The 19th Annual EMS State of the Science: Gathering of Eagles Conference, “dedicated to the men and women of EMS who advocate daily for the sick and injured,” began today, packed with 85 topics, faculty and attendees ready to dive into and learn about the latest in EMS and prehospital care.
The conference began at 7:30 a.m. with the conference overview and philosophy presented by Raymond L. Fowler, MD—officially dubbed “The First Eagle”—and course coordinator, Paul E. Pepe, MD, MPH.
Top 5 Studies of the Year
The conference began with a customary review of “The Five Most Important Publications of the Past Year” presented by one of the most popular Eagles and conference presenters, Corey M. Slovis, MD, the medical director of Nashville EMS, Nashville Fire Department, Nashville International Airport and professor and chair of emergency medicine at Vanderbilt University.
Because this is such a valuable and fast-paced presentation done in two, 10-minute sessions, I recommend that you go to www.gatheringofeagles.us to read it, as well as the other presentations referenced below. You will then be able to review the statistics and can begin to work to address these issues in your own agency and community.
Studies Dr. Slovis covered included a look at the best antiarrhythmic for shock-resistant v fib/v tach (amiodarone or lidocaine). In the field it is hard to say either makes a difference.
Other research examined what works and what doesn’t in cardiac arrest. Dr. Slovis emphasized that what really makes a difference in resuscitations is: 1) high-quality CPR; 2) minimizing interruptions; and 3) reviewing your resuscitations. The literature also looked The importance about giving epinephrine after the 2nd shock, not before it.
A study looking at nitroglycerine warns against its use in tachycardic patients, where patients experienced a heart rate increase of 35% and it caused hypotension.
Finally, Dr. Slovis cited a terrific study conducted in Paris involving 2,799 patients that clearly showed the three criteria to be met in order to be relatively safe in terminating a resuscitation.
Provider Wellness: Caring for Those Who Care for Us
Jeff Goodloe, MD, (Oklahoma City/Tulsa) offered these points:
- You have to take care of the people taking care of people;
- Allowing longer response times of 2 mins (high priority) and 12 minutes (medium priority) does not adversely impact patient care;
- LEAN/Six Sigma principles showed that “scene time” and “total mission time” were important variables in achieving more down time between calls and finishing ambulance shifts on time. Both goals are important to crew physical and mental health. Crews working more efficiently saved nearly 20,000 ambulance hours in a year, adding back 2.25 ambulances in the system at no financial cost AND improving employee morale.
Jose Cabanas, MD, (Wake County, NC) said that his system has used high-fidelity simulation to help crews prepare for difficult or physical patient encounters, recognize the “point of no return” and know when to leave a scene.
Robert Dunne. MD, (Detroit) said that EMS personnel must be trained to defend themselves and also be trained to diffuse incidents. He also suggests agencies have an excited delirium protocol and that EMS and fire be closely linked with law enforcement.
Marshall Isaacs, MD, noted that crews have many problems after a traumatic (emotional) incident and have problems with drug and alcohol abuse and PTSD, but there is hope beyond an employee assistance program. Dallas Fire Rescue is implementing a very comprehensive program to follow and assist employee – the Dallas RENEW (Recovery, Employee Network Emotional Wellness) program.
Peter Antevy, MD, (Broward & Palm Beach County Florida) said that traumatic stress after a pediatric call cannot be prevented by critical incident stress management (CISM) alone. He said that your brain goes in different ways based upon the call and the patient. You feel one way when responding, then another when you get to the patient. What we really have to get to is closure no matter what the circumstances, knowing that you did the best you could for your patient.
Don Locasto, MD (Cincinnati) in a presentation titled “Point of Care Testing Gone Viral,” showed how we can take care of ourselves better after disease exposure. They have a novel exposure program that tests blood (rapid HIV test) ASAP and starts treatment after exposure. They implemented the OraQuick HIV test kit and eliminated many of the hospital hurdles that previously existed.
