For his fourth and concluding report from the 2016 Major Municipalities Medical Director (“Eagles”) Coalition Conference held in Dallas Texas. A.J. Heightman presents important take away messages from additional sessions presented as well as a list of key “statements” he feels were made, clinical revelations he believes may guide and impact EMS going forward and observations he wants to share with you.
Easy Pieces to Save Lives
— Neal J. Richmond, MD (Ft. Worth) presented an interesting summary of solid quality assurance measures/processes that services can and should follow.
Take away message from A.J.: Dr. Richmond takes a practical and non-punitive approach to QA/QI and measures areas that are beneficial to MedStar’s patients and can improve the effectiveness and clinical competencies of field providers. Unfortunately, many systems have cut back on QA/QI and, in particular, QA/QI staffing due to budget cuts or a de-emphasis by management on this critical EMS system area.
How to Know Low (or Even No) To and Fro Flow: Not Missing an Obstructed Airway with SGAs
— Kathleen S. Schrank, MD (Miami)
Take away message from A.J.: The use of capnography continues to be a gold standard and easy way to ensure the respiratory status, oxygenation and stability of our patients. She cautioned that crew must be alert for proper tracings and check to make sure the connector to their cardiac monitor is twisted clockwise properly to ensure accurate readings.
It’s Humanly Possible to Now Demonstrate Obstructed Arteries with SGAs
— Joe E. Holley, MD (Memphis) — showed the attendees compelling videos of blood flow through cadavers that had ET tubes and SGAs inserted. Most importantly, his early work shows that some SGAs do, in fact, compress vessels and have the potential to reduce blood flow to the brain. In this limited study, ET tube intubation (ETT) scored the highest, followed by the iGEL supraglottic airway (SGA).
Take away message from A.J.: Agencies need to focus on proper crew training and periodic retraining in the proper insertion of SGAs because they are not fool proof; it appears that some SGAs may create undue pressure on structures and reduce blood flow to the brain; and crews must remain vigilant in their monitoring of patient vital signs and remove a SGA if it appears to be negatively impacting a patient.
Apneic Oxygenation and the Best Metrics for Success
— K. Sophia Dyer, MD (Boston) discussed use of apneic oxygenation during intubation in non-cardiac arrest situations..
Take away message from A.J.: Dr. Dyer showed the benefits of adding a nasal cannula, flowing at 10-15 liters to an apneic patient during the delivery of compressions. (See her slide set for a more detailed report — To be available at www.gatheringofeagles.us the week of 2/24/16).
Eight Years of Reducing Medication Errors
— John V. Gallagher, MD (Phoenix) presented a good review of dosing and medication error worth downloading and reviewing.
Take away message from A.J.: There are mistakes made in the field, particularly in medication dosage calculation and administration and crews need to be encouraged to report their errors without fear of retribution. Phoenix Fire Department crew have adapted and adopted Dr. Gallagher’s approach and shown a decreasing error rate because of it.
The Benefits of the Flow Sheet in EMS Care
— Andrew J. (Drew) Harrell, MD (Albuquerque) highlighted the tremendous benefits realized through use of flow sheets and checklists. He cited the book, The Checklist Manifesto, by Atul Gawande, where a checklist significantly reduced surgery patient mortality, and a powerful Podcast (#99) — Combat Aviation Paradigms for Resuscitationists located on EMSCRIT Blog.
Take away message from A.J.: Checklists have proven to reduce hospital surgical errors by 30% and highly effective when used in the delivery of prehosptal EMS and fire operations. He referenced the epic work of Shaughn Maxwell, Snohomish County (WA) Fire District Chief and Medical Service Officer in this area. Maxwell was the recipient of an EMS 10 Innovator of the Year Award for his work in this area and author of a JEMS article on checklist use.
Exports from January’s Exceptional NAEMSP Meeting
– J. Brent Myers, MD, MPH — President-Elect, National Association of EMS Physicians; Chief Medical Officer and Executive Vice President for Medical Operations, Evolution Health, Dallas, TX and Associate Chief Medical Officer, American Medical Response (AMR), presented a review of several key areas addressed at the January 2016 NAEMSP Conference.
