for on scene treatment, care, and support. ACEP is also supporting the “Our First Responders Act.” Much of this would make what started with ET3 a reality. Drug shortages are still a problem. There is a legislative call for action o policies and advocacy for correcting the drug shortages affecting EMS.

 

What About Keeping Medical Practice as Medical Practice? What are Key Challenges EMS Specialists, Emergency Physicians, and Doctors as a Whole are Facing Today? – Kupas – NAEMSP – The things threatening EMS practice of medicine is threatening medicine as well. A lot of time being spent in EMS advocacy, but we don’t always do a good job in advocating for the EMS Physician. Things like local and state ordinances banning the use of Ketamine limits the practice of medicine and doing what is best for the patient. EMS has never stopped making house calls. EMS Medical oversite is a practice of medicine. “We support the right of the EMS Medical Director to decide what is best for their community and not be hindered by the decisions of others.” Supporting medical director payment by Medicare. A physician can bill for a house call, but a medical director cannot go to an arrest scene and bill for services (differing taxonomy).

 

What Does Equity Mean in EMS and Why Does it Matter? Weston – Milwaukee – What do we know about equity in EMS? What can we do about it? Why should we care? Do we treat all our patients the same? Data says we do not treat our patients the same. Care can be inequitable by race, gender, age, financial status, medical issues, and other areas. Equity is not a niche issue. It actually represents a majority of patients. Define equity, require demographics, modify training, leverage the data in your system, and ultimately change policies. In doing so, you will improve health.

 


New Mexico’s Unique EMS Corps – Pruett – Albuquerque – A ready workforce exists. Young Adults 18-25. Bring them in and give housing support, monthly earned stipends, mentorship, counseling/wellness, and job placement. They have graduated 67 people. One third are native American. 99% have confirmed employment with 90% working in EMS. 400 hours of EMT content for 18-20 students at a time. Concentration on hands-on training. https://emscorps.org

 

Respect Thy Elders! With Escalating, Longer-Living, Anti-Coag’ed, and Boomer Populations, What Does EMS Need to Know? – Colwell – San Francisco – We are not as good as we need to be with this population. How can we be better? We respect peds but lump geriatrics in with adults. As we get older, we hide injuries and pathology. “Older than 65,” nothing magic about that and an argument could be made for age 35. No literature clearly defines geriatric. “Young old” is 65-80. “Old old” is over 80. More severe response to injury and pathology. Geriatrics have pre-existing conditions and fewer reserves. Most common complaint is a fall. Age is a significant determinant of EMS use and is associated with longer scene times. 18% have repeat transport within 30 days in many cases. Dyspnea is highest number of medical complaints. Falls are 50% of trauma calls in the elderly. A fall in an elderly patient without transport is a sentinel event as death can statistically occur within months of a fall. 49% of those not transported need medical call within two weeks of the call. What caused the fall? Dehydration, delirium, infection? Normal vitals should NOT be a reassurance of normalcy. Vitals affected by medications (beta blockers for example). 14% increase in falls for each medication above 4. Newly started medications cause changes that can lead to falls/incidents. Coming to a hospital near you: There are now accredited geriatric emergency departments. Respect the significance of our geriatric interactions in EMS. They benefit from progressive care.

 

A Bleed Indeed is a Bleed in Need! How Accurate is a New Screening Test for Detecting
Subarachnoid Hemorrhage? – Banerjee – Polk County, Florida –  37.5% mortality rate of hemorrhagic strokes at 30 days. 97% have severe headache. 33% have no symptoms except for a headache. SAH Protocol is used in patients over age 15. CTHEAD anacronym used. How accurate is the index? 96.6% accurate in Polk County.

 

Can We Save the Triage Day? The TBI Biomarker Way? - Kupas – NAEMT/NAESMP – There is a lot of transport for CT scans post fall. Anticoagulant use is a factor as is age. Biomarkers released after brain injury, UCH-L1 and GFAP. Used to have to spin down sample to test from plasma. www.tbibreakthrough.com  only uses a single drop of blood. Results in 15 minutes. Sensitivity is 97.6%. Negative predictive value was 99.6%. 1959 patients, only 3 where test was negative, and the CT was positive. In those three there was not a significant bleed (small). Biomarkers are for specific circumstances. This one is for falls with a head strike. The assay works well in this sub-group. Can be combined with other assessment tools like the Wake County Fall Screen and the Canadian CT Rule. What are the goals of care? This tool would support a treat in place EMS model. About $1,300 per unit. Lots of discussion on this topic and the device. Could be even more of a benefit where long transport times to an appropriate facility exist. Sounds like a great treat in place tool.

 

Senior Moments and Getting Old Remarks: A Brief Discussion on Trauma Triage, Special Precautions and Special Needs – Colwell, Banerjee, Kupas, Gaither – There is a great risk of oversimplifying the geriatric issue. Some studies state that 25% of patients die within a week of a lift assist occurring. We have to do better. The factor that many geriatrics do not wish to be transported is prevalent. Should we take all geriatric injuries to a trauma center? Will this overwhelm trauma centers? Possibly? ACEP is looking into criteria for geriatric specific trauma centers.

 

