EMS MEd Blog

Article Bites #15: Benzo before Blood Sugar: A Proposed Algorithm for Prehospital Management of Pediatric Seizures

Article: Remick K, Redgate C, Ostermayer D, Kaji AH, Gausche-hill M. Prehospital Glucose Testing for Children with Seizures: A Proposed Change in Management. Prehosp Emerg Care. 2017;21(2):216-221.

Background:

Hypoglycemia is an easily identifiable and quickly reversible cause of seizures in the pediatric patient population. Current recommendations highlight the importance of identifying hypoglycemia prior to initiation of anticonvulsant therapy in children with suspicion for seizures. However, these recommendations conflict with prior research that suggest that very few pediatric patients with seizures require treatment for hypoglycemia. The investigators of this study hypothesized that hypoglycemia is an uncommon cause of seizures in the prehospital setting and they sought to derive an evidence-based algorithm for the evaluation of pediatric seizures by prehospital providers.  Furthermore, the study creators hypothesized that repeat blood sugar testing in the ED was not indicated in patients who had return to baseline or normal mental status.

Methods:

This was a retrospective study, the investigators conducted a retrospective chart review for all consecutive pediatric patients (age 14 or less) with a prehospital complaint of seizure that presented to a busy county hospital and pediatric medical center in Los Angeles between January 2010 and January 2011. Information was collected regarding recorded age, sex, past medical history, GCS (mental status), prehospital glucose measurement, whether or not patient was seizing in the field, seizure duration, transport time, mental status on arrival, disposition and final diagnosis.

Key Results:

A total of 770 consecutive pediatric seizure patients were examined during the one year time period. The investigators presented the following important key findings:

·       521/770 (67%) of patients had a glucose recorded on chart review

·       84/770 (14%) were actively seizing on EMS arrival

·       4/770 (0.5%) of all patients were found to be hypoglycemic in the field (0.8% of patients with blood glucose reported)

·       There was no statistically significant difference between blood glucose levels obtained in the field as compared to those in the ED

·       Almost 80% of patients were discharged home from the ED

·       The most common diagnoses were simple and complex febrile seizures

Takeways:

Among pediatric patients with a chief complaint of seizure, hypoglycemia was an extremely rare occurrence. Routine universal blood glucose testing for pediatric patients with concern for seizure prior to administering a benzodiazepine or who had returned to normal mental status was not supported based on the findings of this study.  Furthermore, repeat blood glucose testing was not supported for patients who return to normal or baseline mental status.

 

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What This Means for EMS:

Seizure is a common chief complaint encountered in the prehospital setting. While hypoglycemia has classically been taught to be an important cause of seizures, the results of this study suggest that hypoglycemia is not common in children who present with seizures or altered mental status. Furthermore, fingerstick blood glucose measurements can cause children to experience significant pain. The issue of universal fingerstick blood glucose measurements in patients who present with concern for seizure is also tied into false negative low glucose values which often require repeat testing in the emergency department contributing to increased length of stay. The investigators of this study postulate that routine blood glucose testing of all children in the prehospital setting who demonstrate normal or baseline mental status is not indicated. The detrimental effects of universal blood glucose testing extend beyond just pain and increased length of stay, but has also been linked to potentially delaying administration of antiepileptic medications in children with status epilepticus.

The investigators of the study formulated a new algorithm for prehospital management of the various classes of seizure patients: 1) patients actively seizing, 2) patients with GCS <15, 3) patients at baseline mental status.

 

Figure 1 from Remick et. al.

Figure 1 from Remick et. al.


Article Bites Summary by Al Lulla, MD (@al_lulla)

Article Bites #14: To Tube or Not to Tube in Cardiac Arrest?

Article: Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779-791.

Background: 

The benefit of advanced life support measures in the management of patients with out-of-hospital cardiac arrest (OHCA) is controversial. Endotracheal intubation has long been considered the mainstay of definitive airway control in patients with cardiac arrest, however, there is a growing body of evidence to suggest that alternative airway interventions such as the implementation of supraglottic devices (i.e. laryngeal mask airways) may be of value. This is likely due to the ease in which these devices can be placed, and requirement for less training to obtain proficiency compared to endotracheal intubation. Studies looking at head to head comparisons of endotracheal intubation versus the use of supraglottic devices in OHCA are lacking. The primary goal of this study was to compare the difference in modified Rankin Scale (mRS) scores at hospital discharge or 30 days after OHCA in patients who were randomized to endotracheal intubation versus supraglottic device to see if supraglottic devices were superior.

Methods:

Between June 2015 and August 2017, the investigators conducted a multicenter, cluster randomized clinical trial involving 4 different ambulance services in England. Paramedics were randomized to use endotracheal intubation or supraglottic airways. In order to be included in the study, patients were required to meet the following criteria: 1) known or believed age greater or equal to 18; 2) non-traumatic OHCA; 3) treated by paramedic involved in study who was either first or second paramedic on scene; 4) continued resuscitation by EMS personnel. Patients were excluded from the study if they were prisoners, previously involved in the trial, had been deemed to have inappropriate resuscitation, had an advanced airway that was placed by another healthcare professional prior to arrival of study paramedics and patients that were known to be involved in other randomized control trials. The primary outcome of mRS score at discharge or 30 days after cardiac arrest was divided into favorable outcome (mRS score 0-3) or poor outcome (mRS score 4-6).

Key Results:

A total of 9.296 patients were enrolled in the trial, of which 4,886 patients were randomized to supraglottic airway versus 4410 were randomized to endotracheal intubation.  The investigators presented the following important key findings:

·       Favorable neurologic outcome [ mRS score (0-3)] at 30 days or hospital discharge (whichever came first): 6.4% (311/4882) in the supraglottic airway group versus 6.8% (300/4407) in the endotracheal intubation group (adjusted risk difference -0.6%; 95% CI -1.6%-0.4%)

·       In the subgroup analysis of 7576 patients who received advanced airway management (not intention-to-treat), more patients in the supraglottic airway device group had a favorable neurologic outcome (3.9%) vs. the tracheal intubation group (2.6%); risk difference, 2.1%; 95% CI, 1.2 – 2.9%

·       Successful initial ventilation: 87.4% (4255/4868) in the supraglottic airway group versus 79.0% (3473/4397) in the endotracheal intubation group (adjusted risk difference 8.3%; 95%CI 6.3% to 10.2%).