A more detailed review of these NAEMSP topics areas will be presented at the EMS Today Conference
Take away messages from A.J.: There is widespread progress and support for H.R.4365 — a law introduced that is designed to clarify the prehospital use of controlled substances. All EMS agencies are being encouraged to contact their federal representative ASAP to recommend passage.
The “Protecting Patient Access to Emergency Medications Act of 2016” (H.R. 4365) Grassroots Advocacy
Background: The “Protecting Patient Access to Emergency Medications Act of 2016” (H.R. 4365), sponsored by Rep. Richard Hudson (R-NC), will allow EMS agencies to continue using standing orders from their medical director to administer approved medications to their patients under the Drug Enforcement Administration (DEA).
The unique nature of emergency medical services is unlike other health care services governed by the Controlled Substances Act. There is a routinely encountered clinical need for controlled substance medications in the practice of EMS medicine, ranging from the administration of pain narcotics to anti-seizure medications.
Despite this longstanding practice of allowing emergency medical service practitioners to administer and deliver these controlled substances under the oversight of physicians, primarily through directional guidelines written by physicians, commonly known as standing orders, the Drug Enforcement Administration has determined that it will not allow emergency medical service personnel to deliver or administer controlled substances through standing orders as the Controlled Substances Act is currently written.
To remedy this dilemma, Congressman Hudson (R-NC) has authored H.R. 4365, the Protecting Patient Access to Emergency Medications Act. This legislation will clarify that the current practice of physician Medical Directors overseeing care provided by paramedics and other emergency medical service practitioners via “standing orders” is statutorily allowed and protected. The use of “standing orders” is necessary so that physician Medical Directors can establish these pre-set protocols which emergency medical service practitioners follow in delivering emergency medical care. In the absence of standing orders, patients would not have access to the time-sensitive and potentially life-saving interventions they so desperately need.
H.R. 4365 ensures patients will continue to receive these vital medications by:
- Codifying the practice of standing orders by a physician Medical Director for the administration and delivery of controlled substances, maintaining physician oversight of medical decisions, while,
- Making the EMS Agency liable for the receiving, storing, and tracking of controlled substances, similar to current procedure at hospitals.
NOTE: A one page-summary and section-by-section are included in the toolkit.
Download the H.R. 4365 Toolkit at http://www.naemsp.org/Pages/Advocacy.aspx
Myers encouraged all EMS and fire agency managers to reach out to their Members of Congress in the House of Representatives and urge them to co-sponsor our bill.
He noted that the NAEMSP Website has a template that can be downloaded and edited to be sent to congressional delegations in the House of Representatives. NAEMSP also recommended that, if and agency does not receive an e-mail response after a week or so, they should call the representative’s office as follow-up.
Each congressional office has a devoted health care staffer whose email/phone number is available on an Excel document on the NAEMSP site. If you do not know your Member of Congress, you can use the “find your representative” function at www.house.gov. It’s located in the top right hand corner and generates your Member of Congress by zip code.
Rep. Hudson (R-NC) is the sponsor of H.R. 4365.”‹ If you are a constituent of the offices listed here, it is recommended that your agency send an e-mail thanking the office for their support: Rep. Butterfield (D-NC); Rep. Cohe”‹n (D-TN); Rep. Farenthold (R-TX); Rep. Heck, MD (R-NV); Rep. Ruiz, MD (D-CA) and Rep. Westerman (R-AR).
Provisos for Promoting Provider Protection
Safety Concerns of EMS Crews
— Jay H. Reich, MD (Kansas City) presented safety concerns he believe we should all assess and address in our agencies (see the following slide clips).
Take away message from A.J.: Agencies can benefit from reviewing these insightful areas in detail. They can be downloaded in greater detail at www.emsforward.org
Violence & Abuse against EMS
— Marc R. Conterato, MD (Minneapolis) presented concerning statistics from a well-designed survey his system’s EMS officials designed and tabulated. It reveals that EMS providers are feeling increasingly threatened and are beginning to take courses, and, in some instances, carrying defensive weapons/devices to protect themselves.
Take away message from A.J.: Similar to findings in recent stress and suicide surveys, respondents to this survey report limited training or support by their agencies in this important area of concern, further adding to their stress and frustration on the job.