For the Life of All Flesh is in the Blood Thereof (Leviticus 17:14) – LONG LIST OF PANEL PARTICIPANTS – EMS is an extension of the hospital emergency release program for blood products which is uncross matched blood. Showed map of prehospital EMS locations carrying blood. Need more blood donors. AABB is working on out of hospital blood standards. The standards are currently open for comment. Key questions for EMS blood administration being developed as well. “This could save more American lives than any other initiative in our lifetime.” 4 pillar approach to increasing blood use in the field: 1) Reimbursement for blood, 2) EMS scope of practice changes, 3) Strategic preparedness and 4) outreach to support increasing involvement. Is it time to introduce ARC (Advanced Resuscitative Care) into thecivilian population? This would be adding O negative blood, 10% Calcium Chloride 2gm, and TXA 2gm, into the trauma care prehospital phase. One study on penetrating trauma showed this dropped mortality rate. Use XABCDEF as the treatment priority list. Every minute matters. Even with short transport times, this care shows improvement in outcome. Prehospital blood administration averages a savings of 19 minutes over waiting to start transfusion at the hospital. Having to have the “magic armband” at the hospital delays blood administration at the hospital. Infusion start takes less than two minutes with EMS. Washington DC reports that they are completing transfusions before arrival at the ED. Patients are actually waking up prior to arrival at ED after transfusion. Standardization of tubing and warming cartridges can decrease costs. Some areas report a decrease in hospital transfusions due to EMS completing what is needed before arrival at the ED. One area reports creating a group of dedicated donors from public safety (includes females who are type O that have never been pregnant). Systems report expanding from just trauma to medical hemorrhage patients. Medical patients can be 25% of the administrations. There needs to be more blood available for strategic preparedness. Demonstration shown on process of using a field donor to use for a field recipient. Six-year-old pediatric recipient of an EMS blood transfusion was honored on stage. Mother of patient states that she did not understand the impact until she so the change in her daughters’ condition immediately following the blood administration.  Whole blood is the best treatment for a bleeding patient. Crystalloid fluid is “tradition,” NOT “evidence-based medicine.” Build your program as you would build it to take care of one of your own. Do not exclude kids from your EMS blood program. There is no valid reason to exclude pediatrics from an EMS blood program.

 

ID-Me: What are the Latest Infectious Disease threats Du Jour? And Why Should You Care? – Jui (Portland) and Marty (Eagles ID Consultant) – Influenza A is still prevalent. Children can be contagious 3 to 4 days prior to symptoms. Influenza A can live on stainless steel for up to 7 days. Comparison given of Influenza A, B, C and D. A and B are the most significant and dangerous. Influenza A is very zoonotic and likes to jump around. USA has been the source of three major Influenza pandemics since germ theory was recognized. 2009 flu pandemic killed 18 million people. There is an evolving menace of H5N1. In 1997, H5N1 took less than one year to transition from birds to humans. In 2020, H5N1 is on all continents except Australia. It has devastated bird populations and jumped to 16 mammalian species. Dairy herds are being affected in the United States. H5N1 is only two changes away from going from low transmission rate in humans to a high transmission rate. Antiviral treatment options: So far there have been none that have been overly efficacious in treating influenza. New ones are Favipiravir was designed for flu but is more used for other viruses. It works against the flu it is not yet approved in the US. Baloxavir has been approved for oral pill use against influenza. Cytokine storm must be stopped to prevent death from influenza. Tamiflu does help and is worthwhile if severely ill. Recombinant vaccines tend to be the most stable. Moderna has two additional flu vaccines coming out.

 

Are You Ready Teddy? What is the US Preparing for in Threat Preparedness Nowadays? – Hunt – US Department of Health and Human Services – ASPR is now its own division of the Department of Health and Human Services. Working on hospital preparedness, disaster response systems, national special pathogen system and workforce capacity and capability. Looking at regions as being more than just state based for disaster systems. The national special pathogens system is designed for black swan events.  Four levels of treatment centers. There are currently 13 regional treatment centers (RESPTC) in the US (considered to level 1 hubs). How do we transport patients for biocontainment. Currently only one agency available through the state department for transport. They are building two prototype mobile biocontainment units (PBCU – Portable Biocontainment Unit). Those working on workforce capacity and capability cross multiple partner associations and agencies. We are in a very tricky time nationally when it comes to a pandemic. The momentum to pull things together quickly is there.

 

Eagle’s Member Medical Directors On-Stage – Introductions to the audience.

 

Droning On: How is FDNY Using Robotics? – Aseda – NYC – Opening discussion on implementation of technology and also the impact of when the technology fails. Technology is great but we need to be ready for when technology fails. FDNY used tether drones for scene observation of major scenes. They now have tethered and untethered drones. Drones are also being used in water accidents to get flotation devices to someone in the water. Can drones be used to deliver blood to the scene. Robodogs were used by NYPD but were too intimidating to the public. FDNY now has robodogs for unsafe building entry (painted like a dalmatian), named “spot.” There is a remote-controlled flotation device that is coming as well.

 

The AED for the Active Bleed: What is the utility of the Automated Tourniquet? – Antevy – Coral Springs/Parkland – Dr. Antevy gives history of Davie tourniquet project and invitation to White House with Stop the Bleed history. Presentation on an inventor’s device that automates the tourniquet. Called AutoTQ. www.goldenhourmedical.com Tourniquets are frequently applied incorrectly. Stress can cause incorrect application of the tourniquet. The AutoTQ is to bleeding victims as the AED is to cardiac arrest victims. Currently an 84% failure of appropriate tourniquet application (CAT). Skill in application must be refreshed. One button inflation. Device gives verbal instruction just like an AED. Control box is reusable, strap is single use. $400 per kit (3 cuffs + Inflation unit), replacement cuffs are $40 each.

 


Depletions, Repletions ad Deletions Galore – Augustine – Eagle’s Librarian – The issue is that US manufacturers are not keeping up with obligations to produce needed medications. Some strategies are to create partnerships to get medications easier. We can sometimes substitute medications (some substitutions could be oral or inhalation). Use of expired medication requires official extensions. There is also the possibility of compounding. We should also advise the public that certain therapies are in short supply when the shortages occur. There is a new manufacturer called CivicaRX that was created due to shortages in hospitals. The drug shortage is considered a national security issue. There is currently a call for action.

 

Bringing Up Players from The Pharm Team: What is the Role and Value of an EMS Pharmacist? – Simpson (Minneapolis) and Kazan (LA County) – A pharmacist that is used alongside medical directors and protocol implementations can help identify treatment strategies, assessing new literature, logistics of drug supply and can be a resource for the paramedics. The pharmacist can be utilized in shortage mitigation as they understand usage across the entire healthcare system. They add another layer of validity to EMS treatment decisions for protocols. Can be used to review current protocols. LA County wanted automated drug systems like Pyxis. When a pharmacist looked at their existing system, she found better ways to distribute Epinephrine to EMS units. They were able to get some Epi direct from the manufacturer through their liaison pharmacist. Looked at actual utilization and adjusted supply levels to prevent expiration and reduce waste. Eliminated $300k in waste on medications. Cut expirations by 75% to 80%. Bringing in the expertise shows you what you have been doing wrong all along. Shortages are taken care of upstream from those that give the meds.