·       Rates of aspiration and regurgitation were not found to be different between the groups

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Takeways:

Among patients with OHCA, advanced airway management with a supraglottic device was not associated with a favorable neurological outcome at 30 days compared to endotracheal intubation.

What This Means for EMS:

While the results of this study clearly indicated that advanced airway management with a supraglottic device was not associated with improvement in patient centered outcomes (in this case, neurological function), these devices were still associated with more successful initial ventilation without an increase in secondary complications such as aspiration/regurgitation. Furthermore, given the ease of use, less number of attempts required to obtain proficiency from a standpoint of training, and widespread availability, supraglottic devices are feasible intervention to provide airway support for patients with OHCA. Unlike endotracheal intubation which can be challenging to perform in the field with active chest compressions, supraglottic devices are easier to use in terms of temporary airway management and allow for the focus to be shifted towards measures that improve outcomes including high quality CPR and early defibrillation.

Article Bites Summary by Al Lulla, @al_lulla, Article Bites Editor

The Pros and Cons of Degree Requirements for Paramedics: Kazan and Moy debate

Should paramedicine require a minimum degree? In this post, two EMS physicians, Clayton Kazan (Medical Director for LA County Fire Department) and Hawnwan P. Moy (Medical Director for ARCH Air Methods in Missouri) , debate the Pros and Cons.

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CON: Raise the Roof, Not the Floor.

by Clayton Kazan MD FACEP FAEMS

Far be it from me to knock the benefits of higher education.  It was always one of my narcissistic goals to achieve more letters after my name than in it, and, with the addition of FAEMS this year, I have finally achieved it.  I think that the “associations,” as they describe themselves in the PEC published joint statement (NEMSMA, NAEMSE, IAFCCP), are going about this the wrong way, and the detrimental effects on paramedic programs, particularly fire-based programs, will be severe. [1]  I have been involved in training EMTs and paramedics since 1995 (again with the narcissism), and I would be a huge supporter of this concept if I believed that this was the gap between poor and good (or good and great) prehospital clinicians…that, if only they had fulfilled the general education courses needed to finish their degree, they would be given the tools they need to build strong clinical skill.  By the same argument, I am a better physician today because of the undergraduate coursework that I completed at my alma mater (UCLA).  So, linguistics (my textbook was a freaking dictionary), psychology (rats given dopamine will forego food and sex to get it), art history (pyramids at Giza = cool) are really part of the fabric that makes me an amazing clinician (yup) today?  Even my science courses had very limited applicability…unless the human body has a xylem and phloem, or I am ever asked to synthesize a perfume that smells like bananas.  If you think that these types of courses would not be required of our paramedics, then I invite you to review the A.S. requirements of a junior college. [2]  I took the EMT course as a sophomore specifically because my coursework had NO relevance to my chosen field, and the rest is history.

The issue we have as we strive to develop an EMS profession is not the prerequisites that our paramedics bring as they start their careers, it’s that it is a dead end.  Requiring an A.S. degree does not change that.  The position statement states that 60% of paramedic programs already offer an Associate’s or Bachelor’s degree program is misleading because, using their source, only 1.6% currently offer Bachelor’s. [3]    If you want to take those Associate’s Degrees and use them toward a Bachelor’s, how many of the universities are giving course credits for the paramedic program and not requiring the students to start from scratch with introductory biology, physiology, etc.?  In California (because the west coast is the best coast), the answer is zero.  Thus, the Associate’s is a dead end, and that is part of the reason why many students do not continue their education to finish their degree. 

What is missing in our prehospital clinicians is the opportunity and encouragement to be lifelong learners, to stay in EMS, and to advance past paramedic.  Build the degree programs so their paramedic certificate is worth something to them from a career advancement perspective.  Requiring an A.S. of everybody may raise the floor, but it definitely does not raise the ceiling.  Build bridges within the house of medicine to use that credit towards a nursing, PA, or, dare I say it (I dare, I dare), a medical degree…so our providers don’t feel chained to their ambulance or squad for the duration of their career.  Rather than knocking our current programs back to EMT-I (BTW not recognized in Cali), build an advanced paramedic level with an expanded scope of practice, as we have for our flight programs.  What our profession needs is a carrot, not a stick.

Lastly, I want to comment (rant) on a statement made near the end of the article… “From an economic standpoint it is almost certain that degree requirements will restrict the supply of available paramedics to some extent.”  For fire-based EMS systems, this represents a disastrous, unfunded mandate that will severely affect the supply of available paramedics.  They are right that it creates an upward surge in salary, but their argument that this money will come from third party payers and local governments is ludicrous.  Requiring paramedics to have degrees will not squeeze one penny out of health insurers, local government budgets are nightmarish without this.  To me, “the associations” have not clearly thought through what stream actually fills this imaginary pool of money they think will pay for this.  As huge constituents of the schools and employers of the graduates, it is essential that fire-based EMS provider stakeholders have a voice in the future direction of paramedic programs, and I urge our membership to read their reply.4

References

1.     Sean M. Caffrey, Leaugeay C. Barnes & David J. Olvera (2018) Joint Position Statement on Degree Requirements for Paramedics, Prehospital Emergency Care, DOI: 10.1080/10903127.2018.1519006

2.     Illinois Central College. www.icc.eduhttps://icc.edu/academics/catalog/associate-in-science/associate-in-science-degree-requirements/.  Accessed January 5, 2019.

