The Metropolitan Medical Directors Coalition (AKA “Eagles”) 21st Annual Retreat (AKA “Eagle Creek”) was held Wednesday and Thursday, February 27 and 28, at the Dallas Sheraton Hotel under the leadership of Paul Pepe, MD.
The closed, invitation-only retreat is attended by 70 medical directors from the most-populated metropolitan EMS systems as well as 18 EMS fellows–33% of the nation’s current EMS fellows. This group oversees EMS for a combined population of over 114 million people in the United States and abroad, with representatives from Canada; Germany; New Zealand; Italy; Amsterdam, The Netherland; Bangkok, Thailand; the United Kingdom and France.
In two agenda-packed days, participants chart the future of EMS, discussing major issues such as the problem of opioid overdoses, behavioral health, news media coverage and inaccuracies being inflated or misreported nationwide; as well as areas to address in the future. The Eagles conducted an amazing number of member surveys during 2018, and the group is an important network facilitating the collection of data and information to plan, develop, change and advance EMS practices.
Although exact details and discussions are restricted to attendees, JEMS got an inside look at some of the key medical and trauma areas discussed this year.
Resuscitation and Head-UP CPR
A topic of particular note was the synergistic effects of head-up CPR in conjunction with active compression-decompression CPR (ACD-CPR); proper, uninterrupted compressions; and intrathoracic pressure regulation (ITD) devices as part of a true bundle of care approach to out-of-hospital cardiac arrest. Head-up CPR has been found to:
- Drain venous blood from the brain;
- Lower intracranial pressure (ICP) and allow optimal cardiac perfusion of the brain;
- Reduce the concussion effect (i.e., injury) to the brain during resuscitation; and
- Enhance right to left heart circulation (similar to sitting a patient up when they are in congestive heart failure).
Head-up CPR results when performed in the proper sequence, combined with the proper “Bundles of Care.” Data courtesy R.J. Frascone, MD
In a detailed discussion of head-up CPR and resuscitation practices by Joe Holley, MD, (Memphis, Tenn.); R.J. Frascone, MD, (St. Paul, Minn.); Charles Lick, MD (Allina EMS in Minneapolis); and Paul Pepe, MD, (Eagles Coordinator), special caution was advised for EMS systems as it needs to be implemented the right way as the science becomes clearer.
Head-up CPR results when performed in the proper sequence, combined with the proper “Bundles of Care.” Data courtesy R.J. Frascone, MD
Pepe stressed that systems shouldn’t rush into it, because iot’s been found that it has to be done in conjunction with “priming the pump” properly over a certain duration before it’s applied, and then needs to be adjusted over time. It’s not a fast, early (first moments) therapy that can be applied immediately on arrival, but one that must be introduced in the proper sequence and with the correct timing. The current optimal sequence and height is reported as two minutes of quality CPR “priming”, which is most effective when an ACD-CPR device or the LUCAS 3.1 is used, followed by elevation of the head and thorax gradually over two minutes.
The new, EleGARD Patient Positioning System to carefully perform Head Up CPR with mechanical devices held securely at the proper angles. Photo courtesy AdvancedCPR Solutions
The new EleGARD System from AdvancedCPR Solutions, which facilitates the careful performance of head-up CPR with mechanical devices held securely at the proper angles, was discussed and demonstrated to the Eagles.
Pepe reiterated that head-up CPR is just one of the many critically important bundles of care, which should all be used together during resuscitations to achieve optimal success.
Key Discussion Areas
Other topics discussed by the group included:
- The importance of teaching EMS personnel the positive effects of internal pressure regulation with the impedance threshold device (ITD) was discussed. (This video from ZOLL was also mentioned.)
- Occupational stress and burnout in EMS, including a study that used the “Copenhagen Burnout Inventory,” which will be featured soon in JEMS;
- The potential impact of the new CMS reimbursement model/pilot programs on EMS systems, particularly as it relates to treat and release and telehealth/telemedicine;
- Status of use of tranexamic acid (TXA);
- Emphasis on getting ED staff to “listen” to EMS reports on arrival.
- Amsterdam has a “Dr. Repeat-Back” system in place; U.S. systems use the Columbus, Ohio, Fire Depratment MIST 30-second report and the St. Louis Fire Department’s MIST-E, which includes a radio report/ETA and follow-up in ED with MIST repeated on arrival;
- Current practices in, and additional need for, leadership training for EMS officers and new medical directors and training supervisors;
- Cardiac arrest drug dosing intervals;
- Use of amiodarone (the most frequently used drug in cardiac arrest by the Eagles) vs. l;idocaine;
- Physician response programs and experiences;
- Use of resuscitative endovascular balloon occlusion (REBOA) in the field via common femoral artery access (including a report from the New Jersey physician response car system, which is also using transesophageal echocardiogram (TEE) in the field);
- Washington, DC FD program (“Right Care/Right Time”) that has callers go to locations via non-EMS resources like LYFT;
- Unique “Garage Time” training and updating of staff;
- Pain management drug status, including the use of IV acetaminophen (Tylenol), which is being used in some systems with positive effects;
- Naloxone programs, including progress made and problems experienced, as well as a special report on the Columbus RREACT program;
- The increasing use of extracorporeal membrane oxygenation (ECMO) and a report on the 42-foot mobile hospital with ECMO capabilities that will be on the road in Summer 2019;
- The positive results systems are experiencing with ACD-CPR;
- The success of departments like the Rialto (Calif.) Fire Department and systems in the Minneapolis/St. Paul, Seattle and Palm Beach County (Fla.) areas after revising their practice and protocols to follow a bundle of care approach to cardiac arrest (Palm Beach County has perfected LUCAS application in five seconds to ensure continuous, uninterrupted compressions–one of the keys to resuscitation success);
- The use of naloxone kits in the streets, including a well-written Palm Beach County overdose protocol; and
- Concerns about recruitment and retention of paramedics, as well as about the way systems are adding skills and medications to their BLS personnel.
Find follow-up reports and articles on jems.com and follow JEMS on Twitter for more from #GatheringEagles2019.