 

Long Distance STEMI Care: What is the role of Super Aspirin 23ba in Acute Coronary Syndromes – Levy – Anchorage – Zalunfiban is a new drug that is going to be used for STEMI. It is a next generation GPIIb/IIIa inhibitor that blocks platelet aggregation irrespective of pathway of activation. Given SQ and works within 15 minutes. It is out of the system in two hours. Trials are going on in Europe and US trials starting soon. There is a consent form and checklist to enter the trial. Drug may be very well suited for EMS use. Enrolling in other countries as well. It is potent with a short half-life.

 

What is the RX for AF: Considerations for Safety Treating the Quivering Atrium – Gilmore – St. Louis – Advocates for AF with RVR to be a rate of 120 plus. Should patients with AF RVR be treated in the field? Last fall, an article showed better outcomes with AF RVR patients that were treated in the field. NNT numbers were actually very low to show a positive outcome. Is Diltiazem appropriate? 27% decreased rate. 63% had clinical improvement. Nothing significant between bolus vs bolus and infusion. Slightly less hypotension if on a drip.

 

Rebuking the Puking: Efforts for Weeding Out Treatment of Cannabinoid Hyperemesis – Gilmore – St. Louis – How common is CHS? More common in states that have legalized marijuana. Acute management prevents dehydration and furthering of downstream effects of dehydration. Capsaicin tends to work. Ondansetron and Promethazine do not work well with CHS. Haloperidol and Midazolam may also hold some effect as well.

 

Five Reasons Why You Should Use Ketamine in Status Epilepticus – Scheppke – West Palm Beach and Palm Beach County Florida – Lateral tongue bite occurs in 30% of seizures (great diagnostic finding if not seizing on arrival). What do we do when Midazolam does not work? 15% of seizure patients will experience status. Benzos work through GABA receptors. GABA receptors are the “off switch.” NMDA receptors are the “on switch.” If you block the on switch it becomes the off switch. Ketamine is the Swiss army knife of medications. 100% of the Ketamine usages in the study terminated seizures in adults (82% in pediatrics). No Ketamine associated untoward effects. Benzos remain the first line therapy. Give complete doses of Ketamine.

 

Cerebrovascular Accidents are Waiting to Happen: What is the Latest Advice on Stroke Identification, Triage and Transportation Destinations – Antevy – (Davie) – Where are your stroke centers? If you are within 30 minutes of a CSC, you should bypass the PSC. 30 minutes should be the target for TPA in stroke. Many stroke centers do not report openly outcomes. RACE scale training, looking at data, and bypassing PSCs to go to CSCs improved outcomes. There is now a stroke registry and legislative to mandate reporting and show dashboards. What are each hospitals’ outcomes? Time to TPA? State level attestation had to go for established accreditation.

 

A Hat Trick That Clicks: What are the Latest Results on the Helmet Technology to Diagnose LVO? – Dunne – Detroit – We need an ECG equivalent for strokes. We are seeing more strokes than ever with the aging population base. Thrombolytics are only 10% - 20% effective in large vessel occlusion. Cranial Accelerometry measures blood flow by looking at associated vibrations in the skull. There is more vibration when there is an occlusion. 21-month study in 11 cities. Head trauma excluded. 594 subjects. 313 consented. 25 had degraded readings on initial device. Compared to LAMS score at 40% predictive value, the device was over 85%. It only missed four patients out of 158. Device is far better than a scoring system alone. Device data has been submitted for approval to the FDA.

 

The Nobility of Mobility: What Are the Economics, Benefits and Findings from Mobile Stroke Units? – Lowe (Columbus), Persse (Houston), and Bronsky (Colorado Springs) – Good breakdown of usage of stroke units including unit downtime. Houston reports cost of over $2.4 million annually. Part can be recovered in hospital systems by downstream income from stroke patients. Annually generated about $800k in revenue for the hospital (does not include income from consults, etc. Net is about $1.6 million. If the hospital is operating the unit they really want the patient to come back to them and this becomes an issue of fairness. Some data dis show a decrease in time to thrombolytic treatment with a large number receiving TPA within one hour. EMS medical direction has to be an integral part of development of a stroke unit. Houston is putting together a consortium so that everyone is at the table. Houston reports 45% treated in the first hour of symptoms. Houston is a fire department project using union firefighters partnered with hospital RNs and CT techs. An NYC attendee indicated that in NYC, Stroke is a BLS call type. Columbus uses a neurologist via telemedicine. Each of these systems only have one stroke unit. One set of data indicated that it received requests while already on another stroke call. The Colorado unit was splitting time between Colorado Springs and Aurora initially (there is now a unit in each city). Houston is adding a second unit and potentially a third.

 

No Entiendo Stroke?  Well Then Try This Very Useful CVA Assessment Tool, Por Favor! – Banjeree – Polk County Florida – 12.5% of the US population has Spanish as a primary language. This cultural group has a higher incidence of stroke. AHORA is the Spanish anacronym. Andar, Hablar, Ojos, Rostro and Ambos brazos o piernas. This mirrors the content of stroke assessment tools for the public that are written in English.

 

Not Lost in Translation: Can an On-scene Video App Get You the Right Interpreter ASAP? – Simpson – Minneapolis – Utilizing a video application with field crews with interpreters. Used for multiple languages and dialects. Did training on use within a simulation lab. Last month this was used 2608 minutes in their system. Do we need this? “Probably.” Is it feasible? Yes. The app does not record, it is real time only. Cost is a per minute fee along with a subscription fee to the program.

 

How Good Are Paramedics at Shadowboxing? Our first 3000 Ultrasounds In the field – Simpson – Minneapolis – Storage of images is important (Can use cloud or local). Feedback is important. Use champions of the program to create more educational materials. The program is now mature, and they have ultrasound on all units and every paramedic is trained in ultrasound. You need champions, storage, and feedback to have a thriving ultrasound program.

 

Why Did We Have to De-Train the Trainees? Lessons Learned from 100 Prehospital Videoed Intubations – Lowe – Columbus – Intubation success rate was improved so they wanted to do a deeper dive into what they had learned. What had to be trained out Don’t sweep the tongue, review anatomy, and what is an OK view as compared to a good view? Needed to re-emphasize the importance of suction.

