NAEMSP 2016 - My Notes

This will be another "Lee's Notes" blog entry. I normally just do this for the EMS State of the Sciences Conference. This year I moved up in the world and took an Android tablet with me so that I could take notes, post to social media and still not have to lug a notebook computer around with me. Even though this meeting moves at a much slower pace than the State of the Sciences Conference does, and the sessions are much longer, this meeting is the hardcore science of EMS. You will see NNT (Number Needed to Treat) and research process in many of the presentations.

I had not been to San Diego since 2006 and was kind of looking forward to the trip. It was made even more enjoyable because we flew from twenty degree weather to a sixty degree tropical arrival. I even got to take my loving wife along on this trip.

These are the notes from the sessions I attended as in the afternoons there were multiple sessions from which to choose. My notes are... well... my notes. They are what I took away from the speakers presentation. I must apologize in advance if I get anything slightly incorrect, but there was a lot to write down.

 

So here we go...

 

• NAEMSP President's Address and Welcome (Brice): Apparently the DEA implemented regulations this past year negating the ability for EMS to give narcotics on standing orders. The NAEMSP has introduced federal legislation to reverse this. I think we all need more info on this and need to get behind NAEMSP in this effort so our patients can continue to get adequate and safe pain management.

 

• Identifying Human Trafficking in America (Bender): Human Trafficking looks much different in the US than it does in third world countries. Most falls into four categories: Family, Survival, Gang or Pimp. Most are women are taken from their family by an older boyfriend after being targeted and moved into prostitution. Trafficking occurs frequently in rural communities. Familial trafficking comes in the form of trading services of the child for food or rent. Trafficking for services is very frequent in the homeless environment also (survival). Gang and Pimp control trafficking is more urban. Gang control trafficking is becoming very prevalent. Predators take advantage of human trafficking. The process of taking a target into human trafficking is a slow process. If it was obvious, people would not be easily taken into it. Targets are groomed. EMS and emergency departments will see many victims of Human Trafficking without knowing it. Traffickers are attractive, take interest in targets children, give attention and get very close. They are good at getting inside the targets defenses. Traffickers use fraud and coercion. It progresses to violence if the target becomes non-compliant to the handlers wishes. Those being trafficked are kept scared to be controlled. Those being trafficked are trapped and turn to drugs and alcohol as coping mechanisms. Those being trafficked are frequently sold between traffickers. Sometimes those trafficked are kept in "stables," which are sometimes homes in gated communities or well hidden. It is very hard to plan an escape from a trafficker. The handler makes them feel like they are being watched at all times, appearing out of nowhere. They use children of those being handled as bargaining chips. "Make the lie big, make it simple, keep saying it, and eventually they will believe it." - Adolf Hitler. Age 25 is the full development of cognitive reasoning. It is easier to conform to control under age 25. Those being trafficked start to see their situation as normal. It happens in every big and small town in America. Search: "Boise sex trafficking" on YouTube for a video example of the problem. Those being trafficked are arrested, injured and touch the system a lot without being given a route out of trafficking. EMS and EDs have the ability to intervene. Even when liberated from trafficking, victims often get federal level charges for what they have been forced to do, including huge fines from the IRS for failure to report income. Traffickers brand their victims with tattoos that can be noticed, sometimes inside the mouth. Indicators: Patient may not be seen alone and have someone staying very close, looks down when talking, consistent miscarriages, no payer source, has older boyfriend, signs of domestic violence with hyper-sexuality, patient can be defiant. They can be as scared of the repercussions as much as they are of their handlers. Faith based organizations can be of assistance in recovery. 888-373-7888 National Human Trafficking Hotline, correlates data and can give assistance.

 

• Strategies to Improve Cardiac Arrest Survival (Bobrow): A Time to Act. Primary goal of lecture is to get us to read the IOM report. Bentley Bobrow, MD. This is a consensus type report. We have to eliminate "system malfunctions" where cardiac arrest is concerned. Cardiac arrest REQUIRES a system response. Speed and quality of care matter. Leadership matters. OHCA survival is about 6% nationally. Imperfect data hinders ability to improve and move forward. All current cardiac arrest databases are incomplete. A national cardiac arrest registry is needed (example: CARES is voluntary participation). It is sad that there can be huge variances in survivability between cities. Benchmark cities and systems show that survivability can be improved dramatically. Any CPR or defibrillation by the public is better than no care. 911 activation is crucial. Time too first compressions and defib is crucial. Response time to cardiac arrest clearly matters. Actions of the public are pivotal to success. Bystander CPR and AED are very effective. Only 1-2% of arrest victims get a public AED applied. If a community measures OHCA performance they get better. Appropriate leadership must be generated at all levels to improve outcomes. Better therapies are needed for non-shockable rhythms which are the majority of what is seen (my note: this is the first time I have ever heard anyone admit that VF VT is not what we see most, but is I always see in the data). There is a lack of research on OHCA. "EMS is at the center of all of this." Establish a national cardiac arrest registry. We do not have good data. Cardiac arrest needs direct surveillance as a disease process. Foster a culture of action through public awareness and training. Enhance the capabilities and performance of EMS systems. Dispatch assisted CPR is a huge component. High performance CPR is crucial. There must be a leadership culture of excellence. There must be accountability. Data must be utilized. The enhanced chain of survival must be used. QI must be a component. Accelerate research. Create a national cardiac arrest collaborative. A national responsibility to significantly improve the likelihood of survival and favorable neurological outcomes exists. The IOM report is a call to action. Report at:  http://www.iom.edu/cardiacarrest

 

• An update on the EMS Subspecialty Board Certification Exam (Marianne Gausche-Hill, MD): In 2015 332 physicians took the exam. 223 passed - 67%. Fellowship pathway success was 76%. Practice-only pathway pass rate was 64%. There are now 459 EMS certified physicians total.

 

• PECJ (Menegazzi): Prehospital Emergency Care Journal is now bi-monthly!

 

• Oral Abstract: Hypotension dramatically increases mortality in head injury. It is significantly higher than though. Hypotension doubles mortality. Hypotension doubles cost of care per episode. Most studies look at mean arterial pressure (MAP). This study looks at systolic BP vs. MAP. This is the EPIC study. Uses the Arizona State Trauma Study. Study incudes head injuries age 10 and above. 10-fold cross validation was used for the study. Three models of analysis were used. 8627 patients met inclusion in the study. Study shows that SBP is nearly identical to MAP in measuring hypotension. SBP far more convenient a measure in an ambulance than MAP (my note: for those of us that think NIBP in the prehospital environment is accurate, this is great news). Study shows that SBP is as good as MAP for determining mortality in head injuries.

 

• Oral Abstract: Prehospital Intubation in the Pediatric Patient Across North Carolina: Christopher Higgins, DO. Potentially lifesaving. Part of standard curricula for medics. Studies have shown no difference between PETI and bag valve mask ventilation. Study to determine success rates of PETI in North Carolina. Retrospective database review. Children less than 18 who received transport and required PETI. Transfer patients excluded. 364 patients identified. 189 excluded. 175 were reviewed. 95% confidence interval. PETI occurs 1.5 times more frequently for rural populations. Overall success, rural 65%, urban 74%. 1st time success was 58% rural, 52% urban. Increased number of attempts increases mortality. Severity of illness and time to definitive care requiring PETI seems to be higher in rural environment. Reasons for lower success rates seems to be related to exposure to PETI.

