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.)
Focus on Toxic Thoughts: Two-Thousand and Fourteen Considerations about Street Drugs
Epidemic Proportions: Dosing Ketamine in the Era of Mamba Rumbas
Presented by Christopher B. Colwell, MD (Denver)
Colwell pointed out that there's a big difference in the potency of “regular” marajuana vs. synthetic cannabis (which is illegal) and that the use of synthetic cannabis has increased significantly.
He also said that use of “Black Mamba” (one of the most powerful synthetic cannabis versions) has increased since marajuana use was approved in Colorado.
He said that use of ketamine ($18 per dose) for excited delirium has been effective in the Denver system. They give it as a 5 mg/kg intramuscular dose (100 mg/ml concentration). While some patients arrive at the ED acidodic, none have gone into cardiac arrest in the field as compared to about 20% in the past with other drugs.
They've had 40 uses so far in the field (27 involved synthetic cannabis): 48% received ketamine and 16 were discharged from the ED.
While droperidol is still the first drug of choice for Dr. Colwell, he said he wouldn't hesitate using ketamine for excited delirium patients. He pointed out that the decision to use ketamine is the hardest obstacle to overcome in a system
Managing Fentanyl-Laced Heroin Abuse
Presented by C. Crawford Mechem, MD (Philadelphia Fire Department)
Fentanyl is 80 times as potent as morphine and mixed with heroin can be deadly. Dr. Mechem noted that fentanyl-laced heroin use and deaths appears to be on the rise. He said that Philadelphia has experienced 252 deaths with fentanyl used in conjunction with heroin last year, and they continue to see deaths as a result of this combination.
It was seen as a regional outbreak in Cook County, Ill.; Camden, N.J.; Philadelphia and Allegheny County, Penn.; and other areas. It was often seen in gang areas.
Dr. Mechem stated that the appropriate naloxone (Narcan) dose has generally accepted ranges. In Pennsylvania and Maryland, the prehospital dosage of Narcan is 0.4 mg to 2 mg. His recommendation is to start with a low dose to avoid the side effects of withdrawl.
Drugs Falling into the Wrong Hands—or Not? Naloxone (Narcan) Use by Non-EMS Personnel
Presented by Jeffrey M. Goodloe, MD (Tulsa and Oklahoma City)
The American College of Emergency Physicians supports the prescription of Narcan to the public for the use of reversing overdoses. Many people now feel police officers should carry Narcan to administer to overdose patients. At least 17 states have passed legislation allowing law enforcement officers to carry/administer Narcan.
He cautioned that naloxone is an effective drug, but it isn't benign. It can result in patient withdrawal. He stated that if a person could be supported by bag-valve mask use, it might be more acceptable than having police officers send a patient into withdrawal. In addition, there are issues associated with the cost and availability of the drug—even for EMS systems.
He said what's really needed in an altered mental status patient is early BLS/ALS treatment, and the use of Narcan should be given when several parameters are met and—even then—at dosages of dosage of 0.4 mg to 2 mg.
What is the Responsibility of the Eagles Audience?
Presented by Edward M. Racht, MD (American Medical Response)
In a very powerful and compelling 10-minute lecture, Dr. Racht spoke from his heart to the audience about what they need to do with the knowledge they've learned over the past two days after they leave the Eagles conference.
He presented several “Captain Obvious” things:
• We can learn a lot in 10 minutes;
• Humor (and sometimes irreverence) adds to the experience and allows us to accept the science of the day;
• There's merit in faculty changing their slides often moments before they speak to keep it as current as possible;
• It's OK to disagree with each other;
• There's merit to science with no fluff;
• When lecturers are (or people) "different" (i.e., quirky), they turn people’s heads;
• If we stay banded together, we can change EMS;
• It’s good to leave a conference like Eagles with lots of "what ifs" and wondering "how can I change our system."
• We must change with the times and embrace the power of change; and
• You have to develop the “art” of getting the important messages learned at a conference like Eagles to the masses to change the evolution in the practice of EMS and medicine.
Eagles’ Special Salutes: The Copass and Slovis Award
Presented by the U.S. Metropolitan Municipalities EMS & Federal Agency Medical Directors, Colleagues and Friends
The prestigious Michael J. Copass EMS Medical Director Leadership Award was given to long-tenured EMS medical director R.J. Franscone, MD, from the Twin Cities area of Minneapolis/St. Paul.
The Corey Slovis EMS Educator of the Year Award was given to metropolitan Oklahoma City and Tulsa EMS Medical Director Jeffrey Goodloe, MD.
Gas-Guided Goals: New “End-Tidal-ments” for Trauma Resuscitation
Presented by Jason T. McMullan, MD (Cincinnati Fire Department)
Dr. McMullan pointed out that end-tidal carbon doxide (EtCO2) is very helpful for measuring ventilation quality and, most recently, septic shock (perfusion), but can also be useful in detecting hemorrhagic shock and lead poisoning. He noted that extreme caution must be taken in the polytrauma patient that has a head injury. He also said that 1 mm difference (drop) in EtCO2 could represent a 4% decrease in cerebral perfusion.