 

Land of Enchanting Education: Novel Approaches to Statewide Education in New Mexico –Pruett – Albuquerque – Extend the dinner table conversations. Tell the stories of the difficult cases and rescues. What did you see? What did you think? What approach did you take to treatment? They have now produced 42 videos of these type discussions for statewide use. They are also trying to get physician residents more interactive with EMS training. Follow up is education, but getting follow can be difficult. They are having residents complete a form to send feedback to EMS crews. Producing BLS educational distance learning programs for rural and tribal EMS (twice a month - Project Echo). Users can interact with each other on the platform. This usage resulted in three caregivers present at a mass shooting integrating with each other seamlessly.

 

Scaling Up De-escalation Preparedness: Improving Force Protection Through Specialized Training – Holman and Dunne (Detroit) – Dunne: How do we teach what we learn so the future caregivers feel safe and more protected. We want to prevent escalation. One study showed reduction in aggression from 37% to 3% by instituting preventative training. They use Verbal Judo and other programs. They also do hot wash and performance improvement following incidents. Get peer support involved with training and incidents. Protective gear was assessed. Reeducated on medical restraint. Better integration with social workers and LEO. Looking at staging issues and improving dispatch issues and alerts. Continued focus on situational awareness. Holman: Used simulation labs while in Washington to teach conflict resolution. Showed video of a simulation of conflict between crew members.

 

Agitation Mitigation Nation: What Do We Do When Things Get Outta Hand? Numerous presenters – Pruett, Lowe, Colwell, Gaither, Nacht, Calhoun – Extreme agitation (regardless of term used) will usually require chemical intervention. It is a medical emergency, and you must treat it. Typically, there is profound metabolic acidosis in play and if we do not intervene it may end in cardiac arrest. Options are Benzodiazepines, Droperidol, Haloperidol, Ketamine, and others. Benzos work well when cocaine or methamphetamines are involved (be careful when there is alcohol involvement. Droperidol is good for everything else. Droperidol can be used for nausea as well. No adverse cardiac events noted with Droperidol. Haldol is also an option. Ketamine is good for the extreme agitation case as a first line agent. It is safe in medical hands. Ketamine increases MAP in head injury. Joint statement is out that supports Ketamine use in trauma. Dexmedetomidine mentioned as another potential medication to look at. Physical restraint of patients: How should you select a restraint device? Restraint for agitated patients must be made safer. Everyone must work together on this topic. One agency using the “Wrap Device.” Simulate each device that you consider. Devices must have policies for use. When does EMS care start and when does LEO care end? Define EMS
responsibilities. There must be a QI process to assure compliance with policy and usage. Agitated patients have poor morbidity and mortality. Some tips: 1) Never meet a colleague for the first time in a disaster. 2) Why it was done matters a lot. 3) One size does not fit all when dealing with people. Customize it to your system. 4) There must be a culture of empowerment (everyone must be able to point out issues). Post sedation monitoring and resuscitation: Maintain airway, give oxygen, monitor ETCO2 and SPO2, full vitals and repeated assessment. Is there a good score? One agency (Columbus) uses the Sedation Assessment Tool (they stratify sedation dosing based upon level of the score. New Mexico uses the Behavioral Severity Index. Standardize language and dosing. Improve documentation. Create and publish QI reports. “The best EMS spit mask is a non-rebreather with oxygen.” Geodon and Droperidol are extremely safe (but like any agent, you must watch the airway). Need for EMS body cameras noted by one physician. Discussion regarding Aurora’s consent decree. https://www.auroragov.org/residents/public_safety/commitment_to_progress/consent_decree_progress

 

Day Two

 

Some Highlights from the Past Year’s Eagle’s Surveys and Weekly Zoom Rooms – Augustine – Eagles Librarian – There is a feeling that change is occurring faster than usual. This is followed by three years where there was little change. Another issue is that the patterns of substance use differ widely across our country. Within the Eagles there were 40 major discussion threads that were not COVID in the past year. 120 Eagles members who are medical directors covering about 24 million EMS responses (there are about 36 million transports each year with about 37% being admitted after ED). People was one of the biggest topics. Discussions on recruiting and retention. Discussions held on academies and college degrees. EMS is fertile ground for developing people and that is a very productive use of EMS. We have a responsibility to prepare people for a career. On going supply chain issues. Something different every week. Transport ventilators are now present in 40% of agencies. Need better restraint systems for behavioral patients. Secretions getting into ETCO2 probes when using SGA’s. Tourniquets need to be stored with AEDs for public access. Cyanide antidote now available 70% of the time to fire scenes.  More use of selective BLS on low acuity calls is happening. Sedation usage reviewed with Midazolam being the primary and Ketamine the second most used. Elevator incidents are becoming more common. There have been more uses of dedicated and public busses for MCI transport. More services now have internal crisis management resources. Community paramedicine for low acuity and lift assist calls. Treat in place and alternative destinations are becoming more common. Sporting events are asking for more dedicated services. 75% of services have cricothyrotomy now. Sharing practices is a great practice.

 

Approach to the CBRN Event: A Framework for Patient Care and Movement – Margolis – US Secret Service – Most of EMS is focused on the singular person. Why are we talking about CBRN? If you were the bad guy, what would you do to maximize a attack?  The New England Journal of Medicine has reported on potential chemical agents that might be seen in an attack. Nerve agents, Asphyxiants and Opioids are the top three potential agents that could be used. Does a framework for response exist? MARCHE2. Mask up. Antidotes. Rapid Spot Decon. Countermeasures. Hypothermia prevention. Extrication. The framework will be used in the zones of care (hot, warm, cold). Antidotes: Duodote, Atropine, Naloxone, Amyl Nitrate, Diazepam, Hydroxocobalamin, Calcium Gluconate, Bronchodilators. Life threatening hemorrhage may be present and must be managed. Chemicals must be neutralized. Tourniquets applied in the hot zone may be a source of ongoing contamination. PEEP may be needed in patients with respiratory complaints. The patient will be naked and wet after decon and hypothermia must be prevented. Additional monitoring and transport will occur from the cold zone. Decon is a medical countermeasure. MARCHE2 is dynamic.