 

• Lightning oral presentations: CPR FEEDBACK (Milwaukee County): retrospective data before and after CPR data feedback to crews. 275 encounters, 158 before and117 after implementation of feedback. Results: compression rate improved slightly. Perishock pause decreased from 21 to 14 seconds average. This was a non-randomized. Feedback alone caused improvement. TEMPORAL TRENDS IN OHCA (Ontario): Uses a regional Canadian Arrest Database. 40,000 arrests annually in Canada. Survival at about 10% but on the rise. Data from 2006-2014. 2006 - 5.1%, 2014 - 9.3%. CPR quality was improved during this time. Hypothermia WAS utilized. Could not exclude Hawthorne affect being credited with improvement as well. Improvements made in bystander CPR and AED use. More hospital interventions as well. ELEVATED INITIAL TRAUMA CENTER TEMPERATURES DECREASED OUTCOME IN TBI: High body temperatures most likely due to environment. Having a high body temperature after brain injury is rare. Hospital stay longer if temperature is elevated. Hospital charges are higher if brain injury in context with elevated temp. If they arrive with higher temps, longer stay, more cost. Crux of study: There is significant risk if we try to correct this in the field. MAINTAINING HIGH QUALITY CPR INTEGRATING MANUAL/MECHANICAL CPR DEVICES (Zoll): Used Zoll Autopulse. Manual compressions used until mechanical could be initiated. 71 patients. 39 received manual only. 32 received manual and mechanical compressions. Compression fraction between manual and mechanical was 87% 91.7%. Study advocates placing the device at the ready after ROSC in case of re-arrest. There were NO statistical tests on this data (wow...?). STRESS AMONG EMS PROFESSIONALS (NREMT): Stress has been associated with PTSD. 3.8% of EMTs and 8.2% of paramedics report being stressed. 4,238 newly certified NR EMTs and Medics recruited for a 10 year study. Self-reporting in seven areas generating a composite score. For three years, medic stress increased by year from 18% to over 30%. Incidence of stress was nearly 3 times greater for medics over EMTs. Currently three years into study. Self-reporting may be dropping off as stress increases. Stressors on medics are increasing. Stress reducing tactics needed. EFFECT OF EVENT LOCATION ON DROWNING OHCA SURVIVAL (Korea): Location determines whether there are lifeguards and rescue tools. Used Korean national arrest data. 170,064 patients. 381 excluded due to suicide. Most cases were unsupervised areas. EMS response time shorter in supervised incidents. Lifeguard supervised public areas had highest survival rate. Bottom line, do not swim without a lifeguard. ACCURACY OF MEDICATION INFUSIONS BY EMS PROVIDERS (Roanoke): There are calculation and administration errors. Consistency of errors points to more of an equipment issue than a human error issue. Errors are higher if using gravity flow than if an IV pump was used. ERRANT SHOCK DELIVERY IN OHCA (Pittsburgh): Defibrillation may be lethal if not a shockable rhythm. IRB approved study. Defibrillation download files utilized for the review. 1,377 shocks analyzed. 131 shocks were errant over 91 cases. 9.5% were errantly shocked. All cases were ALS with AED cases included. PUBLIC CARDIAC ARREST IN ENCLOSED PEDESTRIAN NETWORKS (Toronto): These are areas where vehicles cannot get to easily that have only pedestrian access. Used PATH underground network in Toronto. All arrests analyzed were atraumatic. Out of 2621 arrests, 50 were in the PATH area. Arrest density much higher but have no demographic differences from other arrests. Bystander CPR and AED were greatly higher in the PATH. Response time to patient side was NOT increased by the environment. PARAMEDIC AND PATIENT POSITIONING FOR INTUBATION (Pittsburgh): Suboptimal positioning complicates intubation attempts. Six positioning scenarios with choice of laryngoscope blades. Two in ambulance, four outside ambulance. Worst success was patient supine in ambulance with medic sitting. Bottom line: Patient on floor with medic prone was best with 93% first pass success. Success in general was far better outside of the ambulance.



The USS Theodore Roosevelt and the USS Carl Vinson at dock, viewed from the concierge lounge of the Grand Hyatt Manchester in San Diego.

 

• EMS MYTH BUSTERS (Minneapolis/Wichita): 1) Trendelenburg position, does it help shock? Dr. Walter Canon introduced this into practice and later reversed his opinion after WW one. Actually only causes a short term increase of circulating volume of 1.8% that goes away quickly. Increases ICP. Decreases cardiac output. NO BENEFIT... Passive Leg Raise is about the same but might help identify patients that could benefit from a fluid bolus. Head up 30 degrees may actually help increase cerebral perfusion even in CPR. Head down/feet up busted. 2) Injecting a medication in the high port of IV tubing will dilute the medication before it reaches the patient. Some meds may benefit by dilution. They ran an experiment to check this thinking of passive dilution through port use. Does not significantly dilute the medication. Busted. However, if we use slow push with a slow drip rate, it might offer a more controlled administration. 3) You are not dead until you are warm and dead. How cold is to cold to code? HT Level 4 has no vitals. Vitals must be checked for a full 60 seconds. Which came first, hypoxia or hypothermia? Better survival if you get cold before you stop breathing. Do not withhold resuscitation and do not withhold ACLS. Full neurological recovery is possible especially if ECMO is available at receiving facility. Myth plausible if hypothermic before hypoxic. 4) To adequately give Adenosine you must use a rapid administration sequence with a stop cock valve to get it to the patient before half-life is over. Adenosine does have a short half-life. EMS loves a good flashy procedure too. Saline behind the bolus DOES NOT dilute the med (good). Rapid infusion works well at keeping the bolus together. Using a stop cock valve actually separates the administration (not good). Myth busted. No stop cock valve needed. Give it through a rapidly flowing line. 5) EMS should always try to transport pregnant patients on their left side to prevent occlusion of inferior vena cava. Is there really anatomic compression of the IVC? YES. In the supine position it significantly does compress, BUT few show symptoms. Placing on side does help but unsure as to what degree of side tilt. Only 8 to 15% of third trimester patients actually show symptoms related to this. It takes about 30 degrees tilt to improve flow. This means the right shoulder may need 10" elevation of the right side. How can this be accomplished safely for transport? This myth is plausible if the patient is reporting symptoms or is unconscious and unable to report. 6) EMS should never administer more than 3 sublingual nitroglycerine (my note: are we really still doing this anywhere?). If we believe this we have to accept that continuous nitro must be evil and we know better. Busted.

 

• Resuscitation Outcomes Consortium Successes and Impact (Daya): ROC focuses on very early interventions by EMS. $114 million dollars of investment in ROC studies. 264 EMS agencies and 287 hospitals involved. Over than 100 IRBs involved. 60 peer reviewed publications. Greater than 70 abstracts. 1,500 citations. Major impact on AHA 2010 and 2015 guidelines. ROC has gotten EMS providers involved as authors. ROC proved futility of the ITD. ROC also showed fluid limitation provided lower mortality in shock from trauma. There is an Amiodarone-Lidocaine-Placebo study coming out in March (my note: cannot wait to see this!). It has 3,025 patients in the study. ROC is currently looking at TXA in hemorrhagic trauma (randomized-placebo). They are also looking at optimal airway control for OHCA (3,000 patients). ROC mandates collection of data from the cardiac monitor (very positive). ROC communities have varied oversight, EMS performance and populations. EMS engagement in research is crucial. "We need a culture of paying attention to the details." CPR quality is essential to all cardiac arrest trials. All communities involved in ROC have showed outcome improvement over their involvement span. "One size does not fit all." - referring to practice and involvement (my note: I cannot agree more...). https://roc.uwctc.org/tiki/tiki-index.php?page=roc-public-home

 

• I just have to inject this Facebook post I made at the end of Day one, just love spending time with Larry Miller: Having a drink with the man who brought us the EZIO... Larry Miller. Always an immense pleasure.