3. Programs CoAEMSP. Find a Program 2018; Selected Paramedic, Accredited, All States and Provinces with boxes checked for associates, bachelors and masters compared to all chek boxes (inclusive of certificate and diploma). 2019. Available at: https://www.caahep.org/Students/Find-a-Program.aspx. Accessed January 5, 2019.

4. Fire Service EMS. www.fireserviceems.com. http://fireserviceems.com/joint-position-statement-opposition-to-proposed-degree-requirements-for-accredited-paramedic-programs/. Accessed January 7, 2019.





PRO: A Good Build Starts with a Strong Foundation

by Hawnwan P. Moy, MD FAEMS

I’ll start by stating that Dr. Kazan and I are friends.  Like all traditional friendships, we embrace our similarities and poke fun at our disagreements.  I dare not break tradition. While Dr. Kazan MD FACEP FAEMS #SpoiledinCali (sorry @PEMEMS) believes that requiring further education for paramedics is all for naught, I believe this is a crucial step in creating a better trained, more prepared and well-rounded paramedic. 

Critical thinking is essential to practicing excellent paramedicine.  What defines a great paramedic is NOT what procedures they can do, but how they think.  No offense to any 12-year-old, but we can teach any 12 year old how to intubate.  But to teach a 12-year-old when to intubate, when to anticipate a bad airway, or whether they should intubate requires critical thinking.  “Critical thinking is that mode of thinking — about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully analyzing, assessing, and reconstructing it.” [4] Paramedic educators have the responsibility to teach the fundamentals of paramedicine.  Yet they rarely have enough time to build a foundation for critical analysis. This is where creating education requirements for paramedics is paramount.  

In order to engender critical thinking, a solid foundation must be established beyond high school education.  A foundation of critical thinking has to be broad to expose the mind to different ways of thought. So while I agree that linguistics (I can’t believe you took Latin @Clayton_Kazan), psychology (Maslow’s Hierarchy of needs is important, but listen to Ginger Locke’s Hierarchy of needs here!) and art history (pyramids, schmyramids...The Great Wall is so much cooler) have a low correlation to actual clinical medicine, the underlying benefits of challenging the mind to think differently, to understand the world from different viewpoints, to learn from history’s lessons, to understand different ways to achieve the same goal, provides an invaluable foundation to critical thinking.  

 Let me utilize someone from Dr. Kazan’s beloved California as an example, Steve Jobs.  Yes, Steve Jobs didn’t finish college. However, he did enroll in at least a year of college where he had to take general basic courses that had nothing to do with computers.  One such course was calligraphy (see Steve Job’s Standford Graduation Speech).  In the 70’s, the world of computers only had Atari-like block font.  Yet it took someone like Jobs who had experience in calligraphy, an appreciation for design, and the critical thinking to apply calligraphy to computers to revolutionize the world of technology.   Just look at this very webpage you’re reading. All those different fonts evolved from Steve Jobs’ influence. As he said, “…you can’t connect the dots looking forward; you can only connect them looking backward.  So you have to trust that the dots will somehow connect in your future. You have to trust in something your gut, destiny, life, karma, whatever.” So while I agree that taking general education courses may have little relevance to the field of medicine, they do create a foundation for critical creative thinking and may even create unique solutions. 

On that note, I do not believe that an associates degree is a dead end, but a beginning of a journey.  Dr. Kazan is correct in that the sources he cited, only 1.6% of programs currently offers Bachelor’s degree.  Technically speaking requiring a Bachelor’s degree would provide a stronger base, but for those who face real-life challenges where time is not a luxury, a two years Associate’s degree is a good start.  30/50 states have some sort of guarantee of transferring credits to a Bachelor's degree.  

Nonetheless, Dr. Kazan speaks some truth.  Encouraging a love of learning in your paramedics and paramedic advancement are key to job satisfaction.  I think it is great when paramedics gain additional medical training beyond paramedicine to become a physician assistant or physician, but not all paramedics want to leave the job - and we don’t want them to.  I know plenty of paramedics who are in the field because they love what they do and don’t want jobs that take them within four walls. I agree paramedics should have a career ladder. However, that ladder should be based not only on experience but education.  Just look at our fire brethren who require further education - a Bachelor’s (or Masters!) in Fire Science-for advancement in their career. You’re right Dr. Kazan, paramedics do need a carrot and our paramedics deserve to be paid more for their work. That can be justified by a required education needed to become a paramedic.  Nurses did it with their profession. [3,8]  Why can’t we?  

To follow up on the supposed financial catastrophe that the number of paramedics will fall precipitously due to education requirements, let’s look at other states who have paramedic education requirements, Kansas and Oregon1.  Those states have enacted education requirements and guess what?!?!  EMS continued to march on. Yes, change is scary. We have every right to be anxious.  Maybe this will initially affect the number of paramedics enrolling in our systems. Yet looking at these two states as examples, proves that a possible decrease in paramedics will not last indefinitely.  

In the end, Dr. Kazan and I are two sides of the same coin.  Despite our differences (one of the main ones being I’m better-looking :P), we believe in education and care deeply for the future of paramedicine and paramedics.  He works in a successful EMS system and is one of the grittiest, dedicated EMS medical directors I know. I do not fault his comments. In fact, I encourage it. I thank him for it.  It creates thoughtful conversation, a lively debate, and dare I say it a valuable viewpoint that forces you, the reader, to critically think about your own thoughts on education requirements for paramedics.  See what I did there? So, Dr. Kazan, I raise my glass to you and I just have one thing to say to your impending retorts. I know you are, but what am I?

To hear a lively debate about this very issue, check out our PEC podcast discussion here!


References

  1. Caffrey, Sean M., et al. “Joint Position Statement on Degree Requirements for Paramedics.” Prehospital Emergency Care, vol. 23, no. 3, 2018, pp. 434–437., doi:10.1080/10903127.2018.1519006.