Emily Kidd, MD (Acadian Texas) spoke about the way the Texas Emergency Medical Task Force leveraged the Texas HCID (High Consequences Infectious Disease) Response Unit by making sure there are caches of PPE equipment available at a moment’s notice. The Texas Infectious Disease Response Unit (IDRU) also provides for clinical expert teams and expert EMS transport teams. LION Apparel designed an innovative PPE Suit that includes a PAPR
Current Thoughts on Frequent Users of EMS
Jim Dunford, MD. (San Diego) spoke about how emerging technology can target “healthcare hotspots” by mining EMS data. Through a federal grant San Diego developed a cloud-based Regional Health Information Exchange. San Diego Fire-Rescue created a community paramedic program (the Resource Access Program, or RAP) and a cloud-based case management dashboard to identify, sort (ex., homeless, mental illness, elderly), prioritize and alert on repeat EMS users. RAP medics visit clients at home to address underlying social issues. As participants in the 2-year California Community Paramedicine Pilot Program, RAP also intervenes during non-acute calls to provide alternate destinations for their frequent user clients. RAP supported Project 25, a regional initiative providing permanent supportive housing and case management to the City’s 25 most impactful individuals. P25 resulted in a $2.6 million savings to police, fire, EMS, jail, mental health and hospitals over 2 years.
Thanks to a grant to the CA EMS Authority from the Office of the National Coordinator for Health Information Technology (ONC), San Diego is currently developing the first bi-directional EMS-HIE exchange, which will provide Search, Alert, File and Reconcile (SAFR) functionality. Medics will receive patients’ pertinent past history, meds, allergies (and POLST form) within minutes of logging onto the HIE. Patient outcome data including ED diagnosis will be provided to EMS providers. Jim predicted real-time EMS alerting will become a valuable tool to improve individual and population health including automated notification of PCPs for patients with recurrent hypoglycemia, seizures and falls.
Arthur Yancey, MD (Atlanta/Grady) spoke about how they are deploying and using the “Grady EMS Care Delivery Team” (Community Paramedicine) to provide advance practices via a mobile X-ray unit, provide or change batteries for medical devices, gathering with medical and spiritual resources. The paramedics team up with an advanced practice provider to deliver services that keep patients from getting sicker and returning to the hospital. They use online medical direction and other approaches to reduce call demand as well.
Substance-Abusers & Other Behavioral Health Patients
Clemet Yeh, MD, (San Francisco) spoke about the San Francisco Sobering Centers and their extreme value in an EMS system and, more importantly, a community in which the problem of alcoholism exists. SFFD paramedics/ambulances are allowed to transport patients to these centers if their patients meet specific criteria).
Mike Levy, MD, (Anchorage), said that the Anchorage Safety Patrol does a great job of finding inebriants and getting them to a center before they turn into Alaskan Popsicles.
Eagles Lightning Rounds #1
It’s rare to go to an EMS conference and find even as many as 3–4 EMS medical directors in the same room, but at the Eagles conference, the entire faculty of 40 Eagles assemble on stage together for two 8-hour days and field questions from about 40 other regional medical directors in the audience. Some of the topics discussed in the popular Eagles Lightning Rounds were:
- The many ways in which a combined police/fire/EMS communications center are managed, but the critical issue is how much involvement and oversight of patient cares aspects EMS has.
- All have termination of resuscitation protocols in place. (Several, perhaps 40%, don’t currently give naloxone during cardiac arrests because they aren’t convinced that it helps unless there’s a real indication that it is an overdose.)
- Minneapolis presented a great idea for airway management: pairing endotracheal tubes together with advanced airways in their airway kits so either can be used as necessary without delay.
- The recording option on video laryngoscopes has been valuable to many systems in training as well as correcting deficiencies and improving overall intubation success.
- For violent, agitated patients, many systems are using Versed (10 mg administered intramuscular) and Geodon. Some are using ketamine for extremely agitated patients.
EMS Evolution with Law Enforcement, Public Health, and the Community at Large
Marc Eckstein, MD, (City of Los Angeles), spoke about high volume system users and the need for EMS to embrace the fact that we are a part of the overall public health system. He said that EMS Systems have to be proactive, find them and addressing their need. See Dr. Eckstein’s complete lecture slide set for more specific details.
Pepe and Slovis Award Winners
The winners of the 2017 Paul Pepe and Corey Slovis Awards were announced for two very deserving Eagles:
- Peter Antevy received the Paul Pepe Award for his outstanding contributions to EMS
- Marc Conterato received the Corey Slovis Educator Award