 

A seagull attempting to steal my breakfast on day two.

• Promoting Innovation in EMS: Driven by DHS, NHTSA and HHS. Does your state foster innovation or stand in the way? Do your protocols take into account for variances in individual practice? Prehospital EMS is uniquely positioned to take care of 15% of the lowest acuity EMS calls WITHOUT transport. This would provide solid care and save Medicare 600 million dollars each year. The problem is with the barriers. The federal government is funding the innovations in EMS project. Another issue is that people hate change. Maine had to pass a law to allow community paramedicine. Places trying to innovate are reporting that it is hard. NHTSA does not think it should be hard. Remove the barriers. NHTSA is trying to rewrite the EMS Agenda for the Future which is 20 years old this year. Innovation is not an option. If you are not innovating you have missed the train. Learn the new healthcare system and adopt its incentives. Part of this is like reading tea leaves and trying to look into the future. Care is better in home environments than in nursing homes. By 2018 90% of fee for service will be linked to quality, and 50% of the total will be paid by alternative models. The outcomes will be based on population health and not the individual. There will be performance metrics from the National Quality Forum. Socials variables underpin the healthcare costs. No one knows these variables better than a paramedic. The EMS Compass is where we are heading simply to get funded. California now has a Core Quality Measures project to identify metrics. San Diego has a HIE, Health Information Exchange and EMS is a part of it. It is a bi-directional information exchange. There is EMS surveillance and alerting producing a registry of patients that surpasses super users and sends community paramedics to care for them appropriately. The medics develop the care plans. Data tracking also tracks finances and therefore they know the savings. It has even helped with homelessness. They are on the innovation exchange so that you can simply adopt the program idea. The CIE, Community Information Exchange links the program with Senior Care, Meals On Wheels, faith based organizations and other agencies. Medics can refer people (with info) to multiple other agencies and programs using a global consent process once entered into the system. EMS super users were identified through cross matching data as being at nutritional risk so that it could be solved. Innovation is trying to translate an idea or invention into a good or service for which customers will pay. Successful companies have a culture of innovation. EMS has to adopt this culture. Question existing structures. We have trouble moving the needle. We have trouble convincing the stakeholders. Empower the workforce to be entrepreneurial. Reward the pursuit and sharing of knowledge. Ultrasounds, sepsis pathways, blood cultures, lactate levels and telemedicine are already out there on ambulances. Referral programs are becoming more common. There is an EMS organization monitoring TB patients. The biggest barriers are financial, legal and workforce buy-in. State EMS statutes in most states do not reflect what EMS is currently doing or needs to do go forward. There are complex inter-relationships... legal, financial, training, information, etc... The barriers being removed must be the focus at the ground level. Statute and regulation must support innovation not hinder it. www.emsinnovations.org has draft recommendations. Flexible scopes of practice are needed. States MUST be silent on practice settings (ability to function in any environment). Base on NHTSA practitioner levels but be able to customize beyond it. We need to demand longitudinal record keeping rather than single incident reporting. Data MUST be shared. Two entities cannot be working on the same patient and be unaware of each other. EMS leaders in state government MUST be involved in reform initiatives within Medicaid and other areas. Local medical directors cannot have limited authority. Medical directors need support to innovate. Medical directors cannot have conflicts of interest with their duties to the EMS providers. Innovation approach must be interdisciplinary. Evidence based medicine consensus guidelines and best practices should be incorporated into EMS protocols establishing minimum standards of care appropriate for that locale. EMS physicians must be trained in population health (my note: probably paramedics also). www.emsinnovations.org

 

• More oral abstracts: EVALUATING COST AND UTILITY OF EPI AUTO-INJECTORS: Schools encouraged to have Epinephrine capability for asthma and anaphylaxis. 69% increase in epi pens from 2003 to 2010. State of Michigan mandates that all schools stock two Epi auto-injectors at all times. No literature available on time dependent nature of Epi effect on mortality or morbidity. No data on frequency of need in schools. This is a retrospective cohort study. What is the frequency of need in schools and what is the cost? Manual review. Source of Epi also a component. IRB approved. Response times of EMS were also assessed. Training costs not assessed by study. 18 public school cases. Most Epi belonged to the patient. Only 2 received Epi from the school. Allergens were mainly food and insect. Cost was vast compared to those who received benefit. ALS response time was rapid. Study suggests that lack of use does not warrant cost. Some schools at a distance from EMS may need Epi, but not all schools. IMPLEMENTATION OF A DISPATCH CPR SYSTEM WITH GOOD NEURO OUTCOME FROM OHCA (Taiwan): Bystander CPR rate improves OHCA survival. Impact of dispatch CPR is unknown. Study performed in Taipei, Taiwan. One dispatch center. Nurses utilized in dispatch. Nurses give prearrival instructions. The nurse’s purpose is solely to give instructions, not dispatching. 1.9% improvement in survival to discharge. 2.1% improvement in neurological outcome. Limitations: No knowledge of prior CPR training of given bystanders given instructions. PREDICTING SECOND SHOCK SUCCESS (Zoll): Amplitude Spectrum Area is a predictor of successful defibrillation. Retrospectively assess changes in AMSA with CPR. 609 patients. 448 patients failed to convert on 1st shock. 193 patients received 2nd shock. 2-3 minutes between shocks. AMSA measured at first shock and before second shock. Used multivariable logistic regression. Patients who had increased AMSA responded better to second shock success (my note: not so sure this is related to CPR as we already know defibrillation decreases threshold for subsequent successful defibs). Admits CPR quality was not measured also TOURNIQUET APPLICATION (Nova Scotia): Tourniquets have been used for 2,000 years. Indicated whenever direct pressure fails to stem blood flow from external limb bleeding. Is there a difference in outcome between standard hemorrhage control and tourniquet? Observational studies were reviewed as well. Review shows a lack of controlled studies. Lack of info on pediatrics and the elderly. Believed that tourniquet instructions could be given by dispatch. Tourniquets effectively control bleeding but it is unclear at what level it affects mortality. There is an obvious LOWER complication rate if a tourniquet is used versus no tourniquet used (historical viewpoint debunked).

 

View from our hotel room

• TXA and Hemorrhage control in TBI (Jui, Oregon): TXA costs about $100. Speaking on TXA in trauma and TBI. Hemorrhage causes 90% of traumatic deaths. TXA in surgery decreases risk of transfusion by a third without much complication. CRASH 2 study was conducted on 4 continents and was shown to decrease mortality on each. TXA inhibits plasmin and reduces clot breakdown. 20,211 patients randomly allocated to TXA or placebo. Males are predisposed to trauma more so than females. CRASH 2 has a great cross section of patients. If using TXA, quick administration is best. If not going to give within three hours do not give it. No increases noted in thrombosis. DVT was same in both TXA and placebo groups. NNT is 67. MATTERS 1 trial was at Camp Bastion trauma setting in Afghanistan. 896 combat casualties. TXA group was more severe AND had better outcomes. TXA group had decreased mortality in spite of worse ISS scores. Immediate causal relationship noted between hypocoagulopathy and mortality was noted. NNT was 7. There was an increase in DVT and PE in this study, but may be from the combat injuries. MATTERS 2 looked at effect on TXA and Cryoprecipitate. TXA and Cryo had best outcomes. PED-TRAX study was on Peds and TXA (also military theater). Showed decreased mortality once again. No significant complications. TXA group showed better neuro at discharge. CRASH 2 data also showed no difference in survival of isolated TBI but did show less hemorrhage. Only one retrospective study (VALLE 2014) shows worse outcomes with TXA and in that study it was based on physician individual choices rather than a designed trial. A UK trauma system study on civilians showed decreased mortality as well. Use in first hour has best outcomes in summary.