  2. JoshuaG. “Steve Jobs Stanford Commencement Speech 2005.” YouTube, YouTube, 6 Mar. 2006, www.youtube.com/watch?v=D1R-jKKp3NA.

  3. Kutney-Lee, Ann, et al. “An Increase In The Number Of Nurses With Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality.” Health Affairs, vol. 32, no. 3, 2013, pp. 579–586., doi:10.1377/hlthaff.2012.0504.

  4. “Our Concept and Definition of Critical Thinking.” Our Conception of Critical Thinking, www.criticalthinking.org/pages/our-conception-of-critical-thinking/411.

  5. “PEC Podcast.” Prehospital Emergency Care Podcast - the NAEMSP Podcast, pecpodcast.libsyn.com/pec-podcast-6.

  6. “Prehospital Emergency Care Podcast Ep. 58.” Prehospital Emergency Care Podcast - the NAEMSP Podcast, pecpodcast.libsyn.com/prehospital-emergency-care-podcast-31.

  7. “Resource Title:50-State Comparison: Transfer and Articulation Policies.” Education Commission of the States, www.ecs.org/transfer-and-articulation-policies-db/.

  8. Smith, Linda S. “Said Another Way: Is Nursing an Academic Discipline?” Nursing Forum, vol. 35, no. 1, 2000, pp. 25–29., doi:10.1111/j.1744-6198.2000.tb01175.x.

Feel The Heat: Managing Exertional Heat Stroke

by Mark Liao, MD, NRP (@EMSDocMark)

Expert Peer Review by Dorothy Habrat, MD (@EMSDrDorothy)

Clinical Scenario

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A 25-year-old male is brought to your Finish Line medical station. Bystanders noted that he was unsteady on his feet while running a half-marathon before he collapsed. The outside conditions are notable for an air temperature of 22.7 °C (73 °F) and a humidity of 45%, which subjectively feels quite mild to you. The patient does not respond to questions properly, is pale and diaphoretic. Once inside the medical station tent, his skin does not feel hot when his forehead is touched and is otherwise moist. A tympanic membrane thermometer registers an aural temperature of 36.7 °C (98 °F). The patient is persistently confused and a rectal thermometer is subsequently utilized, which registers 41.1 °C (106 °F).

Review

Exertional Heat Stroke (EHS) is an environmental medical emergency from excessively high body core temperature due to physical exertion. National surveillance data for annual prevalence is difficult as these cases are included with classic heatstroke seen in the elderly [1] or reported alongside other types of exertional heat illness such as heat exhaustion [2,3]. Typical risk groups for EHS include athletes (particularly high school football players [4]) and military personnel. In 2018, the US Armed Forces experienced 578 cases of EHS for soldiers on Active Duty during global operations and training [5] . EHS is also a particular concern for medical planners involved in large sporting events: an 8-year study at the Indianapolis Mini Marathon identified 32 cases of EHS among over 235,000 combined participants [6]. Recognizing the need for early and aggressive treatment of EHS, the National Association of EMS Physicians published an important consensus statement in 2018 that outlines the identification and management of EHS in the pre-hospital setting which will be reviewed here [7].   

Identification of EHS

While Exertional Heat Stroke is typically associated with hot conditions, it can still occur in cooler climates.

While Exertional Heat Stroke is typically associated with hot conditions, it can still occur in cooler climates.

EHS should be considered if an individual has been performing physical activity and experiences central nervous system disturbance. This can range from irritability or confusion to decreased level of consciousness. Delays in EHS recognition are multifactorial. Counterintuitively, EHS can still occur in cooler weather despite its association with hot climates [8]. It is a common misconception that EHS patients will have stopped sweating.   Patients, when touched, may not always feel warm and may even feel cool with skin moisture present.

Waiting for the development of profound central nervous system dysfunction such as obtundation or unconsciousness may result in delayed treatment and underscores the importance for maintaining a high level of suspicion during athletic events [9].

 

 Inaccurate Equipment Can Result in Misidentification 

Rectal thermometers, such as the one seen here, are the only way of getting an accurate rectal temperature to recognize EHS.

Rectal thermometers, such as the one seen here, are the only way of getting an accurate rectal temperature to recognize EHS.

The only accurate and practical prehospital method of core body temperature evaluation for EHS is to use a rectal thermometer, placed at a depth of 15 centimeters (about 6 inches) [10]. The National Athletic Trainers’ Association (NATA), like NAEMSP, similarly recommends that rectal thermometers be considered the gold standard for EHS assessment and therefore should be part of the EHS emergency treatment plan for athletic programs [11] . As such, EMS providers should be educated on these thermometers being used prior to ambulance arrival. Once inserted, the rectal thermometer should be left in place for continuous monitoring during cooling efforts and transport. Many rectal thermometers used in the hospital setting are only inserted 1.5 centimeters into the rectum and therefore are not accurate enough for EHS assessment [12]. Temporal artery thermometers, ear/tympanic membrane thermometers, and oral thermometers are not accurate in the detection of EHS and should not be used [13-15].

(A)  Hospital thermometers probes (left) generally are unable to be inserted into the recommended depth of 15cm (B) Clockwise from left: Temporal artery surface thermometer, oral digital thermometer, tympanic membrane thermometer and forehead infrared thermometer. These devices should not used in the evaluation of EHS due to problems with accuracy.

(A) Hospital thermometers probes (left) generally are unable to be inserted into the recommended depth of 15cm (B) Clockwise from left: Temporal artery surface thermometer, oral digital thermometer, tympanic membrane thermometer and forehead infrared thermometer. These devices should not used in the evaluation of EHS due to problems with accuracy.

