Covering an unprecedented number of topics, the 19th Annual EMS State of the Science: Gathering of Eagles Conference concluded Saturday afternoon with 910 attendees treated to rapid-fire lectures presented by the “Eagles”—medical directors from the largest municipalities and EMS systems in the United States, Great Britain and New Zealand.
Led by founder and coordinator Paul E. Pepe, MD, MPH, the faculty of 40 EMS medical directors presented talks that immersed the attendees’ brains in the “state of the science” of EMS, including the latest thinking, protocol changes and explanations of what procedures and practices may be in store for them in the near future.
Eagles Lightning Round #2: Messages from EMS Fellows
In a new twist, Pepe and Medical Director Andrew Harrell, MD, from Albuquerque, N.M., started the morning out in a unique and refreshing manner with an EMS Fellows Lightning Round, where physicians involved in EMS fellowships took the stage alongside their supervising “Eagle.”
These bright young men and women, who will eventually move associate medical director positions, filled the room with their enthusiasm as they fielded questions from the audience and answered them with great poise and confidence. Here are a few of the recommendations, comments and lessons learned presented by tomorrow’s EMS medical direction leaders:
- Listen to the EMS and ED providers;
- Be an advocate for field providers and have great respect for what they do, often under very stressful and challenging conditions;
- Listen to your patients;
- You are an advocate for all patients;
- Be an advocate for a specialty by advancing protocol changes, etc.;
- Measure what you do and improve upon it;
- Get as much experience as you can;
- It’s not just about the equipment and technology, but more importantly, how you train your providers to implement it and use it. (The example presented was ensuring providers learn to put a mechanical CPR device in operation in less than 30 seconds to ensure the emphasis is on uninterrupted compressions resulting in cardiac perfusion and reducing “time off chest”);
- Use a “Just Culture” approach to QA and have a QA/QI “system” that doesn’t just hunt for bad things and reprimand people for errors, but, instead, makes providers feel comfortable coming to their medical director;
- Be familiar with the fire and EMS agencies—and their collective bargaining agreement;
- Be patient because change doesn’t always come quickly;
- There is an art to medicine and not everyone does it the same way and at the same time;
- The fundamental problems that medical directors and EMS providers face are all the same;
- Provider safety is a concern (i.e., don’t do CPR in a moving ambulance!).
Evolving Considerations about EMS Stroke Management
Jon Jui, MD (Portland, Ore.), talked about large vessel occlusions and the stoke screens being used throughout the country. He noted a stroke center should strive to meet the American Heart Association’s goal of stroke care within six hours of patient onset of symptoms. He also pointed out that only 25% of large vessel strokes re-canalization after administration of tPA.
Jui noted that M1 is the first major distribution branch coming off the internal carotid artery, is most easily detected and that there ‘s new stroke imagery (MRI and CTA) technology coming in the future which will help everyone (including EMS) identify large vessel occlusion (LVO) strokes and combat strokes. He stated that C-STAT assessment for LVO strokes can be performed “without calculations” and does not require “grading of weakness and other parameters” making it easy for EMS to follow. His early results after implementing use of the C-STAT assessment criteria has been highly accurate and offers promising results.
Sophia Dyer, MD (Boston), talked about a new stroke/trial program that Boston is rolling out in hopes of narrowing time-to-care for stroke patients. Dispatch will add a few areas to their Boston 9-1-1 caller questioning and call dispatch processing, getting a family contact number to ascertain (when possible) the medications (particularly anticoagulants) that a patient is taking.
Peter Antevy, MD (Broward & Palm Beach, Fla), talked about connecting the GWTG stroke registry and the Florida-Puerto Rico stroke registry to provide data dashboards to hospitals so that they can compare their stroke quality to others. This would be similar to what CARES is doing for cardiac arrest. The program launched on January 1st 2017 and has potential to scale nationally.
Excerpts from the January 2017 NAEMSP Conference
Brent Myers, MD, president of the National Association of EMS Physicians (NAEMSP) kicked off his presentation of highlights discussed in last month’s NAEMSP annual meeting with a famous quote by Dwight D. Eisenhower: “We succeed only as we identify in life, or war, or in anything else, a single overriding objective and make all other considerations bend to that one objective.”
Myers noted that NAEMSP had over 200 research presentations this year. One, on spine board use showed no difference or incidence when spine boards were not used. He also reported that NAEMSP discussed several legislative issues. including the important DEA bill.
NAEMSP will be presenting lectures that further detail the major topics discussed at their January 2017 conference at EMS Today: The JEMS Conference and Exposition in Salt Lake City next week.
Eagles Lightning Round #3
The Eagles again fielded questions from the audience, offering up these bits of wisdom.
- Comforting the patient is important … in addition to treating and medicating them;
- Fentanyl is an important medication for EMS and continues to be studied;
- EMS medical directors need to support their EMS personnel and not allow an ED staff member to give them sh#t!
- The need to curb “disruptive physicians”; a philosophy supported by the Joint Commission was pointed out;
- Bring AED data to the receiving hospital ASAP because its data can be very important to the care of the patient. San Diego has a very successful program that has saved almost 200 patients.
- George Hatch, EdD, LP, EMT-P (below), the executive director of the Committee on the Accreditation of Educational Programs for the EMS Professions (CoAEMSP) commented that medical directors must be actively engaged with their personnel and not be what he termed “Milk Carton Medical Director,” one who can’t tell who their paramedics were if they were in the same room. His comment drew a rounding applause from Eagles conference attendees.
Copass and Anderson Awards
The Michael Copass Award, which honors the exceptional contribution made by legendary Seattle EMS Medical Director, Mike Copass, was presented to Michel Levy, MD, medical director of the Anchorage Fire Department for his outstanding contributions in science, clinical care and education—efforts that improve EMS not just in his system, but in systems worldwide.