Obtain his slide set on www.gatheringofeagles.com and a detailed article from Dr. Conterato in a future issue of JEMS.
The Spice Epidemic Becomes an MCI in Alaska and the Impact of Fentanyl-Laced Heroin in Chicago
— Michael K. Levy (Anchorage) presented startling data and examples of the increasing and system-taxing impact of the drug Spice in Anchorage, Alaska and Joseph M. Weber, MD (Chicago) reported on increasing responses in Chicago to individuals who are using/overdosing on Fentanyl-laced Heroin.
Take away message from A.J.: Epidemic-like, increases overdose responses are impacting crews and operations and agencies are finding themselves confronted with MCI-type incidents and having difficulty separating affected versus non-affected individuals in high volume homeless areas.
CYANOKITS (B-12) at Fire Scenes & Law Enforcement Use of Naloxone
— Andrew J. (Drew) Harrell (Albuquerque) reported very positive results with the use of CYANOKITS in the Albuquerque region, particularly citing impactful, positive results with fire victims subjected to high cyanide/smoke levels.
Take away message from A.J.: Despite high cost, there CYANOKITS are lifesaving http://www.cyanokit.com/
One Year’s Experience with Law Enforcement Naloxone
— C. Crawford Mechem, MD (Philadelphia) reported on his city’s use and success in Narcan administration by police officers in a high overdose area of Philadelphia.
Laws Empowering EMS in Behavioral Emergencies
— Jay H. Reich, MD (Kansas City) – Missouri is on track to repeal and revise a law that will empower and protect its emergency responders confronted by patients with behavioral emergencies, particularly those patients who attempt to, or do, harm EMS responders.
Take away message from A.J.: JEMS will bring you updates on this important legislation, which could be a model for other states, as it develops.
Trauma, Mass Gathering and Disaster Care Issues
Re-Visiting Field Amputations & Response Paradigms
— Craig A. Manifold, DO (ACEP)
— C. Crawford Mechem, MD (Philadelphia)
The need for specialized training of physician/hospital repose teams and an organized response system for occasional field amputations were recognized. Although infrequently needed, Manifold and Mechem noted that, when it is, time and proper training are essential. They recognized the 2015 field amputation by Philadelphia area EMS physician, Melissa Kohn, MD, who performed on a man trapped under a train in the middle of a night. Kohn was present at the Eagles meeting and recognized by the group.
The Eagles were provided with special training prior to this year’s conference and will be presenting a recommended operational/clinical process in the future to assist areas in developing a coordinated response system.
Take away message from A.J.: The Eagles agreed that physicians should be responsible for field amputations. JEMS will be publishing two articles in this area, including a detailed account of Dr. Kohn’s incident/experience.
Wound Packing and the Proper Use of Hemostatic Gauze
— Peter P. Taillac, MD (NASEMSO) — noted that prehospital personnel need to learn and practice wound packing and showed slides and a video to illustrate the proper way to pack a wound with regular or hemostatic gauze.
Take away message from A.J.: Services need to train their personnel (BLS and ALS) in proper wound packing procedures as recommended in the Hartford Consensus Reports. Dr. Taillac and other speakers will be showing the techniques at the EMS Today Conference in Baltimore, Feb 25-27.
How to Measure, Monitor and Document Competencies Better
Report on the NASEMSO Compass Project
— Peter P. Taillac, MD (NASEMSO) — the importance of performance measures and their use to evaluate and improve EMS systems was reported in a summary of the work underway through the Federal EMS Compass Initiative.
Simulation as an Acceptable Surrogate for Credentialing
— Scott Gilmore, MD (St. Louis) reviewed the history and values of simulation for skill honing and evaluation.
Results of a Series of Double-Sequential Defibrillation Cases
— Jonathan Jui, MD, MPH (Portland), a proponent of double sequential defibrillation, presented cases and successes from this technique which is being used in many hospitals and some EMS systems
How to Survive to the Cath Lab via ECMO
— Scott T. Youngquist, MD (Salt Lake City) gave an exceptional review of the benefits of ECMO in hospitals — now often in the emergency department and, in some counties in the field by physician response teams and predicted that we will see expanded use of ECMO for selected patients delivered to specialty centers by EMS.