 Strategies for Rapid Cooling

This 50 Gallon tub is used at the Indianapolis Mini Marathon for Cold Water Immersion

This 50 Gallon tub is used at the Indianapolis Mini Marathon for Cold Water Immersion

Rapid cooling is the key management step of EHS. Rapid cooling should begin when the patient is symptomatic.  Based on expert consensus, if the rectal  temperature is greater than 40.5 °C (104.9 °F), Cold Water Immersion cooling should occur when available (see algorithm below), as it most expeditiously accomplishes rapid cooling.  This involves placing the patient into a tub of ice water (with enough ice to maintain a water temperature of 10 °C / 50 °F  ) and the body immersed in water from the neck down. Tubs of approximately 50-gallon capacity are generally sufficient for this task, though some programs prefer tubs of 150-gallon capacity [16]. Proper cooling techniques should result in a reduction of rectal temperature to less than 38.6 °C (101.5 °F) within 30 minutes.

 

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Other alternatives include the use of a tarp (“tarp assisted cooling”), also filled with ice water, while the water is agitated continuously by responders to keep the cold water moving [17]. A similar technique involves using a fluid impervious body bag filled with ice water, which may be helpful in the hospital setting if no tub or tarp is available.

Other field methods of cooling

The use of ice packs placed close to arteries (neck, axilla, groin) has been taught for many years and may be one of the few practical options in an ambulance. However, this technique appears to have marginal cooling benefit when used alone and should not be used as the primary method of cooling whenever possible[18].

The US Army Training and Doctrine Command is a proponent of ice sheets as part of heat casualty response plan for trainees, which utilizes cotton sheets soaked in ice water and stored in coolers [19]. This requires placement of sheets onto as much bare skin as possible except for the face, and rotated with fresh sheets when the placed sheets start to feel warm. The technique is not as effective as cold water immersion [20].

Recommended rectal temperature thresholds to start and stop Cold Water Immersion

Recommended rectal temperature thresholds to start and stop Cold Water Immersion

Evaporative cooling, such as fanning a patient or even using the rotor wash from a helicopter, appears to be significantly slower than cold water immersion in reducing body temperature [21-22]. Evaporative cooling may also be less effective in high humidity situations.

While it may seem intuitive that chilled intravenous fluids would be helpful for rapid cooling, research in this area is limited. In a small study of healthy human volunteers, chilled saline of 4 °C (39.2 °F) decreased core body temperature by only 1 °C  (1.8 °F) after 30 minutes [23]. Though using cold saline infusion in combination with other cooling modalities may improve patient outcomes [7].

 

Prehospital Protocol Considerations

Given the importance of rapid cooling in the setting of EHS, EMS protocols should consider prioritizing cold water immersion over transport if the equipment is available onsite; NAEMSP and NATA both recommend a “cool first, transport second” approach. Communication with the receiving hospital is essential, particularly if onsite cooling is unavailable as Emergency Departments may need to initiate cooling in non-traditional care areas such as a decontamination room. EMS providers should be reminded to consider other causes of collapse and confusion, including hypoglycemia and hyponatremia.

Prevention

Monitoring Wet Bulb Globe Temperature provides a real-time assessment of heat risk

Monitoring Wet Bulb Globe Temperature provides a real-time assessment of heat risk

The risk of EHS is increased in the setting of hot, humid conditions. Providers working at mass gathering or athletic events should evaluate event policies regarding adjustments to work/rest cycles, safety messaging, rest/sleeping facilities, provision of cooling devices (such as arm immersion cooling systems) and ensure appropriate EHS response equipment is available [24]. The Heat Index or Wet Bulb Globe Temperature are tools that are useful in developing an understanding of current or projected risk of heat related illness [25].

 


Conclusion

EHS can be effectively managed in the prehospital environment when recognized in a timely fashion. A high index of suspicion is needed anytime an athlete experiences CNS disturbance after doing physical activity: responders can be falsely reassured when the climate does not appear too warm, CNS disturbance is only mild or if the patient’s skin is not hot to the touch. A multidisciplinary approach should be taken to incorporate on-site medical personnel, such as athletic trainers, in developing protocols to ensure the coordinated management of EHS. Finally, EMS agencies should take steps to ensure the availability of equipment such as rectal thermometers and cold-water immersion supplies at local athletic centers, sporting events and military training venues.

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 References

1.     Choudhary, E., & Vaidyanathan, A. (2014, December 12). Heat Stress Illness Hospitalizations — Environmental Public Health Tracking Program, 20 States, 2001–2010. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6313a1.htm

2.     Yeargin, S. W., Kerr, Z. Y., Casa, D. J., Djoko, A., Hayden, R., Parsons, J. T., & Dompier, T. P. (2016). Epidemiology of Exertional Heat Illnesses in Youth, High School, and College Football. Medicine & Science in Sports & Exercise48(8), 1523-1529. doi:10.1249/mss.0000000000000934

3.     Yeargin, S. W., Dompier, T. P., Casa, D. J., Hirschhorn, R. M., & Kerr, Z. Y. (2019). Epidemiology of Exertional Heat Illnesses in National Collegiate Athletic Association Athletes During the 2009–2010 Through 2014–2015 Academic Years. Journal of Athletic Training, 54(1), 55-63. doi:10.4085/1062-6050-504-17

4.     Centers for Disease Control and Prevention. (2010, August 20). Heat Illness Among High School Athletes --- United States, 2005--2009. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a1.htm

5.     Armed Forces Health Surveillance Branch. (2019, April 1). Update: Heat Illness, Active Component, U.S. Armed Forces, 2018. Retrieved from https://www.health.mil/News/Articles/2019/04/01/Update-Heat-Illness

6.     Sloan, B. K., Kraft, E. M., Clark, D., Schmeissing, S. W., Byrne, B. C., & Rusyniak, D. E. (2015). On-site treatment of exertional heat stroke. Am J Sports Med, 43(4), 823-9. doi:10.1177/0363546514566194