The prestigious Ronald Anderson Memorial Award was presented by the Eagles to Peter Antevy, MD, a person who the Eagles feel has made outstanding contributions to EMS and mankind, particularly in his efforts to improve pediatric assessment and care as well as in many other areas of adult/pediatric EMS and maladies.
Challenges of EMS Practice
Fionna Moore, MD, (London, UK), spoke about a BBC Documentary that was filmed with the London Ambulance Service, which serves a population of 8.6 million people, and the impact it had.
Glenn Asaeda, MD, (New York City), the chief medical director of FDNY (which also serves a population of 8.5 million), spoke about what happened when one of their affiliated/contracted voluntary 9-1-1 response agencies/hospital suddenly went out of business under a Chapter 7 bankrupt filing on February 25, 2016.
A Chapter 7 bankruptcy is a liquidation filing that means an organization/business is going completely out of business on a certain date, a significant difference from a Chapter 11 filing that means an organization may try to recover from their financial difficulties and return to a service status.
FDNY transports 1 million patients annually so the 81 ambulance tours (accounting for 7% of daily transports) that disappeared, literally overnight, had a major impact. But by instituting an ICS-type system and several new staffing and vehicle approaches, FDNY was able to increase staffing and vehicle availability.
Jeff Goodloe, MD, (Oklahoma City/Tulsa), shared one solution for hospital diversions to help crews and patients avoid experiencing excessive “wall times.” He talked about the diversion of STEMIs, strokes, etc., noting that patients in the OKC/TUL system being transported to hospitals requesting divert are diverted if the patient is UNstable. If the stable patient is “established” (via a prior admission, recent ED evaluation, or has a treating physician referral) then the medics override divert status and transport to the original destination. Since these patients are clinically stable, they can often be transitioned to non-tele ED exam areas, triage, or even the waiting room.
John Gallagher, MD, (Wichita, Kansas), spoke of important considerations in credentialing, asking the medical directors if they would be willing to sign off on every paramedic if their job depended on it. He cited an NAEMSP/NREMT position paper on clinical credentialing of providers that details four key domains: accredited education, certification, licensure and credentialing.
Mass Casualty & Active Shooter Reports
Multiple Eagles reported on large MCIs, mass shooter incidents and special events that occurred over the past year. The audience heard general information regarding the Orlando Pulse Nightclub and Fort Lauderdale Airport incidents (specific details about the Fort Lauderdale MCI were not presented since the incident is still under investigation) and the complexities of covering the Super Bowl in Houston and the parade through Boston a few days after the big game. Both cities were well-prepared to handle each event. Pepe, a true innovator in education, also wowed the audience by including Dr. Pierre Carli, SAMU (Paris) Medical Direct in this session via FaceTime.
Special Ages & Patient Populations
Peter Antevy, MD (Palm Beach, Fla), a pediatric specialist and EMS medical director, presented on challenges in pediatric medical care:
- Airway adjuncts: Antevy believes the best option for pediatric patients is to use a BVM and supraglottic airways, such as the King (multi-sizes), LMA (multi-sizes) & I-Gel (multi-sizes), all which now come with gastric ports. He recommended use of the NeoBar to hold the smaller sizes, specifically for the I-Gel, which doesn’t currently have hooks on them to secure then in place.
- Pain: All pain should be scored and documented. Antevy noted that Fentanyl works faster than Morphine, and that there’s some dead space in the MAD device that restricts 55% of a dose when given to a very young (e.g., 4-month-old) child. Ketamine is very useful in pediatrics but with a few caveats. If Ketamine is given too quickly, it can cause laryngospasm in children, and so he recommends a 10 mg/mL concentration, not the 100 mg/mL concentration used IM in excited delirium. Secondly, the volumes in pediatric patients is so small when using the 100 mg/mL concentration that errors are more likely. Most systems now use Midazolam because it’s fast acting and works via all routes, with the best routes being intramuscular or intranasal. Dosing for these 2 routes should be higher than the IV route.
- Hypoglycemia: Antevy recommended that systems use a 250 mL bag of D10W and administer it 5 mL/kg and max it out at 100 mLs, then repeat it as necessary.
- Fluid: Antevy believes in adequate fluid resuscitation of children and that he used to use the syringe “push-pull” method to get fluids on board but recently saw, used and likes the new LifeFlow Rapid [fluid] Infuser, a device that looks like a “Back to the Future” water gun and allows you to insert a 10 mL syringe and give 10 mLs per pull on the device’s trigger, allowing that ability to give 500 mL in less than 2.5 minutes. (He pointed out that the 10 mL syringe offers much less “push resistance” than a larger syringe (e.g., a 50 mL syringe).
Scott Gilmore, MD, (St. Louis), spoke about children with special needs. Showing a slide of a crib with a ventilator and BVM on a nearby shelf, Gilmore noted that one in 12 children have special healthcare needs. He then spoke about the STARS Program, developed by two paramedics, which is color-coded and easy to follow.
Ed Racht, MD, (AMR National), spoke about how concussions, a malady that’s often neglected, have now become a priority for EMS assessment and care. The CDC estimates there are 1.6 to 3.8 million annually. Racht discussed:
- Chronic Traumatic Encephalopathy (CTE) is a degenerative disease that develops after repetitive concussion and can have devastating effects on people, as acknowledged recently by the NFL; and
- Second-Impact Syndrome (SIS) occurs when the brain swells rapidly and catastrophically if a person has a second concussion before the first one has a chance to heal.
He recommended EMS services become familiar with the Sports Concussion Assessment Tool (SCAT 3), which is available online.