Below are summaries of important EMS clinical information presented at the 2014 Gathering of Eagles in Dallas on Saturday, May 1, 2014.
(Presentations will be made available for download at www.gatheringofeagles.us following the conference.)
What the Eagles are Doing in the Off-Season? A Report on Eagles Surveys
Presented by James J. Augustine, MD (Dayton, Ohio & Eagles “librarian”)
The “Eagles” conducted 78 Eagles polls in 2013. Results of some of these polls are listed below. The Eagle “Library” has been indexed and resuits of polls will be posted in the future in a special (upper right) tab labeled “Eagles Nest” at www.gatheringofeagles.us.
Some of the important results:
• 58% still using TH the prehospital environment
• 42% not using TH the prehospital environment
• Remove motorcycle helmets: 85%
• Remove sports Helmets 60%
Use Ketamine in the field
• 56% do
• 44% do not
Transport with CPR in progress
• 70% Yes
• 30% No
Is TB Testing Performed Routinely on EMS personnel
Using electronic dispensing systems
39% of Eagles Cities
Practice Permissive Hypotension
27% Do not
FOCUS ON CARDIAC ARREST: Evolving Considerations about Out-of-Hospital Cardiac Arrest (OHCA)
The Windy City CARES About OHCA: Are Outcomes Affected?
Presented by Joseph M. Weber, MD (Chicago)
Dr. Weber noted that in the past (1991), Chicago was reported as only having a 2% survival rate, referenced on page 120 of Mickey Eisenberg’s widely read book Resuscitate.
Dr. Weber noted that Chicago has been working hard since that time at improving their save rate and move the ROSC needle. He said that, in 2013, the State of Illinois received a CARES grant that enabled Chicago and other areas to begin to gather CARE data. The overall CARES data showed a 9% resuscitation rate in the period of 2005-2010.
CARES compared to the Chicago Fire Dept system:
CARES Bystander CPR compared to the Chicago Fire Dept. EMS system
CARES = 33.3%
• You must measure in order to improve.
• Chicago has been able to reach out to other cities and medical directors, particularly “Eagle” cities, and both have been invaluable in their assistance.
The Effect of Airway on Cardiac Arrest Outcomes
Presented by Jason T. McMullan, MD (Cincinnati Fire Dept.)
The science of airway management in resuscitation was reviewed by McMullan, who says supraglottic airways (SGAs) “rock” and are very helpful in many systems. The Resuscitation Outcomes Consortium (ROC) study showed that endotracheal intubation had better results over SGAs, while a Japanese study showed that patients did better with bag-valve mask (BVM) vs SGA. However an ROC study from 2014 still favored BVM vs. SGA, and a recent meta-analysis still favored no formal airway (BVM) vs. SGA.
What McMullan teaches his paramedics:
He stated that “positive pressure ventilation is the devil” and noted that PPV has some negative effects. You must use capnography to make sure you are not obtaining results and to time ventilations.
No Interruptions Please! The CPR Pit Crew Approach—on Steroids
Sabina A. Braithwaite, MD, MPH (Wichita, Kan.)
Dr. Braithwaite reported on how the Wichita (Kan.) EMS System was able to reduce peri-shock pauses and therefore improve resuscitation rates. They send a squad (2 first responders), an engine (4 providers) and an ALS ambulance (2 providers) and carefully choreograph their resuscitations with great effect.
• Utilize metronomes set to 110;
• Utilize a pit crew approach (“stolen” from Austin/Travis County Texas–Dr. Paul Clinchy);
• Created an app that's available in the app store on their process;
• Utilize continuous compression CPR for the first 6 minutes of cardiac arrests;
• Stay for the full resuscitation of their patients; and
• Annotate/document/review during and after all codes.
A Change in Scene-ery: Re-thinking On-site Management of Cardiac Arrest
Presented by Paul R. Hinchey, MD, MBA (Austin, Texas)
Hinchey feels resuscitation is “all about the compressions”: Depth, rate and chest release to maximize refraction. He noted that his crews are trained to resuscitate the patient wherever they code (but not in a moving ambulance), even if it means stopping the ambulance.
An Annals of Emergency Medicine Nov. 2011 article "ROSC or Death" detailed a cardiac arrest case Austin/Travis County EMS ran in the ambulance bay of an ED and saved the patient.
Hinchey said that his system reviews all cardiac arrests and provides feedback to all crews involved in cardiac arrest cases. They look at pauses and depth of compressions. They also use checklists, metronomes and a choreographed (“pit crew”) resuscitation process.
Learn more about the Austin/Travis County EMS pit crew approach at www.atcomdce.org.
Mechanical Behaviors: The Latest Word on the LUCAS Device
Presented by Joseph E. Holley, MD (Memphis)
Dr. Holley addressed the LINC Trial vs the Memphis Experience with the LUCAS mechanical CPR device made by Physio-Control. He reported that his system initially deployed the devices on 50% of their ambulances and now deploys them (and is studying their use and effectiveness) on all Memphis ambulances.
He said while the LINC trial reported the device did CPR as good manual CPR, his experience is that the LUCAS is having an impact on increasing return of spontaneous circulation (ROSC) in Memphis.
Dr. Holley has found that LUCAS CPR:
• Has doubled their ROSC in patients;
• Affords them fewer pauses;
• Provides consistency in resuscitations; and
• Allows for less moving in the back of the ambulance.
He said they do handle all arrests “cold” and use adult IO. He said the bottom line is that good quality CPR does matter.
Term Limits: New Data May Modify the Timing of When We Terminate CPR
Presented by J. Brent Myers, MD, MPH (Raleigh, N.C.)
Dr. Myers noted that his system used SAS software to determine when to terminate resuscitations and his research has shown that they have ROSC with neurologically intact patients during resuscitations that have lasted as long as 1 hour. Therefore, Wake County EMS has adjusted their termination of CPR (20 minutes in most cases) to much higher resuscitation times when they're getting results (particularly if the patient’s end-tidal carbon dioxide is > 30%).
His system (Wake County EMS) sends an advanced practice paramedic, an assistant chief, an engine company and ALS ambulance to all cardiac arrests and now runs successful codes (on scene) that last as long as 60 minutes.