7.     Belval, L. N., Casa, D. J., Adams, W. M., Chiampas, G. T., Holschen, J. C., Hosokawa, Y., … Stearns, R. L. (2018). Consensus Statement- Prehospital Care of Exertional Heat Stroke. Prehospital Emergency Care, 22(3), 392-397. doi:10.1080/10903127.2017.1392666

8.     Roberts, W. O. (2006). Exertional Heat Stroke during a Cool Weather Marathon. Medicine & Science in Sports & Exercise, 38(7), 1197-1203. doi:10.1249/01.mss.0000227302.80783.0f

9.     Hostler, D., Franco, V., Martin-Gill, C., & Roth, R. N. (2014). Recognition and Treatment of Exertional Heat Illness at a Marathon Race. Prehospital Emergency Care, 18(3), 456-459. doi:10.3109/10903127.2013.864357

10.  Miller, K. C., Hughes, L. E., Long, B. C., Adams, W. M., & Casa, D. J. (2017). Validity of Core Temperature Measurements at 3 Rectal Depths During Rest, Exercise, Cold-Water Immersion, and Recovery. Journal of Athletic Training, 52(4), 332-338. doi:10.4085/1062-6050-52.2.10

11.  Casa, D. J., DeMartini, J. K., Bergeron, M. F., Csillan, D., Eichner, E. R., Lopez, R. M., … Yeargin, S. W. (2015). National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. doi:10.4085/1062-6050-50-9-07

12.  Welch Allyn. (2018). Capturing Rectal Temperature. Retrieved from https://www.welchallyn.com/content/dam/welchallyn/documents/sap-documents/MRC/80022/80022620MRCPDF.pdf

13.  Ronneberg, K., Roberts, W. O., McBean, A. D., & Center, B. A. (2008). Temporal Artery Temperature Measurements Do Not Detect Hyperthermic Marathon Runners. Medicine & Science in Sports & Exercise, 40(8), 1373-1375. doi:10.1249/mss.0b013e31816d65bb

14.  Huggins, R., Glaviano, N., Negishi, N., Casa, D. J., & Hertel, J. (2012). Comparison of Rectal and Aural Core Body Temperature Thermometry in Hyperthermic, Exercising Individuals: A Meta-Analysis. Journal of Athletic Training, 47(3), 329-338. doi:10.4085/1062-6050-47.3.09

15.  Mazerolle, S. M., Ganio, M. S., Casa, D. J., Vingren, J., & Klau, J. (2011). Is Oral Temperature an Accurate Measurement of Deep Body Temperature? A Systematic Review. Journal of Athletic Training, 46(5), 566-573. doi:10.4085/1062-6050-46.5.566

16.  Zhang, Y., Davis, J., Casa, D. J., & Bishop, P. A. (2015). Optimizing Cold Water Immersion for Exercise-Induced Hyperthermia. Medicine & Science in Sports & Exercise, 47(11), 2464-2472. doi:10.1249/mss.0000000000000693

17.  Hosokawa, Y., Adams, W. M., Belval, L. N., Vandermark, L. W., & Casa, D. J. (2017). Tarp-Assisted Cooling as a Method of Whole-Body Cooling in Hyperthermic Individuals. Annals of Emergency Medicine, 69(3), 347-352. doi:10.1016/j.annemergmed.2016.08.428

18.  Gaudio, F. G., & Grissom, C. K. (2016). Cooling Methods in Heat Stroke. The Journal of Emergency Medicine, 50(4), 607-616. doi:10.1016/j.jemermed.2015.09.014

19.  Training and Doctrine Command. (n.d.). Prevent of heat and cold casualties (TRADOC Regulation 350-29). Retrieved from Department of the Army website: https://adminpubs.tradoc.army.mil/regulations/TR350-29.pdf

20.  Nye, E. A., Eberman, L. E., Games, K. E., & Carriker, C. (2017). Comparison of Whole-Body Cooling Techniques for Athletes and Military Personnel. Int J Exerc Sci, 10(2), 294-300. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360373/

21.  Armstrong, L. E., Crago, A. E., Adams, R., Roberts, W. O., & Maresh, C. M. (1996). Whole-body cooling of hyperthermic runners: Comparison of two field therapies. The American Journal of Emergency Medicine, 14(4), 355-358. doi:10.1016/s0735-6757(96)90048-0

22.  Poulton, T. J., & Walker, R. A. (1987). Helicopter cooling of heatstroke victims. Aviat Space Environ Med, 58(4), 358-61.

23.  Moore, T. M., Callaway, C. W., & Hostler, D. (2008). Core Temperature Cooling in Healthy Volunteers After Rapid Intravenous Infusion of Cold and Room Temperature Saline Solution. Annals of Emergency Medicine, 51(2), 153-159. doi:10.1016/j.annemergmed.2007.07.012

24.   DeGroot, D. W., Kenefick, R. W., & Sawka, M. N. (2015). Impact of Arm Immersion Cooling During Ranger Training on Exertional Heat Illness and Treatment Costs. Military Medicine, 180(11), 1178-1183. doi:10.7205/milmed-d-14-00727

25.  Casa, D. J., DeMartini, J. K., Bergeron, M. F., Csillan, D., Eichner, E. R., Lopez, R. M., … Yeargin, S. W. (2015). National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. doi:10.4085/1062-6050-50-9-07

EMS MEd Editor : Maia Dorsett, MD PhD (@maiadorsett)

Article Bites #13: How Often Do They Get More Than One? Naloxone Redosing in the Age of the Opioid Epidemic

Klebacher R, Harris MI, Ariyaprakai N, et al. Incidence of Naloxone Redosing in the Age of the New Opioid Epidemic. Prehosp Emerg Care. 2017;21(6):682-687.

