The more than 50 “Eagles” Medical Directors attending the 17th annual Gathering of Eagles Retreat in Dallas communicate on a daily basis. This week the Eagles reviewed many of the issues that have been discussed over the past few month and areas that are still “Hot”. This is accomplished via a lively, private, roundtable discussion of issues being confronted in their systems. This information is valuable for EMS systems of any size to review, consider and address.
JEMS Coverage of 2015 Gathering of Eagles
Highlights: Part 1 | Part 2 | Part 3
A summary of some of the key Eagles discussion areas are presented here:
Why do Eagles share issues & concerns on a daily basis?
- So they can share best practices
- Address important problems
- Allow Industrial tourism, which means Eagles virtually “visit” the other EMS systems that contribute answers
- It’s a highly efficient way for rapid information sharing
- Make decisions ahead of the literature
How do the Eagles share?
- It is how all EMS Leaders share? (A discipline set a while ago)
- Quick Questions, Short Answers
- They attach important documents if needed
- An Email thread is consolidated and sent back rapidly to the “flock”/group
- Additional discussion follows on hot issues
- Some get assigned for Eagles presentations, or “consensus” papers (Not policy statements)
The Most Active Topics in the Past Year:
How tourniquets are currently being placed in Eagles’ systems?
- In Law Enforcement (90%)
- In Tactical (almost all)
- For law enforcement, most are trying to pair with gloves, trauma gauze, and AEDs
What is response to medical alarm calls & lift assists?
- Who goes on these calls? (Over 50% do ALS response with Red Lights and Siren (RLS). Others are responding with an engine using RLS, and the ambulance without RLS)
- Who is needed? (Systems continually attempt to get to the right set of MPDS questions to determine how many needed for safe patient movement)
- Is there a charge for “lift assist”? (No)
- Charges for repeated false calls? (Not yet)
How is trauma triage performed & destinations determined?
- Transport to Level I and II Centers when using CDC trauma triage criteria, or similar
- Most systems transport to Trauma Center Level I/II if a person is in the same vehicle as a fatality, if a tourniquet is used, or if another likely surgical emergency
What tools are used & needed for EMS quality improvement?
- Time on Chest (TOC) in CPR cases, using Monitor-Based Programs (CodeStat) (90-95% Threshold) The GOAL = no cases with lower than 80% Time on Chest
- Points to need for rapid review of airway management cases, and good ED interfaces, and use of machine-based code summaries
- Missed Intubations or poor airway decisions? Waveform ETCO2 is changing the game!
- Lack of opportunities to get hospital intubations is resulting in the need for more simulation hands-on training/exposure/evaluation.
What medications are used for EMS pain management by the Eagle systems?
- Fentanyl (60%)
- Morphine (43%)
- Ketamine (16%)
- Ketorolac (16%)
- Nitrous Oxide (6%) — Mostly outside the USA at present
- Dilaudid (6%)
- IV Acetaminophen (1 system)
What happens when unrecognized esophageal intubation occurs?
- Jeff Goodloe, MD: “Our ethical duty is to not have unrecognized esophageal tube fail one patient and their loved ones.”
- If there’s NO CO2 waveform or it is lost, yank the tube!
- Waveform use should be extended until after ED turnover of the patient
- Failure means 30 days without the ability to function as an ALS provider, and remediation
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The 3 Sins of Modern EMS presented by Ray Fowler, MD (“The First Eagle”)
- Unrecognized Esophageal Intubation
- Unsafe Vehicle Operation
- Paramedic refusal to Transport
How Narcan is being used/deployed
- EMTs (There is support by 80% of Eagles for EMT use, but only 20% are currently using)
- Use Intranasal (most have as first line for BLS, option for ALS)
- Law Enforcement (mostly pilot programs, state laws are changing)
- Public programs (families) becoming more prevalent
- The Eagles stress the importance of Medical Direction, Shared Protocols and training materials
What are effective transport policies?
- Transport Rate (The range is from 43% to 86% of incidents resulting in an EMS transport, with the largest segment in the range of 70 to 80%)
- Cardiac Arrest and Termination of Resuscitation (TOR) (50%)
- PEA (Yes or No)
- To Freestanding ED’s (Yes, where available)
- Transport to Psychiatric Facilities (OK if available and fulfills EMTALA)
- Inebriates (Many are working on better programs)
- “Familiar Faces” (Many are working on Case Management)
What Tools are being used for airways?
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Type of Supraglottic Airways in use?
- King still the King, then LMA
- Many systems in the process of moving to iGels
- Disposable ETT Blades? (Yes in about 50%, no predominant type)
What are Eagle responses to the medication shortage?
- Use of substitution lists for each medicine in the drug box
- Epinephrine Kits which are simple kits containing vials of epinephrine with small needles, that replace very expensive epinephrine injectors, that are also very difficult to obtain due to shortages (Seattle, and Minneapolis have model programs)
- Use of D10 bags as an alternate for D50
- IV Solution Rationing
- Just in time Education programs for the paramedics on any substitute medications, or those that are present in different forms
Are these elements in use?
- Plasma (No, except Richmond, VA, pilot in Denver and helicopters)
- Midazolam (Yes, IV, IM, IN, IO, Peds)
- Glucagon (Decreasing availability, used in 1-2 patients per 1,000 seen. Now as much as $250 a dose)
- CO Monitors (Yes for patient monitor, and a growing number using ambient air monitors)
- Duodotes (Yes, on many front line vehicles)
- iStats (No. But are being used in some helicopters and at marathons)
- Opiate Restrictions (No)
Other Hot Topic Areas for Medical Directors and the Eagles
- The availability and packaging of critical EMS medications, and their alternatives
- Devices to use
- Communications & Technology
- Response and Transport
- Cardiac Arrest and TOC
- Trauma
- Quality Personnel and Quality Management
- Skill decay
- Major Incident Management
- Role of the EMS Medical Director
<– Back to Part 1 | Go to Part 3 –>
Would you like Access to the Eagles Library? Go to the “Eagle’s Nest” at www.gatheringofeagles.us.