 

Premature Launches: What are the Considerations for EMS Crews Faced with a Precipitous Delivery? – Colwell – San Francisco – For the most part these go just fine. Standard process used by EMS works in most cases. Breech, Shoulder Dystocia, and Prolapsed cord are the three to worry about. Breech: Don’t pull. Hands off until umbilicus seen. Then you can move and turn to remove. Shoulder Dystocia: 3% of vaginal delivery. Turtle sign (baby retracts back during contraction. Mom back flat and hyperflex the thighs. Flex elbow and move over infant face and two other maneuvers. Prolapsed cord: Cord compression creates hypoxia. Raise the head off the cord and you are there until arrival. Must hold head off the umbilicus. Think and train before this happens and do not forget post-delivery care.

 

It Ain’t over till it’s over: Consider post-partem lethal states (REWORD) – Miramontes (San Antonio) and Weston (Milwaukee) – Miramontes: Preeclampsia can sneak up on you. Deaths are common. There are numerous risk factors. 1.4% of deliveries have eclampsia. Prevent seizures by using Magnesium. If BP is over 160 Systolic do seizure prevention. Treat the blood pressure (“Treat the damn blood pressure!”). Weston: Preeclampsia can occur up to six weeks after delivery. Out of 1575 pregnancies, 504 are hypertensive, 75 will be severe, but only 1 will have hypertension as the primary complaint. Miramontes: A BP of 140 systolic is not normal in pregnancy.  BP must be managed if at 160 or higher “Be aggressive. Be. Be Aggressive!” Transport with Magnesium prophylaxis.

 


How My Crew Does “bu”! Opioid issues – Weston, Youngquist, Miramontes, Jui, Mechem, Scheppke – Cartel drug production is up. Overdoses are up. Relapse rates are high. “You can’t help someone if they are dead.” Treatment lowers HIV and Hepatitis rates as well as decreases crime. 20% mortality with detox. Buprenorphine is effective in preventing withdrawal symptoms. Two to three days of BU treatment makes the patient a much different person. San Antonio has a field BU program. BU can last greater than 24 hours. The first 24-48 hours after an overdose is when they are most likely to die. If BU is given you may be preventing another OD for at least 24 hours. Don’t be deterred, take the first step. BU is not going to get them high, and they will not OD on it. Giving BU has a great impact potential. Oregon provider has an aftercare team. Just starting. Have 18 patients enrolled. Transporting to a clinic and not the ED. Currently reducing withdrawal patient symptoms. Philadelphia has had an opioid response team for 5 years. Warm handoffs to rehab. Able to place 1313 people into treatment programs. Chance or overdose reduced by 85% after contact with the opioid unit. Good political support in Philadelphia. Florida has the CORE network in place. There is a centralized, tax funded addiction stabilization center. Overdose rates virtually eliminated after treatment. With proper treatment, people stop using.

 

Panel On Ambulance Parking, Ambulance Ramping, Extended Wall Time, APOD or Whatever You Call It!  Kazan, Obert, Stone, Goodloe, Asaeda, Scheppke and others – “EMS is just dumping patients on the hospitals,” was heard in one venue. This is not a new problem. ED overcrowding first discussed in 1974, diversions discussed in 1994. Hospitals have had decades to figure it out. Ambulances should be out on the street not stuck at hospitals. ED and EMS utilization are both up dramatically. About a 5% increase annually in EMS volume. California has mandated RN to patient ratios that have created a nursing shortage. Beds must close if staffing is lean. “Inmates are running the asylum.” Facilities will stay open to patients while multiple ambulances are on the wall. Who is responsible for the patient? CMS has weighed in. EMTALA obligation at the hospital begins on arrival. Hospital responsibility begins before the wheels of the ambulance stop. Hospitals do not like this. Holding ambulances become a free tool ED’s use during surge. EMS did not speak up soon enough on the issue. Pandemic caused this to be a tipping point. Hospital problems cannot be used to crush the EMS systems. Medical literature shows that diversion does not work. The hospitals need to hire LPNs or some level to sit with patients. This is patient advocacy. In Canada, at a provider in Vancouver, they have created waiting room criteria so that patients can be moved there, and the unit can go available. There are exclusion criteria. EMS also bills hospitals for offload delays. A supervisor escalation is used if unit cannot drop patient and return to service. Crew can activate an immediate need protocol when there are no units available, and the hospital must release the unit. There have been no patient safety events reported. Communicate early and communicate often. Maryland is unique in that they had the longest offloading delays. The wall time issue is multifactorial. Wall time is an extreme patient dissatisfier.  Set boundaries with the ED. Share data on the issue (both ways). Direct to triage when you can. Escalate if wait time is longer than expected. Some use of alternative destinations. “We will not normalize EMS wall times. EMS personnel will not act as surrogates for ED staff.”  $31,519.85 in waste with wall time in that system. The NYC approach: They do 4500 EMS calls a day. 1.6 million calls a year. 1 million patients transported annually. 60 receiving ED’s. They want low turnaround times, but they are averaging 40 to 45 minutes. Ambulances are redirected if ambulances are already stuck at a receiving facility for more than 20 minutes. Treat in place and alternative destinations have been explored. Light duty EMTs and medics are y=used for ambulance handoff so crew can leave in some cases. The on-site EMT/paramedic then hands off to hospital. Successful when things are running well. Scheppke: Wall time is not an EMS issue. It is not our problem. It is the hospitals problem. Show the data and place the shame. Pepe: Once we are there it is their patient, period.

 

Nursing the 9-1-1 Call: Success of a Triage Line to Re-direct Low Risk Patients – Holman – Washington DC – Six years. 74,300 calls triaged. 35,000 patients diverted. 62% of those diverted stay out of ED for at least 7 days. Lyft is utilized if transport is needed. Components: Self-care, clinics, telehealth, and urgent care. NTL is supported by medical literature. Field referral empowers crews to be clinicians. DC believes that 26% of their calls should be sent to NTL. DC dispatch not sending all that they should to NTL. Trying to fix the issue. Trying to get CMS funding support for NTL in the future.