Background & Objectives:

The surging opioid epidemic has largely been combated with the use of intravenous and intramuscular naloxone administration. More recently, intranasal naloxone has been shown to be easily administered by not only EMS providers, but also law enforcement and family members to help reverse potentially fatal overdoses. Recently, mixed overdoses and ingestions with far more potent agents (such as carfentanyl) are on the rise, necessitating repeat naloxone dosing. The primary objective of this study was to determine the incidence of repeat naloxone administration for patients with suspected opioid overdose. The secondary endpoint was a more detailed descriptive and statistical analysis evaluating the precise characteristics associated with individuals who required repeat naloxone dosing.

Methods:

The investigators conducted a retrospective chart review of the electronic health record of the largest EMS service in New Jersey. Charts were searched for the presence of naloxone administration and other key words including “drug overdose”, “poisoning” and “unresponsive”. Charts were examined between April 2014 and June 2016. In order to be included in the study, patients had to be over the age of 17 years and administered an initial dose of 2mg of intranasal naloxone. Initial naloxone administration was performed by law enforcement or a BLS unit per New Jersey state regulations. Subsequent doses of naloxone were administered by ALS units.  Resolution or “response” to therapy was defined as GCS of 15. In addition, demographic data was extracted from each patient encounter. 

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Key Results:

In total, 2,166 patients received naloxone for suspected opioid overdose during the study period) April 2014 to June 2016). The key results from the study were as follows:

  • 1,971 of 2,166 (91%) of patients had reversal of overdose symptoms after a single dose of naloxone administered by law enforcement or BLS units 

  • 195 of 2,166 patients (9%) required a second dose of naloxone by an ALS unit given failure to respond after the initial dose

  • 53 of 2,166 patients (2.4%) required a third dose of naloxone by an ALS unit

  • Patients who required a second dose of naloxone had a mean GCS of 5.3 (standard deviation of 3.7). The mean respiratory rate was 10.4 breaths per minute with a mean oxygen saturation of 86.8%. 

  • Patients who required a third dose of naloxone had similar mean GCS scores (4.9) and oxygen saturations (86.4%). Two-thirds of the 53 patients who received a third dose of naloxone improved to a GCS of 15, suggesting that the remaining 1/3 patients may have had an alternative diagnosis for their altered mental status.


Takeaways:

  • Among patients with suspected opioid overdose treated with intranasal naloxone by first responders or ALS units, 91% of patients had complete reversal of symptoms after a single dose of naloxone, with 9% requiring repeat dosing.

  • Naloxone is overall very effective at reversing symptoms of opioid overdose after a single dose

What this means for EMS:

With the rising incidence of mixed ingestions, more potent opioids such as carfentanyl, EMS providers are faced with more complexities in the management of opioid overdose. This study suggests that, in addition to basic support of ventilations, naloxone is still the mainstay of management in these patients, and highly effective at reversing overdose symptoms. Furthermore, this study suggests that in the majority of cases, first responders including law enforcement, and BLS units may be able to safely manage opioid overdose without the need for ALS units. This may improve resource utilization in EMS systems that are already stretched very thin. 

Article Summary by Al Lulla, MD (@al_lulla)

Article Bites #12: The Profile of Wounding in Civilian Public Mass Shooting Fatalities. 

Article: Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016;81(1):86-92.

Background & Objectives:

Civilian mass shootings are unfortunately on the rise and afflict the lives of many individuals and their families. Given the rising incidence and severity of these events, there has been much in the way of public initiatives at improving morbidity and mortality in individuals who have been critically wounded. Much of the prior emphasis on management of these patients in the prehospital environment has focused on external hemorrhage control with widespread education on use of tourniquets. The strong focus on civilian management of exsanguinating extremity hemorrhage during mass shootings is largely based on the blast injury patterns identified during the US operations in Iraq and Afghanistan which suggest that between 52% and 64% of injuries in combat are to the extremities. Whether these lessons translate to civilian mass shootings is unclear. The overall purpose of this paper was to precisely identify the anatomic wounding pattern, fatal wounds and incidence of potentially survival wounds in civilian mass shooting incidents. 


Methods:

The investigators conducted a retrospective study evaluating autopsy reports performed by medical examiners or coroners in 12 different mass shooting events. The investigators utilized the term “mass shooting” as defined by the FBI to mean:

  1. An incident occurring in a public space with 4 or more deaths (not including the shooter);

  2. Gunmen who select victims at random

  3. Violence without means to an end (i.e. not associated with robbery

Using reports made available by the New York Police Department and the FBI that provide detailed descriptions of civilian mass shootings dating back to 1966, the investigators identified 78 events that met the above definition for mass shooting events. 56 events that met the above definition had medical examiners or coroners that could be contacted. If the medical examiner or coroner was not listed or they could be not be contacted, the mass shooting event was eliminated from analysis. Request for official autopsy reports were sent to the respective examiners/coroners. Based on these reports, data was compiled regarding body site of wound, type of injury, probable site of fatal injury and whether wounds were potentially survivable. 

Key Results:

In total, based on responses from medical examiners, a total of 12 mass public shooting events were analyzed in the study. A total of 139 fatalities with 371 total wounds were examined by the investigators. The key results from the study were as follows:

  • There was an average of 2.7 wounds associated within the group of fatalities

  • The case fatality rate for civilian mass shootings was 44.6% (compared to approximately 10% during Operation Iraqi Freedom and Operation Enduring Freedom as reported in other studies). 

  • 58% of all victims (with fatal and non-fatal wounds) had at least one wound to head or chest/upper back

  • 20% (28/139) of all wounds were to the extremity, of which none were deemed to be fatal

  • 77% of all fatal wounds were identified in the head or chest/upper back. 

  • In total, only 9 of the 125 fatalities or roughly 7% (14 excluded given absence of autopsy data) were determined to be potentially survivable 

  • The most common survivable injury was a wound to the chest (89% of all survivable injuries) without obvious evidence of vascular or cardiac injury

  • There was 100% agreement between the reviewers of the study regarding potential survivability of injuries

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Takeaways:

  • Only 7% of victims in civilian mass shootings had a potentially survivable wound. No fatalities likely occurred secondary to exsanguination from extremity hemorrhage

  • The majority of wounds in civilian mass shootings occur primarily in the head, chest/upper back compared to combat environments where the majority of wounds occur in the extremities. 

