High Speed Education Where Eagles Gather

Dallas is the place to gather today and tomorrow if you are like me and actually enjoy the most current thinking on pre-hospital medical practice coming at you like a fire hose from the very “eagles�? of our business. Unfortunately, I am not there. Instead, I was standing a thousand miles away this morning in a dim light hallway peering into a bedroom where a large chested man had been pulled from his bed onto the floor and was surrounded by a team of EMS professionals efficiently working to bring him back to life. The call was a mutual-aid assistance request from a neighboring district and I was one of a handful of “trained providers�? simply waiting my turn to begin compressions. We haven’t justified the money in my county for mechanical CPR devices.

At the Gathering of Eagles conference in Dallas, the first lightning round of topics for this morning was scheduled as “Resuscitating Resuscitation: New Technologies and Approaches for Achieving ROSC�?. I wished desperately that I could have been walking down a hallway in that Texas hotel instead of standing in that local house between a husband and his wife.

Still, no matter where I am, I try to take in all the information I can and learn something from it. Here, I was limited to watching each fresh new rescuer dutifully assume the position for compressing our patient’s chest. Why is the room always so small? The bed is always so close and the personal effects of a lifetime are always stacked neatly in the way. Worst of all, the patient never seems to resemble the size of the mannequins we use in practice. But what struck me most vividly this morning was watching the inconsistencies between each of these well-meaning rescuers. I even started a checklist in my mind of the failures I saw. It was that attitude that led to the most important failure, it was the fact that I could almost viscerally feel a lack of hope in that room.

Also lacking in the setting was anything to keep cadence for the compressions or the rescue breaths. The eagles were about to tell me that without a metronome, providers typically compress too fast. I saw exactly what they discovered, that rescuers could routinely hit a rate as high as 140 compressions per minute even though we know we need to stay in the range of 115 to 120. The idea that “more is not better�? is quite clear here and we need to build better muscle memory. I knew we were being good about limiting the pauses, but I would soon be reminded that our enemy is not that “we suck�?, but that we are satisfied that we are doing “good enough.�? I learned from the Resuscitation Academy at EMS Today last year of the importance of going into every OHCA with the attitude that “everyone survives.�? However, my faith somehow still gets robbed.

In just a few hours, I would be reading notes from attendees in Dallas promoting the virtue of consistency in providing “world-class manual CPR.�? But at that moment, I didn’t feel surrounded by “eagles.�? The Eagles would tell us about places like Oklahoma City and Tulsa that use the “pit crew�? approach so everyone knows what they are doing. We’ve got that in place here when it comes to pushing drugs and managing airways, but the prevailing opinion here is still that compressions are just a brute force task to manually maintain circulation through the heart. I would also hear that Memphis, where each ambulance is equipped with a LUCAS device, is getting ROSC in 30% of arrests compared to 21% of arrests employing manual CPR. Probably the same type of CPR that we were performing today.

What we needed to hear was more than just advice to minimize compression pauses, to slow them down, maintain compressions even while the AED is charging, and always remember the fundamentals! We needed the advice that helps us recognize that PEA is a health hazard when it is distracting us from focusing on compressions by spending too much time looking for that elusive pulse. I needed to know that only 15% of pulse checks are accurate when done within the AHA guideline of 10 seconds or that if you don’t have VF, even the AED can be a health hazard due to prolonged compression pauses for rhythm analysis.

We all need to be convinced that with the advent of LUCAS/ITD and easily applied ECMO/LVAD, we may not need to care as much about the condition of the heart as we should be concerned over the resuscitation of the brain. The Eagles are further suggesting that traditional “supine CPR�? should soon become a thing of the past in favor of a 30-degree “heads-up” Gravity-Assisted CPR that promises to improve patient outcomes. As they explained today, standard CPR increases ICP and facilitates only low cerebral perfusion pressure. A trend which is reversed by elevating the patient’s head up 30 degrees. We can also hope that someday we can be using ultrasound in the prehospital setting to determine optimal position of chest compressions. And it’s not just compressions that need our attention, but to understand that positive pressure assisted ventilation actually decrease the coronary perfusion pressure.

What I learned today in both of the settings where I found myself is that there is no “silver bullet.” There is still much to learn and understand and it is only hard work and an interest to do better that will ultimately ensure a future where everyone will have a better chance at survival!

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Quick Thoughts from EMS Today 2013 Conference

Since the EMS Today conference for 2013 started a week ago I know that my thoughts at this point can hardly be considered “quick” any longer. However I wanted to share my experience of the highlights from this event anyway. JEMS has always been known for putting together a great product whether in print or performance and this show was not a disappointment. While I have not heard about attendance figures, it did seem just a little smaller in Washington, DC this year compared with Baltimore last year. I also had a hard time capturing a single shared mood or tone for this year. Perhaps it was the cancellation of my pre-conference course and inability to get registered into any others that may have set me off on the wrong foot. Especially easy to do after a day of work followed by an evening Con Ed class and an all-night drive to beat the forecast “Snowsquester�? that was sure to shut down DC. But it didn’t take long to begin catching up with colleagues and realize there were fewer flakes than predicted.