 

Show Me the Money: Funding MIH and Outcome Tracking – Miramontes (San Antonio and Holman (Washington DC) – Miramontes: Multiple MIH service lines in play. Some hospice entities actually pay for MIH. Hospice does not want ambulance transport in most cases. Manage the patient on scene. Number one issue faced is that families do not know how to use a 1ml syringe. They can remedy that.  The goal is to work with the family, treat pain and symptoms and NOT transport. Molina sends MIH patients that are costing them large sums due to non-compliance. MIH works to get them what they need, and MIH is paid to keep them out of the ER. This stabilizes the patient. Using homeless shelter care stations (decreasing responses).  Holman: DC received a state plan amendment for Medicaid and was able to bill using actual costs. They will receive supplemental Medicaid payments. This will be used to develop new initiatives to create better patient care. Rules for this differ by state. Agency must qualify before entering this Medicaid program. Document best practices so that you have the information to support doing more.

 

No Small Matter: MIH for Kids! – Pruett – Albuquerque – Train MIH providers on peds respiratory distress. There should be a clinical rotation in peds ER. Review OTC med dosing for fever. Train how and when to suction. Assure food security, home safety, car seats and safe sleep. With program, 23 patients sent home on O2 since 8/23 with only one return to ED.

 

Can REBOA Catheters Be Readily Used for Cardiac Arrest? – Youngquist – Salt Lake City – Case study of REBOA at 70 minutes of arrest. There have been 10 performed so far with 6 ROSC and 1 discharged neuro intact. Main skill is cannulation of the femoral artery. Looking at REBOA combined with the neuroprotective bundle (HUCPR). More to come.

 

Who CARES? Why should We Use a National CA Registry to Enhance Survival? – Weston (Washington DC) – Are you using the data internally? Are you making it public? Do you know where your arrests are occurring? Who is it witnessed by? How many received bystander CPR? Knowing these things can target care. If you have the data share it and use it.

 

A Heads-Up and C.A.R.E.S. – Bachista - Augustine – Heads up CPR showing better outcome data in non-shockable rhythms. 3% improvement in outcome with PEA and Asystole. 42.5% improvement in neuro good outcome in all arrests (looked to be about a 5% improvement in neuro intact discharge). More to come.

 

Not Dead – Just Mostly Dead: Resurrecting Those with Asystole and Unwitnessed Arrest – Schorz – Witness Protection Program – Is there something else we can do? Medical literature supporting use of neuroprotective bundle for cardiac arrest to improve neuro intact outcomes. So, what about Asystole? There are physiological limitations of conventional supine CPR. We know that ACD + and ITD improve neuro intact survival by up to 50%. What about raising the head? You just cannot raise it all at once. Must be primed supine and then raise head slowly. Cerebral perfusion is near normal using this method. Again, what about Asystole in unwitnessed arrest? Individual system low improvement still means thousands of lives saved nationally. HUCPR does improve survival in this group over standard CPR.

 

Drain Those Brains and See the Gains: Updates from Tennessee and Oklahoma – Holley (Memphis)– Looked at 87 patients and isolated CPC1 survival with HUCPR. Greatest improvement was in the groups that rarely show survival.

 

Some Shocking and Non-Shocking Outcomes – Bachista (St. John’s County) and Antevy (Palm Beach County) – Neuroprotective Bundle is BLS. Case study presented with HUCPR. Young patient. 21 years old. Single shock and the HUCPR with ROSC. CPC1 discharge. Next is a 70-year-old, short of breath, dizzy. Wife cannot get him out of chair. Took four minutes to get him to floor. Unable to do bystander or DACPR. Got neuroprotective bundle on arrival. Refractory VF. 12 defibs with 8 being DSD. Epi, Amiodarone and Mag. 38 minutes on scene. Transported with HUCPR. No ROSC with EMS. In arrest for 72 minutes before ROSC. Went to Cath lab. Extubated 3 days later. Discharged neuro intact. Neuroprotective CPR protected brain function. Three weeks later, patient met the EMS crew. “Why do we do what we do? THIS is why we do want we do.” It is all about perfusion. Antevy: Next, EMS, fire crew and patient (and family) involved in a tennis court arrest came on stage. Covered timeline of event. Esmolol used in this arrest. Time to first defib was 2 minutes 22 seconds. ICU nurse follows up with patient (voluntarily) at home. Patient went home CPC1. Patient speaks to the audience clearly and with many accolades for everyone involved. He plans to get back to playing tennis. He wants to be the oldest person to win the U. S. Open. Crew received awards on stage. They also thanked Dr. Pepe and Dr. Scheppke for their “mad scientist dreams” making this possible. Another note: Dr. Antevy’s father-in-law was playing tennis on the court next to this event and he got his number to the family, and Dr. Antevy followed this case as well and helped get resources for the post-arrest care. Dr. Antevy states, “How can we make care equitable so that everyone can get the right resources and care?”

 

Gilding the Chain of Survival: Progress on Creating Resuscitation Centers in Florida – Kuhlman – Orlando – Healthcare is relationships and full-time trust. All emergency departments are not created equal. Resuscitation centers must be able to do emergent caths and have interventional neuro. The CMO of the hospital is the one to meet with in creating a resuscitation center and who you would share the criteria with. Multiple departments of the facility must be involved. Comment by Scheppke: Mimic what processes trauma centers do to build a resuscitation center.

 

Sudden Death Clean-up on Aisle 5: Is Systemwide Deployment of AEDs In a Large Supermarket Chain Worthwhile? – Scheppke (Florida Department of Health) and Pepe (Eagles) – Public access AEDs exist but they are hard to find. Large southern US supermarket chain trained employees and placed the AED in the same place in every store. Deployment is commonplace in public, but actual use is infrequent. Goal was to track usage across one supermarket chain. Barriers to an AED program can be fear of liability and upkeep cost including training. The supermarket in question made the decision to do the right thing. The very first use was a Publix employee. 1,335 locations (847 in Florida), all with training and AED. Data comes from Florida locations. Data from Publix internal reports is being matched with state EMS data reports. Six years of data. 342 times the AED was retrieved. 80% inside, 20% outside. 109 cases of shocks delivered. Median age was 60. Median female age was 55. 68% of shocks were men. Of those, the percentage of those they could get outcome data on that had discharge from hospital was 85%. 33 of the total AED cases proved to be of substance use origin. Publix has 1 to 2 shockable cases each month. Increases chance of survival for non-elderly customers (low median age). Casinos may indeed have similar numbers (from a comment).