 

• Bariatric Patients in EMS (Clarke): Training for a Growing Problem (Akron): Bariatric patients have higher incidence of diabetes, hypertension and many other disease processes. Biggest issue was training sensitivity toward the issues. The number of physical barriers is staggering even with EMS equipment. Do not make jokes. Do not make a public display of the need for larger equipment. Bariatric patients commonly have decreased mobility. Schedule needed equipment in advance. There may be prolonged extrications from buildings. Air transport may not be feasible in some cases due to airway and weight issues. Bariatric patients have a very low threshold for intubation need. Can you get to where you need to be to perform procedures on the patient in an aircraft? Clear plans and manpower are needed to insure crew and patient safety. The training was designed to be three hours. It is a mobile program. Combination of didactic, skills and scenarios. Skills stations are airway and miscellaneous skills. Uses IO, IV models, airway trainers, bariatric cot and bariatric tarp. Bariatrics have increased chest wall resistance and greater abdominal pressure on the diaphragm. Bariatrics desaturate more quickly. Traditional BVM ventilation is difficult and may require a two-person technique. Most are very difficult intubations. Sniffing position is best. Alternative airways may not work. Surgical airways are difficult. Try and keep bariatric patients upright. They also have an increased risk of aspiration. They built a bariatric intubation simulator. It may be difficult to obtain blood pressure and cuff size is crucial. Venous access is problematic. Even splinting may not be easy to accomplish. Bariatrics get hypothermic more quickly. Needle decompression may need longer needle. There is a bariatric water suit available for rescue manikins to bring manikin weight to 500 lbs. Lifting techniques must be defined and practiced.

 

• Everest Basecamp MCI (Zafren): Speaker was there when earthquake happened. 7.8 earthquake. April 2015. Killed 9,000 people. Injured 22,000. Everest base camp had 19 dead. Nepal is the least developed country. No roads. Existing roads are rough and slow. No formal SAR. Military handles incidents. Most rescue is by companions or other expeditions. No ALS ambulances in Nepal. Prior to this earthquake, last major one was an 8.0 in 1934. The earthquake was somewhat expected at some point. There were many aftershocks. Hundreds of thousands were left homeless. Deaths were decreased by time of day and day of week as children were not in school. Base camp is at 17,598 feet elevation. Accessible only by foot or helicopter. Most deaths at base camp were from avalanche blast force. Most deaths were immediate due to head injury. 17 died right away. 80 injured included extremity fractures, pelvic fractures and soft tissue injury. Three doctors at the makeshift base camp ER. The ER tent was destroyed and one physician died. A second doctor was injured, leaving one uninjured doctor. Communications were limited initially... meaning NONE. No helicopters had night vision or IFR capability. Closest hospital is a 15 hour walk. The two remaining doctors were busy overnight with poor conditions forecasted for the next several days. Weather actually cleared overnight and the first helicopter arrived unannounced. Each helicopter took two critical and one walking per trip. 16 patients staged from Everest at Pheriche. White tape with text was used for triage. Mattresses were used to carry people to and from helicopters. Patients went from Everest base camp to Pheriche and then to Lukla and then to Kathmandu. Definitely an austere environment. Kathmandu had less damage than expected. It is impossible to plan for every wilderness disaster. It is hard to be a victim and a rescuer at the same time. There were many depression issues.

 

• Prehospital care for the spinal injured athlete (Hudson): Athletic Trainers are first line of defense and understand the equipment and mechanisms of injury. team physician training varies greatly. Most are family medicine and only 4% are emergency physicians. NFL now has "airway" docs. NHL now has emergency physicians. EMS may be on standby or dispatched. Read "Prehospital Care of the Spine Injured Athlete." More mounting arguments about long spine boards being used. There are decision trees that should be used to determine when spinal stabilization is used. There are about 10,000 spinal injuries a year and about 10% are from sports... all small numbers. ACEP states backboards should not be used as a therapeutic device. Sports still indicating use. Axial load is the most common injury. Three times more likely to occur during a game than practice. Sports is an austere environment. Football equipment is designed to maintain neutral alignment. Not true for hockey. Most helmets do not accommodate a c-collar. C-collars may even be debated. Airway control after face guard removal is not a challenge but speaker recommends a non-visualized airway over intubation. LIFT, don't roll onto devices. Keep stretchers ow to avoid tips (EMS needs to learn this for ALL patients, period). If you respond to hockey, MANDATE Yak-tracks for crew and patient safety when on ice. Everyone needs to know each other. Athletic trainers, physicians and EMS should work together. Avoid conflict. Use LSB to extricate and then get them off the board to the cot. LSB should be removed before transport.

 

• Just looked at a poster study confirming our local use of steroids in respiratory patients. Good to know our local long-term thoughts are confirmed regarding Solu-Medrol usage. Good stuff in realtion to reducing length of stay.

 

• Electronic Dance Music, Designer Drugs and Teen Death (Fitzgibbon, Lawner, Levy, Seaman): Designer drugs including Molly are a lethal threat to teens and adults. Electronic music dance festivals produce unprecedented patient numbers related to this issue. Patient numbers start as soon as the Rave begins and escalate during the event. Some of these events draw large crowds. Drugs are used to enhance the music experience. Fastest growing genre of music and attracting as young as 14 year olds. One chemist designed 179 different designer drugs. Finding the exact drug used is almost impossible. Care is supportive to hydrate, stop seizures, prevent hyperthermia and use benzos to decrease agitation. Prevention efforts are needed. Best practices need to be identified and shared. Six deaths were attributed to drug usage at three different festivals (all had multiple patients). One best practice is to deny access to event for unescorted minors. One event had 21 transported patients with two cardiac arrests. Friends may abandon victim when patient becomes unresponsive which may prolong recognition of emergency. Reviewed major patient case studies from one event. Benzos may have limited effect. Mass gathering prediction models are overwhelmed and inaccurate for these festivals. Parents must teach children about these drugs as well as those commonly mentioned. Excited delirium has been seen in these cases. There must be pre-event intelligence looking at what happened in the cities they were at before. Deny concert permits if prior issues. People who are on Molly do not respect boundaries. Station EMS and first aid at a distance from the spectators so that they are not immediately overwhelmed and have to determine first aid versus real issues. Form medical action plans. Get support from poison control centers. Have a separate command center from treatment areas. Starting to not allow liquids to be brought in and using controlled water supplies. Some are using paramedic treatment areas with physician presence. Have lots of benzos and tubs to cool down hyperthermia and excited delirium. Treatment areas and tents must be designed for patient flow and segregation by type of patient. Ketamine on site may be needed.