Wednesday: Improvisation is a primary characteristic of both EMS professionals as well as politicians. Fortunately, both implemented plenty of it on Wednesday during a modified “EMS on the Hill Day” event sponsored by NAEMT in conjunction with the conference. While not as many elected representatives were available as hoped due to a weather-related shut down, there was opportunity to explain the impacts of legislation such as PPACA (“ObamaCare”) and the Field EMS bill on our industry to those who knew where it was happening. (An awareness shared by those attendees who participate in social media at conferences.) This is an important annual day of advocacy open to all EMS professionals who register in advance and one that everyone should be involved in supporting. As representatives were found to be available, they were visited by attendees on your behalf.

For those of us attending the impromptu hotel meeting, we heard several good speakers on topics passionate to them. Matt Zavadsky of “MedStar Mobile Healthcare” (formerly ‘MedStar EMS’) discussed his agencies view of changes to the industry saying “we are not Emergency Medical Services (any longer), we are Unscheduled Medical Services.” Others, like Chris Montero, spoke on our increasing role in public health and promoting community paramedics. One easy example was assisting with “mobile immunizations” for the community (or what was jokingly termed “drive-by shootings”). Later in the evening JEMS announced the “EMS 10” Award Recipients for 2012 at a special gala event recognizing those who drove the EMS profession forward. It is definitely worth reading through the accomplishments of these individuals and agencies and commit to continue their work nationally. LeFlore County EMS located in “super rural” Oklahoma, just as an example, improved their save rate from 6% to 40% and has not failed an intubation in 3 years.

Thursday: By far the busiest day with endless concurrent sessions. I tweeted as many of the pearls of wisdom that I heard live as fast as I could. Whether you are attending a conference or not, the ability to share knowledge through social media at an event like this is incredibly valuable. For those at home or on the job, it was their first opportunity to hear even pieces of great lectures and those in the same room get to hear what resonates with others immediately. One of the key points I took away from this day of courses was that as an industry, we need to communicate that EMS response is more than a measure between receiving a call in the dispatch center and the wheels of an ambulance hitting the curb at the scene. It is also important that we “take stock of our dysfunctions in order to embrace the change that means improvement for the benefit of our patients.”

Representatives from the “Gathering of Eagles” presented in a forum session where several “sacred cows” of pre-hospital care were lined up for the slaughter. Such controversial ideas as: “IVs being the only method to administer drugs is becoming an antiquated idea”; “to save patients as well as money, focus on driving safety and alternate endpoints for treatment�?; or “where are the papers that support the benefits of the backboard?” Cervical collars, it was argued to the delight of the crowd, properly strapped with patient on a stretcher can be safer than a “slip-n-slide” (i.e. “backboard” which can add to compression/decompression injuries during transport.) I know many of us are watching intently for the paper coming soon on new ideas for spinal immobilization. In short, the best summary of the “Eagles�? session was “everything is changing.”

Another informative and challenging session was “What EMS has Learned from the Iraq and Afghanistan Battlefield” with Peter Taillac. Much of this presentation focused on the return of the tourniquet. This device, according to Tallic, got a bad rap because there was historically no evacuation plan once applied, but more recent research shows that survival rates for patients are 96% if a proper tourniquet is applied before signs of shock are present while rates decrease rapidly to only 4% when it is used only as a “last ditch effort.” The other challenge to traditional thinking was stated clearly in the thought that “only a doctor can remove a tourniquet is bullshit.�? Medics should apply tourniquets early, as indicated, but reassess the need for a tourniquet during transport and remove if possible. One warning, however, is that if blood pressure increases after removal, the likelihood of “popping a clot�? increases too. However, he contends that the goal of an IV is to prevent shock by maintaining perfusion not returning normal blood pressure in the field. Tallic also praised topical hemostatic agents when used properly but chastised the industry in general saying that typically “EMS sucks at pain control.”

The opening ceremonies on Thursday night had all of the requisite pomp and ceremony to make any fire-based EMS service feel comfortable. But it was all pure EMS history as Dan Swayze of the Center for Emergency Medicine in Pittsburgh (CEM) led the audience through a dramatic trip of historic “pre-hospital medicine firsts.” I know I had personally wondered where some practices came from, but it was definitely thought-provoking when Dan asked, “so, you are the first person to ever attempt increasing blood flow with direct intravenous fluids, how do you do it?” Following this presentation, the exhibit hall was officially opened and I got to attend the premier of the latest Code STEMI video in the inspiring FRN series taped this time at the world’s busiest EMS service. Take a look and share it as part of the “Community Connected” initiative I mentioned in my last post.

Friday and Saturday: Continued more sessions and time in the exhibit hall as well as annual favorites like the JEMS Games and the Cook-Off Challenge. Unfortunately, I had to leave before the closing ceremonies and last session, “Gaining and Keeping the Public’s Trust” by a popular and entertaining speaker, Gordon Graham. I do look forward to next year though and hope to see you there.