On June 30, 2010, Dr. Jullette M. Saussy is currently the director and medical director for New Orleans EMS, and also serves as medical director for the New Orleans Fire Department as well as the chief medical officer for the Office of Homeland Security and Public Safety in the city of New Orleans., presented a webcast on how EMS is driving care. During the webcast, we were able to answer only a handful of questions. Here are Dr. Saussy’s responses to all other questions submitted by attendees.
Q: What is the ITD?
A: Impedance threshold device. Google “ResQPOD”—it’s a device that maintains negative intrathoracic pressure thereby increasing venous return to the right heart. This helps maintain coronary artery perfusion pressures, right heart pressures and intracerebral blood flow.
Q: Wasn’t a clinical trial stopped recently using the ITD?
A: The ROC PRIMED trial was stopped for many reasons. One finding in their study was no difference in outcomes using ITD. Remember, this was a huge study in multiple places with less-than-optimal standardization. We’re trying to look at this in a smaller, more manageable system to see whether it makes a difference. So far (and it’s early) the “bundling” including the ITD is making a difference ROSC and survival to discharge neurologically at baseline. The jury is still out, but physiologically it makes sense.
Q: Out of the return of spontaneous circulation (ROSC) cohort, what number survived?
A: We’re working on our survival data now. As you know, this is often difficult to obtain. We should have it by end of August. I personally know of five survivors who walked out; two were double sequential defibrillation cases for refractory VF.
Q: Did you separate the survival numbers by ITD alone and hypothermia alone, versus together?
A: That’s the plan. The numbers are too small now.
Q: Do you measure quality of CPR?
A: That is why we deploy the LUCAS device to assure quality and uninterrupted CPR.
Q: Shouldn’t there be an arm study with ITD alone? I understand the ROC trial with ITD was stopped. I agree with your ideas on varying arm studies, but I feel it is a foregone unproven conclusion that ITD is the “key” to ROSC alone.
A: I agree. I don’t think there’s a “key.” I think bundling is the way to improve survival moving forward. The question is what combination of bundling is most productive and worth the cost. To any survivor they would tell you its worth the cost, but it’s a historically poor outcome disease state so we must really drill down and figure out the cost/benefit to our treatments moving forward.
Q: My understanding with respect to external compression devices is that if ROSC; is not obtained quickly that the likelihood of neurologically intact patients is decreased. The areas that use this device do not have documented higher rates? Thoughts?
A: Our experience has been that the CPR devices have multiple utilities and improve ROSC; they allow the medics to focus on other areas surrounding “working” the cardiac arrest; they decrease fatigue and injury; we have seen improved ROSC rates in my area with this included in the “bundle” of cardiac arrest tools. How can one argue with consistent, uninterrupted CPR in the out-of-hospital cardiac arrest (OHCA)?
Q: Do you have any manual CPR vs. LUCAS CPR statistics? Is it easy to apply and use?
A: It is very easy to use. What we have is improved ROSC rates with these devices as part of a “bundling” mentality for OHCA, including impedance threshold devices, intraosseous—preferably the humeral head as immediate access to central circulation, induced hypothermia and CPR devices.
Q: I’ve tried to make the argument to our medical director many times about morphine and hydromorphone or fentanyl, and I’m told that morphine is cheap, safe and very effective as an analgesic and for use in pulmonary edema. Any suggestions on study data I can present?
A: Look at my PowerPoint at www.gatheringofeagles.com for safety profile on fentanyl. My opinion, clinical experience, and budget analysis says fentanyl is the same cost as morphine with less waste, quicker onset, less sedation and less vasoactivity. It’s also shorter acting should untoward effects occur. Finally, I haven’t seen the nausea associated with this drug that I see with morphine sulfate, and the patients love it when they’re in pain.
Q: What temperature device did you use for your “Code 80?” I tried to implement an infrared thermometer to maintain a “social distances” of six feet but found them to be irregular on the actual readings.
A: An inexpensive digital thermometer with inexpensive sheaths worked beautifully and provided very useful information for hospital and crew. It allowed us to do surveillance maps and keep statistics as the pandemic played out.
Q: Have you thought about taking proof pictures of successful intubations? I heard from some groups doing this with C-MAC.
A: I haven’t, but it’s interesting. It may be worth the time, but a good quantitative ETCO2 reading and good documentation has sufficed. As the saying goes, they say “a picture is worth a thousand words.”
Q: What do you see as the future of expanded practice paramedics who can treat and release people that need care, but not ED as a way of decreasing ED traffic?
A: I’m very, very excited about this for a number of reasons. A few caveats: It must have very strong medical direction with 24/7 access to system doctors to discuss cases. Standing orders with not enough in depth education is dangerous. Paramedics don’t diagnose or treat and release without medical control.
