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.
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.
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.
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.
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.
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.
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.
***
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.
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| An additional flooding photo from Ft. Lauderdale Airport |
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"Welcome back my friends to the show that never ends. " - Paul Pepe
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