 

• Top Innovations for 2016 (Brent Meyers): 1) Active assailants have become a big issue. Everything we have done to prepare for active shooters is based on data from 2000-2013. Most incidents involved a single shooter. Most were male. Most were caught. It also showed that law enforcement engaged and about 25% of the time an officer was injured. The shooters almost always committed suicide or were taken out by LE. During that time only a few used IEDs. We thought we could plan a response for this based on the numbers. We are going to have to be prepared for five or more critical patients and understand and operate in the austere environment. 2015 negated all of the previous data because there were multiple incidents with large numbers with multiple shooters, sometimes in a single day in multiple cities. He showed 12 slides of tables with just 2015 data. When does an MCI become a disaster? Stress and debrief are going to be an issue. 2) Healthcare reform is for real. Reimbursement changes are coming. Three to five year VERY substantial changes. Value-based payment is becoming a reality. By the end of 2017, 80% of payment will be based on value per government sources. Payment will be based on doing things correctly. We will move from volume based Fee for service to value based for population. We have to decouple "transportation" from what we do in the prehospital environment. We have to get states to stop saying what environments a paramedic can and cannot function in. Bundled payments for quality improvement are coming. EMS can do both simple and sophisticated things to assist the patient and the hospital in this environment. Prehospital clearance of chest pain has been studied and is viable IF done correctly and objectively using patient scoring, 12-lead and on scene Troponin assay. 3) Narcotic dependence and overdose: 700% increase in narcotic dependence in Vermont over last decade. NYC CVS soon to sell Narcan OTC. It now only costs $6 for an overnight high. Parents have been caught overdosing while at hospitals visiting admitted children. As the price of Heroin dropped and prescription opioids increased, Heroin took over. Note that 350 million prescriptions for narcotics were written last year. Narcotic overdose is now the biggest issue in the United States. Public access Narcan is here to stay. We need to account for public access Narcan in our cardiac arrest survival data. This is a true epidemic. 4) Advocacy: We have an obligation to stand up for what we believe. We also have an obligation to stand up for our patients. NAEMMSP is moving forward with the DEA bil to advocate for pain relief in our patient. The DEA has no sense of humor. Every local DEA representative has a different interpretation of EMS and narcotics. Advocate for this Bill with your legislators. 5) International outreach: NAEMSP held three medical director courses outside of North America this year (Havana, Mexico City and Taipei).

 

• I have to start carrying WHAT on my ambulance? (Cooley, San Antonio): Speaker has Congenital Adrenal Hyperplasia (CAH). Cortisol deficiency. Some have Aldosterone deficiency. Androgen excess. There is a lot of variability n patient presentation. Some have salt wasting and are more severe. May have hypertension. Cortisol increases contractility and cardiac output. Patients present with virilization, early puberty, short stature, acne, infertility and depression. What we are worried about from an EMS perspective is adrenal crisis. Triggers are stressors: Trauma, fever, dehydration, surgery and extreme exercise. Emotional and mental stress are not a stressor for induction of adrenal crisis. Weakness, fatigue, fever, vomiting, diarrhea, abdominal pain, lethargic, AMS, tachycardia, tachypnea, metabolic acidosis and hypotension. Receptors do not work so Epi may be non-effective. They may have elevated potassium. They are diagnosed at birth or later in life due to crisis. Initial episode may take 10-14 days to develop. Use Hydrocortisone, 0.9% NS for IV, potassium may need to be managed in ER. Unknown as to whether Dexamethasone works or not. ERs and EMS may be education deficient on this topic. Communication and retrieval of information are key to success. Patients and families may have Hydrocortisone with them for injection. You can make a known CAH protocol or just a protocol allowing medics to administer patient carried medications. Speaker makes note that he went to Philmont as a boy scout and got his injections in the backcountry of New Mexico. Solu-medrol can be used if hydrocortisone is not carried or available. The disease is not common but the care is lifesaving. He feels that medics should always have the ability to utilize patient's medications.

 

• The EMS Compass Initiative (Garza): Is EMS accepted as a medical practice within the house of medicine? It should be. You have to know the WHY before you can show the HOW. How do you define quality from the aspect of value? Alice's conversation with the Cheshire cat rings true here... where do you want to go? Healthcare costs are the highest in the US without providing great outcomes. EMS is only mentioned in the ACA seven times. The IHI Triple Aim should guide us. We must forge a stronger link between quality and payment. The most valuable commodity is information. Show the data or you will not be believed. It is not enough to do your best; you must know what to do and then do your best (Deming). The National Quality Forum and Hospital Compare are great websites to look at basic metric use. How does EMS show value? EMS Compass is the HOW. EMS Compass is not punitive. Measures are being designed and tested. "Amateurs talk strategy. Professionals talk logistics." - Omar Bradley. The effort must be continued post-compass development. Improvement equals quality. Quality equals better patient care. Better patient care equals value. www.emscompass.org

 

• TEMS Response to Civil Unrest (Ferguson) (Dr. Tan): Intel was used utilizing social media. Decontamination was improvised from fire departments in case biological fluids or chemicals were used. Specific kits were put together for supplies. Stress issues were addressed using buddy checks. Use unified command. Run table top exercises before events occur. Know what destinations will be used. Know the capabilities and staffing of your destinations. Look at quantities. Do you have 100 tourniquets? Do you even have 50 tourniquets? Be very specific on kit design. Pneumo kit needles need to be 3-3.25 inches in length. Learn tactical priorities of care. Protocols must allow for austere environments. Do your protocols have chemical munitions exposure care? Do you have eye wash? TEMS should coordinate with local EMS. Be crystal clear regarding security plans for your personnel. Clarify with command staff as to expectations and responsibilities. Who is defined as the patient? EMS is caught in the middle in these incidents. Incidents must be studied to learn how to respond. Stage and wait is not practical. If that is your plan today, work with other agencies to change it.

 

• DEA Update (Sahni): HB 4365 needs to pass to make our current EMS operations legal. Most DEA rules for EMS are made up by the local DEA contact as there are no EMS rules. EMS has asked the DEA for rules for many years. The CSA says no standing orders for narcotics. Must have a name and DOB for narcotic administration. Must be audited. Please write your congressional representative to support 4365 which fixes the issue. Supported by the American Ambulance Association and the IAFF. If 4365 passes, the agencies will register as opposed to the medical director. Do this quickly. Letter template, info and tool kit at www.naemsp.org

 

• The 2015 AHA Guidelines: Not Carved In Stone (Sayre): This guideline cycle has significant changes, but it is a focused update to the 2010 guidelines. There are two chains of survival, IHCA and OHCA. Training materials will differ. Cath lab is now a link in OHCA (Good!). The AHA now encourages adoption based upon your environment. The AHA now expects you to figure out what works for your system and community. No impact on outcomes with ITDs (blinded study with sham ITDs). However, ITCD plus ACD CPR (not blinded) did show approximately 2% improvement in outcome (NNT was 45). ITD not recommended alone, but ITD with ACD CPR may be reasonable. Mechanical CPR: Four studies, none showing improvement in outcomes. Manual chest compressions remain the standard for care BUT may be useful in areas of decreased manpower or safety of personnel. Vasopressors: Nothing showing standard dose Epi improves outcomes. Same with high dose Epi. However, time to Epi may matter. IHCA data shows much better outcomes if Epi is given in the first few minutes of arrest. Standard dose Epi may be reasonable but is now a class IIb LOE recommendation. HD Epi is not to be used. Nothing wrong with Vasopressin but it is no longer in the algorithm but it can still be used. It was removed to streamline teaching. Failure to achieve ETCO2 greater than 10mmHg after 20 minutes is associated with poor outcomes. Insufficient evidence to recommend ECMO unless there is a known reversible etiology. Cath lab should be used emergently if there is a STEMI. Hypothermia: Prehospital cooling with saline no longer recommended. No differences in outcome.