 

Dengue Fever – Marty - A zoonotic disease. Multiple species can carry. Incidence has doubled each decade since 1990. Now doubling yearly. It is in the Americas. This year 7.6 million cases already. 1706 cases in US and protectorates/territories. There are four serotypes (DENV 1 through 4). The warmer the climate gets, advances mosquito population time frame and at the same time the amount of virus in each mosquito grows. Can be transmitted from mother to baby, possibly even through breast feeding. Look at mental status, hemodynamic status, hydration status and signs/symptoms of plasma leakage or bleeding. There are rashes and possibly flushing of face. Rash may blanch when touched. After bite, it can take 3 to 14 days to show symptoms. Fever is 2 to 5 days. Severe phase is after fever phase. Nausea, joint and bone pain, leukopenia. Severe abdominal pain in the critical phase along with persistent vomiting. May have liver enlargement and clinical fluid accumulation. Can have flank pain and respiratory distress. About 30% have mild bleeding in gums and urine. Severe cases can have massive GI bleeding. Diagnosing Dengue can be difficult. Rapid diagnostic test for NS1 antigen. Blood glucose and ECG should be assessed. At hospital look at WBC and Hematocrit. IV saline is appropriate. Fresh whole blood may be helpful (must watch for transfusion reactions).

 

Advancing to the Basics: Can BLS Providers Use SGAs and Epi? – Youngquist – Salt Lake City – BVM alone can be ineffective. Ineffective but due to technique air is not going where it is needed. Other than emesis in tube, Igel had less complications than BVM alone. Early Epi shows benefit. Could IM Epi be useful in arrest by EMTs prior to medic IV access and administration? Work in progress but IM Epi seems to affect data positively through discharge neuro intact.

 

It’s Less About the Lane, More About How We train: What are the Pros and Cons of Various SGAs? – Holley – Memphis – Is the tool we are using the best one? Data presented in comparison. Compared against ET tube. The King still struggles and has the weakest presentation in the data presented. SGAs have improved. Ballon devices seem to be weakest in general.

 

Seeing is Achieving: A Visionary EMS Systems Experience with VDL – Jui – Portland – Initial premise is that there is no improvement in success with video laryngoscopy. However, in ICU and infants in hospital there was greater success with video laryngoscopy. How does this translate to field patients in Oregon. System has a mandatory difficult airway course for paramedics. Twice a year mandatory training also. Two pass rule in place for ET intubation then use Igel. Overall success was 85% to 90% with direct laryngoscopy. Video laryngoscopy went to overall of 93%. EMS personnel must be able to use both DL and VL. Training is key. VL is a major paradigm change.

 

IO Where Do We Go: What Are Outcomes in Comparing Humeral vs. Tibial Sites in Cardiac Arrest – Jui – Portland – Humoral is superior to tibial in cardiac arrest. Does the route make a difference for Epi? Early Epi is important. In swine, Epi plasma levels are highest/quickest with IV over all IO routes and ET. May not be statistically significant. Humeral IO does tend to beat the tibial IO. Upper extremity IO was superior in ROSC and discharge over lower extremity IO.

 

Why the Thigh: What is the rationale for Using Femoral IV Route (Especially in Kids!) – Antevy – Florida NAEMSP – Should we use the distal femur in adults? Should we abandon IO Amiodarone and Lidocaine? Should we abandon tibial IO? Femur location is much more stable. Malpositioning is VERY common in the tibia. Pediatric Landmark is 1 to 2 CM above the patella. Get rid of pink needles in Peds. A large green 65mm needles is coming later this year also. Success is far better in using the femoral site. What about Ami and Lido (for arrest) in IO? These meds are worthless if given via IO. Much better if given IV. If you use Amiodarone IO, the rate of death is double. Get rid of tibial IO. Can we use femoral IO? Yes. Abandon Amiodarone IO? Yes. Miramontes: You must immobilize the leg if you use Femoral IO.

 

Putting Pressure on the Little Ones: Can CPAP Be Applied Properly to Children? – Lowe – Columbus – The awakening moment was a ped with asthma where the father was a medic. He recommended CPAP at the hospital, and it worked well. This posed the question of why do we not do this? In peds this uses a mask covering the entire face in hospitals. CPAP not for croup. Lower BP limit is 90 systolic (less than 70 in those under 10). Have had six cases. Five were respiratory and one drowning. They were already carrying peds masks for small adults. Has had great patient response.

 

A Festive Day Gone Far Astray: What Did I Take Away from the October 7th Massacre Day? – Mechem – Philadelphia – Hamas launched an attack. 1,143 killed. Largest terrorist attack in Israel history. 3000 Gazans breached the security fence while many wore body cams.  Targeted towns and Israel Defense Force sites. “Kill as many people and take as many hostages as possible” was the Hamas goal found on dead fighters. 364 attendees were killed at the Supernova Music festival with 40 taken hostage. Those not killed on site were killed in their cars while trying to escape on Route 232. National EMS System is Magen David Adom. There is also a volunteer agency. Staging areas were used as there were not enough transport resources. Emergency supply of blood was released. 1612 dispatches that day. 22 locations. The attack went on for days. EMS were in body armor and being targeted. Fighting escalated as police and IDF arrived. Most care was BLS and load and go as extraction was highly dangerous. AK47s, RPG and knives used. Central command centers helped coordinate resources and supplies. One medical center received 626 casualties. Multiple, dispersed attacks. Civilians attacked with military tactics and weapons. Antevy comments: His family is from Israel. He had family members injured and killed in this attack. One was kidnapped and killed. This needs to be exposed. These things must stop. The attacks were against innocent people. Pepe: There is a text available on Mass Casualty Medicine.