Take away messages from A.J. for these areas: EMS Compass is an important process to watch. There will be a full-day workshop at the EMS Today Conference next Wednesday, 2/24 on EMS Compass that will detail the project and the 21 performance indicators being considered and JEMS will be publishing a detailed supplement on EMS Compass in the near future..
The Pros and Cons of “Free-Standing” Emergency Centers
— Peter P. Taillac, MD (NASEMSO) explained the big difference between free-standing Emergency Departments and other facilities and stated that he believed EMS agencies/ambulance in some states will be allowed to transport patients to approved, properly equipped and staffed free-standing EDs in the future.
It’s Time to Say Goodbye to “ALS” & “BLS”
— Edward M. Racht, MD (AMR) — presented a powerful, insightful and thought provoking talk on why EMS should no longer be so divided by BLS and ALS lines and should evolve into a delivery system that is better suited for today health care needs.
Challenging the Perennial Obsession with Response Intervals
— Jeffrey M. Goodloe, MD (Tulsa and OKC) presented an update on his system’s results after reducing the use of red lights and sirens on many EMS responses and patient transport, showed that increase response time have not negatively impacted patients and reduced stress on responders.
Some of A.J.’s clinical trends, system progress, challenges and technological advances gleamed from the 2016 Gathering of Eagles Conference.
- There are benefits to adding a nasal cannula, flowing at 10-15 liters to an apneic patient during the delivery of compressions.
- Supraglottic Airways are in widespread use but there is some evidence that some may place excessive pressure on vessels and reduce blood flow (circulation to the brain)
- In a cadaver study, the iGEL SGA scored highest, behind ET tube oxygenation.
- QA/QI should be a high priority in all EMS systems, it should be non-punitive and used to improve the effectiveness and clinical competencies of field providers.
- Many EMS systems have, unfortunately, cut back on QA/QI and, in particular, QA/QI staffing due to budget cuts or a de-emphasis on this critical EMS system area.
- There is increased support for the ResQCPR System, the combination of the ResQPOD (ITD) and the ResQPUMP ACD-CPR Device compression system. Systems are now using it on scene and then continuing using the ResQPOD (ITD) in conjunction with the LUCAS 2 mechanical compression device during patient transfer. (Reason: There is a recommendation that the ResQPUMP ACD-CPR Device not be used if the rescuer is standing, used during patient movement or during transportation because of the potential for rescuers to apply excessive force.
- There is early evidence that a patient’s intracranial pressure drops, and cerebral cardiac perfusion improves when the patient has CPR performed on them in a waist-head 30-degree elevated position. Physio-Control being asked to offer an accessory to keep the LUCAS 2 secure if it is used or transported on a patient (perhaps post ROSC) on a stretcher being moved to an ambulance or in moving ambulance.
- There is increasing use of the LICAS 2 compression device in the field because it applies uninterrupted, constant depth compressions, particularly during patient transfer/movement, and is being shown tremendously beneficial in long running resuscitation and CATH lab procedures.
- Crews should be encouraged to report medication dosage calculation and administration errors without fear of retribution.
- Checklists are highly effective when used in the delivery of prehosptal EMS care and their use should be expanded.
- There is an increasing volume of overdoses in American, particularly Spice and Fentanyl-laced Heroin, creating MCI type conditions in many large cities, and they are having an impact on operations and the personnel who have to respond to them.
- Police are increasing their use of Narcan and the public, in some areas, is being given inflated numbers for patients law enforcement officials are claiming had their “life saved by the law enforcement” delivery of the opioid-reversing medication.
- Many systems are reporting skill decay due to an overabundance of paramedics with the infrequent opportunity to use critical skills.
- EMS providers are feeling increasingly threatened and are beginning to take courses, and, in some instances, carrying defensive weapons/devices to protect themselves.
- Similar to findings in recent stress and suicide surveys, personnel are reporting limited training or support by their agencies when they express concern over safety and fear of violence in the field, further adding to their stress and frustration on the job.
- There will be expanded use of ECMO for selected patients delivered to specialty centers by EMS.
- System will move away from firm response time parameters based on increasing evidence of the benefit of reduced red light and siren use and alternative EMS delivery/response unit deployment.