 

• Articles that may change your practice (Bigham, Millin, Rittenberger): 1) Older injured adults are often under triaged against the CDC trauma criteria. Using AIS instead of ISS to score patients. Mapped to ICD 9 codes. 33,000 patients with most common injury being extremity injury. 80% were falls. Turns out that CDC guideline with any positive worked well. But by using the criteria they increased over triage by 164%. Under triage was however reduced. Poor specificity in study. Instead of using the exact criteria, simply use a higher level of interest in assessing and triaging this population. Lactate measurements may help determine if a trauma center is needed. 2) Ischemic stroke treatment: Discussing IA therapy. Demographics of included patients similar to other studies. Possibly better functional outcome with IA therapy if under 6 hours from onset. Not without risk. CT scanners in ambulances? Are there adequate numbers to support this? Are there other ways to operationalize this? TPA early may be better. Looking for patients that benefit from IA may be like looking for a needle in a hay stack. 3) STEMI: Is bypassing local hospitals to go to PCI centers supported? Can BLS crews safely triage to more distant PCI centers safely (many BLS units have 12-lead in Canada). 12% had events on way to the PCI center. Many required ALS intervention by ALS intercept. Closest hospital increases time to PCI by 47 minutes. ALS intercept only increased time to PCI by 1 minute. The entire 12% received ALS by intercept. Conclusion, BLS transport to PCI at a distance decreases time to PCI and is safe even if ALS intercept needed (my note: this data would finally support 12-lead for BLS). Limitation: Distance to PCI capable hospital was only an additional 12-15 minutes. 4) Pediatric airway: This study used experienced medics. All medics had OR experience INCLUDING pediatrics. Used peds bougies and Succinylcholine as part of tool kit. 66% first pass success with 97% overall success. There were no unrecognized esophageal intubations. If you design your airway training well, pediatric intubation may be safer (my note: but does it affect outcome?). 5) Continuous or Interrupted chest compressions in cardiac arrest?: AHA says 60% CCF. This study showed 77% was really good at producing better outcomes. MICPR obviously better than continuous compressions. Speaker states that perhaps the greatest intervention is passion and enthusiasm. ROC studies are driving improvement... period.

So therein lies a summary of my notes from the 2016 NAEMSP Annual Meeting. Again, as those who have read my notes from these type meetings before well know, if you attend EMS conferences, please assure that the NAMESP Meeting and the EMS State of the Sciences Meeting are the two at the top of your list. These two meetings are at the top of the mountain for evidence-based medicine in our EMS world.

 

Back in Evansville, in my little corner of the world, we can attempt to translate these things to applicable practice to benefit the outcomes of our patients.

 

Another trip completed... one more little trinket placed in the stone bowl of memories from places visited and things experienced... maybe I should write about that sometime too. Hope these notes are helpful.

 

Till next time... God bless.

Christmas 2015: A Reflection



 

Last night, when I made my last blog post, I honestly had no clue what I was going to write for this annual post on Christmas. All I had to do was wait. It landed in my head in small pieces throughout the day.

I started today, December 24th, on a bad note. I just wanted to stay in bed. Kids were all off school. My oldest daughter is in town from her last year of Veterinary Medicine at OSU. And... quite frankly... I'm a bit sick of EMS at the moment.

With an ongoing paramedic and EMT shortage, my usual five day work week has turned into seven most weeks and has not slowed down since August. This shortage, coupled with the surges in drug abuse cases... K2 and heroin are running rampant... along with EMS becoming the catch net for more and more uninsured (which the ACA was supposed to fix), is wearing on my ability to get things done and my nerves. So when it came to dragging myself out of bed this morning, it was less than easy. I was kind of wishing that Christmas Eve was actually one more day away...

So I got in the car, and before even leaving the house, I posted to Facebook:

"The FDA has issued a black box warning regarding contact with me today. I am to be considered toxic unless significantly diluted with proper amounts of caffeine. In the absence of caffeine, eggnog may be considered as an alternative diluent but may not be as effective as observed in clinical trials. Limit contact until dilution is assured... effects may be negated by significant amount of snowfall or limiting the use of three letters of the alphabet starting with the letter E."

Needless to say, I got through 1/3 of a cup of coffee before I was out on a rig. If you work on an ambulance you will most likely encounter someone suffering from depression on Christmas Eve or Christmas Day. When I encounter these folks, not to downplay their very real issues, but I sometimes think there should be a sign on the ambulance that reads... WARNING: If you are suffering from depression, chances are that the crew on this emergency vehicle are exponentially more depressed than you.

Sorry if that comes off harsh, but everything EMS does is in a hurry and racing the clock. Sometimes that is time dependent care, sometimes it is customer dependent time frames, sometimes its just getting available for the next run. There is a lot of dissatisfaction to be weathered on an ambulance... we cannot fix everything. Some pain cannot be relieved. All procedures are not successful. Sometimes traffic does not move out of the way. Sometimes there is not time to call the hospital... we take the brunt of it all. It is not all bad, but some days are worse than others.

So several hours of needles, medications, listening, reacting, monitoring, treating and transporting marked December 24th, 2015.

So what does this have to do with Christmas?

I was supposed to leave my desk job at Noon. That stretched out till almost three as the run volume stopped long enough for me to actually get some office work done. Then it was off to get the kids and head to the 4:00pm Christmas Eve service. I was a little cranky with the kids as two of the four that were home were not ready to go when I got there... I needed to get there.

Some of the stress came off when I walked through the door. It finally started feeling like Christmas. The hymns... the familiar liturgy... it all started falling into place. It was not entertaining... far from it. It was worship. It was what was needed. Pastor Eckels hit on four or five of the things that were my current stressors in the first two minutes of the sermon. Then he hit the nail on the head when he was talking about Christmas being far from silent. He said the word... "cacophony." What a perfect word to describe Christmas in America... Everything from sales, to traffic, to kids, to noise... well... cacophony.

What is the cure for cacophony? Get away from it. Retreat from it. Or even better, as Pastor Eckels was saying... Silence. My cure for it started when I walked in the doors of the church and saw the Altar. My silence is the church. It allows me to focus and come back to where I can focus. It isn't me coming to God. It's God coming to me through His means of grace, His scripture, His plan...

So, I am brought back to what matters. This is Christmas... This is about that time... remember that time? When God became man for the purpose of saving His creation? As it was foretold by the scriptures through His prophets long before a mild virgin gave birth in a stable... Nothing tells it better than scripture. These passages are from the readings from today with a couple of extra I selected to illustrate...

Isaiah 9:6-7 (ESV):
For to us a child is born,

to us a son is given;

 and the government shall be upon his shoulder,

and his name shall be called

Wonderful Counselor, Mighty God,

  Everlasting Father, Prince of Peace.

Of the increase of his government and of peace

  there will be no end,

on the throne of David and over his kingdom,

to establish it and to uphold it

 with justice and with righteousness

from this time forth and forevermore.

 The zeal of the Lord of hosts will do this.

 

Isaiah 7:14 (ESV):

Therefore the Lord himself will give you a sign. Behold, the virgin shall conceive and bear a son, and shall call his name Immanuel.