 

Active Shooter: It’s Not Over Till It’s Over – Pepe – Eagles – Dallas police Ambush July 7, 2016. Perpetrator was a 25-year-old. Look for the sniper. The sniper may shoot after deploying something to make people panic and run. FFL Airport Shooting January 6, 2017. Targeted people in the baggage claim area. Marjory Stoneman Douglas Shooting on Valentine’s Day. Antevy was on the outside looking in. Half a century of ACLS “Alternative Clinical Life Style.” There is a review of mass gathering event attacks in the Mass Casualty Medicine text. Text on Mass gathering medicine? In a traditional, MCI what percentage of patients are critically injured? 5% to 10%. What is manifested emotionally by survivors and caregivers? Guilt. Use alternative triage management in a major event. Advanced Disaster Life Support can be useful. It is tough to make predictions. ICS function failed at Parkland. Protracted suicides are hard on EMS personnel with long periods of time and speculation causing fatigue. Second pass phenomenon and secondary devices are predictable. One site is a distractor for another. The IRA used the tactic of one bomb to draw everyone to the scene and then set off the bigger bomb or ambush. Las Vegas October 1, 2017, showed us ricochet can cause many severe casualties. Be prepared as any of this can happen anywhere at any time. This impacts our families as much as it impacts us. Colwell: There are immediate effects, some are weeks later, and others are years in how everyone is affected by these events. We do not like to keep talking about it, but it is a must to keep in mind. Antevy: On site internal peer resources are a must. Health and safety must have a focus on what affects us.

 

The Done-Got Poisoned Blues: What Do We Need To remember About Cyanide? – Calhoun – Cincinnati – Why is this an issue? What are we looking for? What should we do? When many things in normal life burn, they produce cyanide. Heating some substances and post-fire items can still off gas cyanide. 30% to 90% of fire related deaths have cyanide at toxic levels (depending on data source). Cyanide gas is also absorbed through the skin. You cannot fix fire related cardiac arrest without correcting cyanide poisoning. If the neuro system or cardiovascular system is compromised, cyanide poisoning should be considered to be a cause. If antidote cannot be brought to scene, transport should not be delayed. If using cyanokit understand that it is complicated, so have a reference card. Case study by Asaeda from FDNY: Fire response. Interior attack crew calls a mayday and firefighter pulls his mask off. They leave internal attack. Medics activate protocol as the firefighter is in respiratory arrest and gave antidote. Both firefighters were dived in hyperbaric chambers. Both get better. FDNY has given over 500 administrations.

 

Hazardous Judgements: What Kind of Decision Making Should We Anticipate in Haz-mat Response? – Augustine – Lee County Florida – Over time we have cycled through various threats including nuclear. It is very rare that there is an isolated exposure without injury or burns. Decon is based upon the agent in play. Bad stuff in patient eyes requires irrigation as the ultimate priority. Gasoline can be decontaminated after treatment of life-threatening injuries (must get off skin and get clothing off). Isolate the airway and cover wounds and decontaminate. Nuclear is only an issue if they have the material on them. Biological agents require varied response and decontamination. There should be designated EDs used and contaminate as few EDs as possible. Patients expect care as fast as possible. Talk then through the process. Work with industry to assure processes are closed in a timely manner.

 

Rehabbing Rehab: 2024 Ways to Manage Fire Ground Rescue – Dunne – Detroit – Modern fires burn faster than traditional materials. Most common cause of death is inhalation of noxious gases and not thermal injury. Airway burns: expect difficulty and use all your tools, time is not your friend. Carbon Monoxide: just assume it is a factor, use CO monitoring. There may be a combination of CO and CN. Cyanide: antidote should be utilized. There must be comprehensive rehab. Rehab requires protocols. Manage airway with a cuffed ET tube if there is inhalation injury.

 

Eagles Take the Stage – Eagles Electrical Storm – All medical directors on stage – Short discussion on how they learn from each other by sharing. 1) Cyanide antidotes are best given in the field as there are more barriers at the hospital. 2) One person in audience mentions they would like to do better dosing on Droperidol and implement Lucas. 3) Discussion on carrying both direct and video laryngoscopy. Consensus is not to take one tool away for another. Carry both. McGrath can do both video and DL. DL has a definitive role in vomiting patients. Miramontes states VL works great for those wearing reading glasses. Why has it taken so long for VL to be adopted? The stakeholder group weighs things before adopting. Adaptive behaviors come into play. 4) What to use for AF? Most support Diltiazem.  If Esmolol is used the patient may have to go to CCU/ICU. LA County says that Diltiazem seldom drops BP. One medical director stated that if they are unstable just shock them, if not unstable just transport rather than do the math. If cardioverted, someone along the line needs to give Lovenox to prevent a clot in the next 48 hours. 5) A New Jersey hospital is asking providers to bypass other hospitals with cardiac arrest patients so that they can do ECMO. Pepe says the number of cardiac arrest patients needing ECMO is probably less than 5%. Miramontes: ECMO takes a lot of hoops to jump through to get started upon arrival at ED. Many things are looked at closely before going on ECMO. When it fits, the results are “miraculous.” He does not support bypassing facilities just because one facility wants to do ECMO. Valenzuela: Make the hospitals get together and decide what they all can agree to on this issue. Cohen: You must have mechanical CPR if transporting to receive ECMO (it is a safety issue for crews transporting). Antevy: Predicts that there will be one shock then move to DSD, then there will probably be one area ECMO center for transport. Scheppke: We need resuscitation centers of excellence. Not everyone will need ECMO, but the receiving hospital for cardiac arrest needs to be the best possible. Gaither: It is easy to put someone on ECMO. It is hard to take them off and have the conversation with families. ICU docs need to be part of those decisions. Antevy: Used stroke ambulances as an example. He disagrees with stroke ambulances because they exist only because hospitals cannot get their act together. Hospitals need to be able to deliver needed care. States that locally there are now five cases where the medics have run the code in the ED as they are in their element, and it is collaborative. Gaither: CPR is of poor quality in many hospitals, even teaching hospitals. 6) Question from attendee from Alaska: States she is encouraged being here at the changes that can be taken home. She points to Doctor Pruett’s lecture as speaking to her on child advocacy. Another attendee states he loves the collaboration at this meeting. He points out that the Eagles group cares. There is a lot of mutual respect inside this group. Miramontes: Get the people in the people in the room and fix the problem instead of pointing fingers (he suggests coffee and tacos). Get everyone talking.

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Well, that is it from Eagles XXV. Hope these notes help you spur progress and create ideas at your EMS provider. Thank you for reading.


An additional flooding photo from Ft. Lauderdale Airport

"Welcome back my friends to the show that never ends. " - Paul Pepe

I can never pass one of these up for a conference breakfast.