Where I do see this going is as community outreach to prevent unnecessary trips to an emergency department (ED), including BP checks, glucose monitoring, wound checks, packing changes, general follow up post urgent care, primary care or ED discharge to avoid revisits. Just imagine if you could help your community of diabetics and hypertensive patients keep a good log of their BP and glucose checks on a jump drive and e-mail it to their primary doctor, or have them keep all their info on the jump drive so anyone could access it in primary care setting or an emergency setting.
A world where everyone has all their meds, allergies, history and logs of vital information on a drive created by their health-care practitioners (of which these EPPs qualify)? There are so many worried well visits, such as high glucose, wound check, sutures, that could be redirected to a branch of prehospital emergency medicine (EM).
Q: How could we get a copy of your double sequential external defibrillation protocol?
A: I got mine from Dr. Brent Myers in Wake County, N.C. It’s on their Web site at www.wakegov.com/NR/rdonlyres/3BD4E0B0-1A9C-40FC-A73B-A622A332CCAD/0/WakeCounty2010ClinicalOperatingGuidelines.pdf
Q: On any given day, what are the criteria to implement the expedited offload directive?
A: Lately, every day at every hour we are on expedited offload. In the beginning, it was when we were down to two clear units to cover our city. Hospitals are typically given 20 minutes to offload without issue, but when we are so low on resources, we try to offload by any method we can ASAP. If patient can be placed in a wheelchair they are; if patient on a spine board/C-collar and can be clinically cleared we ask the doctors to do this so they can go in a wheel chair if possible.
Unfortunately, we look for any open bed (staffed or not) in the ED and attempt to give report. Remember, they have “come to the hospital” as defined by CMS. Additionally, we pay a medic everyday to go to the various hospitals and offload our patients to another EMS stretcher until an ED bed becomes available. They are not to stay longer than 40 extra minutes for a total of an hour. This costs us about $400–800 in personnel costs, but allows our units to respond to 9-1-1 calls which more than pays for itself and is what is best for public safety. So far, with our deep budget cuts, this has not been on the chopping block.
Q: Does NOFD stop the clock for you on critical calls?
A: No. We don’t count their times, but I foresee this happening as we move forward and try and get more visibility on their response times, at patient times and time to CPR or AED etc.
Q: What technology or protocols do you utilize to deal with maintaining normothermia?
A: Do you mean do we treat a fever? Do we treat heat stroke? Or do you mean how do we not overshoot while cooling? We do not use meds to treat a fever. We do use ice packs and cool fluids for heat strokes and induced hypothermia post arrest.
Q: How do you expect the MDs to take the liability for patients on the street? I know where I work no MD would take that liability. And who would pay that MD to ride?
A: There isn’t a system in the U.S. or Canada that doesn’t have a medical doctor taking the liability for their medics on the street. That’s delegated practice and what allows medics to work in a prehospital setting. Who is your medical director? He or she is extending his/her medical license every time you respond. Who is your online medical control? Whoever answers the radio and gives orders is extending their medical license.
In New Orleans, we generally have three doctors available in the prehospital setting: me, Dr. Jeff Elder and, depending on the residents’ schedules, an upper-level emergency medicine resident is riding. We all go on calls and answer the radio. In addition, Jeff and I are available by phone 24/7. It isn’t uncommon to see us at a citizen’s house or business or in the middle of the street. This is our specialty. The city of New Orleans pays for me as the director/medical director and Dr. Elder as the deputy medical director; the residency program pays for the resident as part of their education.
It’s an investment in your community and has paid off in terms of decreased malpractice cases. Having physicians on the scene is a billable charge, as is online medical control. It isn’t uncommon to have a resident doing their EMS rotation but more exciting is choosing to ride with NOEMS as their elective. I guess it’s all about if you have an EMS medical director who has chosen this as their career. It’s a great way to serve your community.
Q: Where can we get information on the defibrillation technology most of us didn’t know about and are you using it?
A: Yes we have a double sequential defibrillation protocol and we are using it for refractory VF/pulseless VT. Dr. Brent Myers came up with the brilliant idea and his energy settings allow for up to 720 J. We can only get to 400 J with two sets monitors. But we have two survivors as living proof it works. We were well into these codes and they both walked out.
Q: What hard science is there to back that up 34°C?
A: If you review the literature, moderate hypothermia 33-36 degrees is what has been used; there are a number of articles that speak to this. The most recent is in the July 2010 issue of Critical Care.
Q: Do you see video laryngoscopy as a growing access methodology based on the limited number of intubations that EMS personnel perform and thus translating to ED hospital personnel as well?
A: First of all, EMS personnel (at least in my system) intubate a lot. That being said, I believe we may see a trend toward use of supraglottic airways in future. Video laryngoscopy is expensive, but missing a difficult airway is “expensive” for the patient. If your intubation skills are rusty, video laryngoscopy will be difficult too, so I’m not sure it will help in a low-frequency scenario. I do think that EM physicians, as the front line difficult airway specialists, should have these tools at their disposal and know how to use them. An emergency department (ED) can afford one of these devices, and it can be reused. I just think we need to be proficient in all difficult airway adjuncts