 

Micah 5:2 (ESV):

But you, O Bethlehem Ephrathah,

who are too little to be among the clans of Judah,

from you shall come forth for me

one who is to be ruler in Israel,

whose coming forth is from of old,

from ancient days.

 

And then it came to pass... they were expecting a warrior king... but instead, God entered the world as a man and His will would be done...

 

Luke 1:26-38 (ESV):

In the sixth month the angel Gabriel was sent from God to a city of Galilee named Nazareth, to a virgin betrothed to a man whose name was Joseph, of the house of David. And the virgin's name was Mary. And he came to her and said, “Greetings, O favored one, the Lord is with you!”  But she was greatly troubled at the saying, and tried to discern what sort of greeting this might be.  And the angel said to her, “Do not be afraid, Mary, for you have found favor with God.  And behold, you will conceive in your womb and bear a son, and you shall call his name Jesus.  He will be great and will be called the Son of the Most High. And the Lord God will give to him the throne of his father David,  and he will reign over the house of Jacob forever, and of his kingdom there will be no end.”

And Mary said to the angel, “How will this be, since I am a virgin?” And the angel answered her, “The Holy Spirit will come upon you, and the power of the Most High will overshadow you; therefore the child to be born will be called holy—the Son of God.  And behold, your relative Elizabeth in her old age has also conceived a son, and this is the sixth month with her who was called barren.  For nothing will be impossible with God.”  And Mary said, “Behold, I am the servant of the Lord; let it be to me according to your word.” And the angel departed from her.

Luke 2:1-20 (ESV):
In those days a decree went out from Caesar Augustus that all the world should be registered. This was the first registration when Quirinius was governor of Syria.  And all went to be registered, each to his own town.  And Joseph also went up from Galilee, from the town of Nazareth, to Judea, to the city of David, which is called Bethlehem, because he was of the house and lineage of David, to be registered with Mary, his betrothed, who was with child. And while they were there, the time came for her to give birth. And she gave birth to her firstborn son and wrapped him in swaddling cloths and laid him in a manger, because there was no place for them in the inn. And in the same region there were shepherds out in the field, keeping watch over their flock by night.  And an angel of the Lord appeared to them, and the glory of the Lord shone around them, and they were filled with great fear.  And the angel said to them, “Fear not, for behold, I bring you good news of great joy that will be for all the people. For unto you is born this day in the city of David a Savior, who is Christ the Lord.  And this will be a sign for you: you will find a baby wrapped in swaddling cloths and lying in a manger.”
And suddenly there was with the angel a multitude of the heavenly host praising God and saying, “Glory to God in the highest, and on earth peace among those with whom he is pleased!”
When the angels went away from them into heaven, the shepherds said to one another, “Let us go over to Bethlehem and see this thing that has happened, which the Lord has made known to us.”  And they went with haste and found Mary and Joseph, and the baby lying in a manger.  And when they saw it, they made known the saying that had been told them concerning this child.  And all who heard it wondered at what the shepherds told them.  But Mary treasured up all these things, pondering them in her heart.  And the shepherds returned, glorifying and praising God for all they had heard and seen, as it had been told them.

Of course there is more... both on the prophecy and on the fulfillment side of this coin. But that is the simplicity of the Gospel... it shines through any cacophony of secular noise and confusion. It shines through stress and depression. It seeks you out and finds you and makes you reel in wonder of what our Lord has done. It is His doing and none of ours. His grace. His faith that He instills in us...

The story does not end here. It appears to end on a cross

with nails and blood... but it does not. It ends with an empty tomb. Christ crucified, died and risen again. That's how the story ends... but again, it does not. He ascends. He is coming again for His bride the Church triumphant.

I could post more from the Gospels on the crucifixion, but instead, I will go back to Isaiah who foretold not only the birth, but the crucifixion of our Lord.

Isaiah 53 (ESV):
Who has believed what he has heard from us?

And to whom has the arm of the Lord been revealed?

For he grew up before him like a young plant,

 and like a root out of dry ground;

he had no form or majesty that we should look at him,

and no beauty that we should desire him.

He was despised and rejected by men;

a man of sorrows, and acquainted with grief;

and as one from whom men hide their faces

he was despised, and we esteemed him not.

Surely he has borne our griefs

and carried our sorrows;

yet we esteemed him stricken,

 smitten by God, and afflicted.

But he was pierced for our transgressions;

he was crushed for our iniquities;

upon him was the chastisement that brought us peace,

 and with his wounds we are healed.

All we like sheep have gone astray;

we have turned—every one—to his own way;

 and the Lord has laid on him

the iniquity of us all.

He was oppressed, and he was afflicted,

 yet he opened not his mouth;

 like a lamb that is led to the slaughter,

and like a sheep that before its shearers is silent,

so he opened not his mouth.

By oppression and judgment he was taken away;

and as for his generation, who considered

that he was cut off out of the land of the living,

stricken for the transgression of my people?

And they made his grave with the wicked

 and with a rich man in his death,

although he had done no violence,

and there was no deceit in his mouth.

Yet it was the will of the Lord to crush him;

he has put him to grief;

when his soul makes an offering for guilt,

he shall see his offspring; he shall prolong his days;

 the will of the Lord shall prosper in his hand.

Out of the anguish of his soul he shall see and be satisfied;

by his knowledge shall the righteous one, my servant,

 make many to be accounted righteous,

 and he shall bear their iniquities.

Therefore I will divide him a portion with the many,

 and he shall divide the spoil with the strong,

because he poured out his soul to death

and was numbered with the transgressors;

yet he bore the sin of many,

and makes intercession for the transgressors.

 

This is Christmas. When God came to redeem His fallen creation.

 

All of the noise and strangeness of a sin scarred world matter not in comparison. Depression is cast away by the means of grace. We are forgiven through nothing of ourselves and everything through his body and His blood, given and shed for the forgiveness of sin.

 

This is Christmas.

 

Gloria in excelsis Deo!

 

This day is almost at an end. I am preparing to go to the 11pm candlelight service with my beloved wife who God has given me. He has also given her the patience to put up with me... a poor miserable sinner.

 

When that is done and we have sang Silent Night in near darkness... after the late night Sacrament of the Altar, I will leave refreshed... I will add some pictures to this particular blog entry... maybe even some of the Altar at St. Paul's and then publish this post.

 

Wishing you the grace of our Lord. Peace on Earth. Good will toward men. Good job Pastor Eckels... as always. Message delivered to one sitting in the pew.

Postlude: It is now after 1:00am on Christmas Day. The 11:00pm service was as expected: firmly rooted in the Word and Sacrament. Pastor Schilling made a statement in the sermon that resonated with my earlier day: The world is ill-prepared to receive its Messiah...

This is as evident today as it was two thousand years ago.

Merry Christmas!

 

A Blogging Redirect: My Favorite Lutheran Blogs and Bloggers

Nope... this is not my Christmas 2015 blog entry... that will probably come sometime in the next 36 hours if I survive being a paramedic through Christmas Eve and Christmas Day...

This one is on the blogs I read and enjoy. Actually, it is more than that... I learn a lot from all of the ones I follow, search out, or come across in Facebook feeds. 

I read some things and just have to sit back and contemplate the accuracy of the other writer's feelings in matching to how I feel, my views, my need for learning or some other epiphany of the moment. Sometimes it is just about how they further explain scripture.

Almost every blog I read is Lutheran in origin.

Sure, there is the occasional EMS or Scouting blog, but none of those are my regular reads.

So I thought I would share some of my favorite blogs. I love to read, but with busy schedules and little time to sit in one place, I have taken to trying to read more blogs and spend short vignettes of time in the areas I like the most. Blogs work well for that...

My all time favorite single blog entry is one by Chad Bird. I will let you see why.. it reflects how I view the Divine Service. All of Chad Bird's writings are excellent, but this one is my all time favorite and I want to share it far and wide:

https://birdchadlouis.wordpress.com/?s=how+a+small

The hub for all of his excellent writings can be found here: http://www.chadbird.com/

This next one is written by someone named Tanya... I do not know Tanya, but the blog entry she wrote recently (link below) really resonated with me. I had struggled with Americanized evangelical Christianity for many years before I went to my first liturgical service at a Lutheran Church-Missouri Synod congregation on Maundy Thursday 1996. My feelings mirror hers but I could never write this as eloquently... well worth the read!

http://sellersofpurple.blogspot.com/2015/11/why-i-joined-dead-religion.html

Some of the bloggers I follow write almost every day. Oh that I could be so prolific! The next contrast a bit even though they are both Lutheran pastors. The first is Pastor Mark Surburg. His offerings cover many commemoration days, scriptural explanations and liturgical history descriptions. I find his blog to be a daily learning experience. I love the intellectual depth and historical nature of this blog and it helps me grow as a Missouri Synod Lutheran. He even posts his sermons as well. I have included a link to one of his entries below:

http://surburg.blogspot.com/2015/12/o-antiphons-dec-20-o-key-of-david.html

The next blog belongs to Pastor Peters. He presents a diverse offering (as the word "random" indicates in the subtitle of "Pastoral Meanderings") of entries that range from a pastoral view of current events to thoughtful things that just need to be said. His are quick reads filled with content. As Advent changes to Christmas, her is a good example of his work:

http://pastoralmeanderings.blogspot.com/2015/12/when-day-of-our-homecoming-puts-and-end.html

I would be remiss if I did not include the work of Scott Diekmann. He is probably hands down one of the best Christian layman writers from my perspective. He stopped writing his blog some time ago, but the whole of his blog is still available to read. It is quite the learning experience as well and well worth reading from start to finish:

http://stand-firm.blogspot.com/

There are far more than these... and the list could go on for ever. I highly suggest all past and future blog writings by LCMS President Matthew Harrison. Being the president of the Synod, his writings are varied, insightful and timely. These can usually be located via http://www.lcms.org/

I would also suggest following any of the regular contributors at http://steadfastlutherans.org/

Now to go slightly off topic... I would be entirely remiss if I did not mention all of the video and other work being performed by Worldview Everlasting. Pastor Fisk and Peter Slayton (and all of the other contributors have put together an all encompassing hub for Lutheran learning through many video presentations, links and discussions. This site is beyond priceless... http://www.worldvieweverlasting.com/

Again, from a video perspective, but with a touch of humorous satire, I have to recommend the work of Pastor Hans Fiene at Lutheran Satire. Learn while laughing... My all time favorite is the one on St. Patrick describing the Holy Trinity... Check them out at http://lutheransatire.org

The St. Patrick's Bad Analogies can be found here: http://lutheransatire.org/media/st-patricks-bad-analogies/

On one last note... read this one the other day from a Lutheran pastor in Indiana, Rev. Jeff Alexander. He is in Greenwood as a matter of fact. I go to Greenwood on occasion for work and need to stop in and meet him sometime. It says quite a bit with the backdrop of a new Star Wars movie in the theaters... https://www.cph.org/b-258-the-faith-awakens.aspx?utm_source=Facebook&utm_medium=social&utm_content=Faith+Awakens&utm_campaign=Facebook

I hope this particular blog entry gets some additional read/views for those listed. They have all been great pieces of learning for me and I continue to go back for more.

Give these authors and video producers a few minutes of your time each day and be rewarded by the insights they provide.

Till next time... be safe and spread the Word.

Contemplative Thoughts of a Scout Leader

As I stood outside tonight in the dark, watching the scouts of our Boy Scout Troop do physical
activity, my mind started to wander. Our troop, Evansville Lutheran Troop 310, is entering its sixth year of existence. Spawned from a Cub Scout Pack that is now roughly a decade old. Like most starting endeavors, it has struggled financially, but the boys that have been here from the start know what it was like to do a first campout without having tents. It has been an interesting journey.

Some of the boys that started with the troop have turned 18 and "aged out." Others have gotten their Eagle Scout award. Others, at least five of them, are very close to earning that achievement as well. We have watched them try, learn, fail and succeed at leadership and becoming a "youth led unit."

Although we have a few members who are not Lutheran, we have maintained Lutheran devotionals and a focus on not conflicting with the youth teachings within the church. We have always focused on the twelfth point of the Scout law. A scout is Reverent. We have assured that we maintain our religious beliefs and practices in our unit.

My thoughts settled on a single question as I watched them all play games in the dark tonight outside the school.

What good have we accomplished in the past five years?

For the last few hours... long after the meeting closed with Scout Vespers and prayer... the answers have flooded my mind.

- We have had four scouts awarded with the Eagle Scout rank.
- We have had only two age out without Eagle, and they were both Life Scouts.
- We have at least five now who are within a few months of doing their Eagle projects.
- The Troop has performed around 4,000 man hours of community service for multiple organizations in the community.

- We have honored veterans secluded inside of hospitals on Veteran's Day.
- We have helped them learn how to cook... and understand this... they can cook.
- We have watched as the youth have written a devotional service with a strong liturgical consistency and use of litany.

- We have had two scouts engage in life saving activities with one of these receiving the BSA National Medal of Merit.
- With only a four person patrol, our unit received the number one patrol award at a summer camp.
- We have had scouts attend the National Jamboree and NOAC.
- We have a large percentage of scouts in the Order of the Arrow, scouting's honor camping association.

- The Troop has literally sold tons of popcorn, supporting the activities of scouts and teaching salesmanship.
- We have watched them make do with very little equipment as we grew and succeed doing it.
- We have rode out many a rain storm in tents.
- We have stood on top of mountains, backpacked and hiked.

- We have had our scouts attend National Youth Leadership Training and several have went back the next year to be on staff.
- We have had three of our youth act as staff at summer camps.

- We have introduced some to travel, having never been outside of their own city before.
- We have mixed boys of various backgrounds and interests and watched teams developed.

- We have opened baseball games by providing flag ceremonies.
- We have taught and practiced numerous flag retirements.
- We have performed numerous honor guard activities.

- Our boys earned the Gold Journey to Excellence Award for 2011, 2012, 2013, 2014 and already have the points to do it for 2015.
- We have seen them learn, practice and depend on land navigation and map reading.

- We have seen the phases of team building occur before our eyes... forming, storming, norming and lastly performing.

- We have watched them plan and execute a 70 mile hike at Philmont in New Mexico.
- We have sang songs under the stars and talked about God, life and dreams around a campfire.

There is much more that can be placed on this list, but my day is ending and I grow tired.

We have some great young men in our troop. They will do wonderfully in being part of the community and taking care of their future families.

We hope we have instilled in them the importance of being Reverent.

So... what does the future hold for these young men in our troop.

I don't know...

I just don't know...

Whatever it is, they are better prepared for having been here in this place and in this time.