  • The case fatality rate for civilian mass shootings compared to military data was much higher, and associated with lower number of potentially survivable injuries 

What this means for EMS:

While our nation faces a crisis with the issue of gun violence at the forefront of public discourse, regardless of what stance one may take on this issue, one thing remains abundantly clear: EMS providers are front and center when it comes to management of victims of mass shootings in the field. Historically, much of the focus on managing victims of mass shootings has been based on Tactical Combat Casualty Care (TCCC) guidelines based on the US military conflicts on the battlefields of Iraq and Afghanistan. These guidelines are largely predicated on the management of exsanguinating extremity hemorrhage with the use of tourniquets. This study despite all its limitations including retrospective design, missing data, and possibility of miscategorization of survivable and non survivable injuries, calls into question the applicability of these findings to the civilian arena where body armor is not worn. Based on the results of this study, EMS providers on the front lines who bravely care for victims of civilian mass shootings may encounter patients with wounding patterns that differ significantly compared to those seen in combat. While there is no question the importance of training and implementation of easy interventions such as tourniquets for the management of extremity hemorrhage, perhaps EMS providers must have a broader implementation of other treatment strategies that more accurately reflect the injury profile seen in civilian mass shootings, such as penetrating chest trauma. The authors of the present study carried out a more recent analysis looking at the victims of the Pulse nightclub shooting in Orlando, FL. The findings of this newer study which examined this single event (versus the 12 events in the examined in the present study) identified a disproportionately higher rate of individuals with extremity wounds (90% versus 20%). In this newer study, 4 patients were determined to have preventable death secondary to extremity hemorrhage (or in this case, junctional hemorrhage in the axilla). These patients who died did not have any evidence of tourniquet application, further emphasizing the point that despite the overall low incidence of death from extremity hemorrhage in mass shootings, it remains a quick and easy intervention that has the potential to save lives. The authors further concluded that in the Pulse nightclub shooting, similar to the 12 prior incidents, the majority of fatalities were again secondary to torso injuries highlighting the need for other interventions such as decompression of tension pneumothorax, basic airway management and management of hypothermia, which likely play a critical role in improving the dismal survival rates associated with civilian mass shootings. 

References:

  1. Smith ER, Shapiro G, Sarani B. Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event. Prehosp Emerg Care. 2018;22(6):662-668. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29693490


Summary by Article Bites Editor, Al Lulla MD (@al_lulla)

BSI, Scene Safe: Debating the Personal Protective Equipment of Today

by Noah Tyler, EMT-P

Peer Review by Aurora Lybeck, MD

We’ve all seen the news stories and videos: Mass shootings, violent gang activity, and targeted assaults on first responders are on the rise.  Fortunately, bullet and stab resistant vests have been effectively protecting most of our law enforcement officers for years.

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Today, we see EMS personnel wearing ballistic armor to every call.  But wait a minute… we’re medical people, not one of those proverbial sheepdogs who protect the flock.  Is this overkill for EMS?  Are we addressing a blatant disregard for scene safety with a quick fix instead of education?  Are “tactical paramedic” ambitions jousting towards Don Quixote’s windmills?  Aren’t most violent or weapons-related responses contained and controlled by law enforcement long before paramedics step foot on scene?  They are in Lubbock, Texas… we call it “staging” in the area.  So why are we wearing ballistic vests for body armor?

A little history: A few years ago, our hospital-based EMS recognized the increasing rate of violence within Lubbock and began considering options to protect our EMS personnel without impeding patient care.  Our agency acknowledged that just like in the rest of the country, there were shootings, stabbings, and mass casualty threats within our city of nearly a quarter of a million people.  That said, we also had a strong, dedicated police force to keep us safe and we worked well together. 

Now jump ahead to 2018 --- Our hospital purchased ballistic vests for every field EMT, paramedic, and supervisor within our service.  It was not a strategically-planned and targeted weapons attack that brought about this change in protection.  There was no conflict or concerns about police protection for our staff.  Instead, it was the enormous rise in synthetic cannabinoid and bath salt abuse from 2013-2017 and the subsequent rise in calls for excited delirium, where we were confronted with patients who could not even be controlled with our standard sedation drug, Midazolam (Versed).  Small foil packets of tainted grass and other dried vegetation - something innocently named “Scooby Snax”, “Breeze”, or “Mr. Happy Potpourri” - sold for just $5 at the local smoke shop were presenting risk of serious injury to not only patients, bystanders, law enforcement, but our EMS personnel as well. 

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Intramuscular ketamine quickly became our medication of choice to protect and tame the patient, as law enforcement was not always deployed for our scene safety needs as these 9-1-1 calls may have come in as an unknown medical, vomiting, seizures, or check welfare.  We saw a need for ballistic vests to protect ourselves from the weapon threats usually involved in these patient encounters. 

With multiple raids on smoke shops, improved legislation on synthetic cannabinoid sale and prosecution, and targeted efforts by Lubbock police working with state and federal agencies, the synthetic epidemic finally tapered down.  But Lubbock’s population was increasing and as with any growing city in the US, the rate of violence was on the rise.  Two of our EMS stations were shot at in a single night – fortunately, no one was injured.

Improved dispatch algorithms for EMS and law enforcement evolved and police were responding to the suspected weapons calls and now more potentially-violent excited delirium patients.  2018 seemed safer, so again, do we really need all of that expensive body armor?

The ball was already rolling through the finances department and UMC approved the purchase of the armor.  Our EMS staff started wearing the lightweight ballistic vests for those just-in case encounters with a violent, armed patient or questionable scene.  While the past history of violent events led to body armor use, we soon discovered a previously-unrecognized benefit in our daily meat-n-potatoes type responses.

One of our frequent 9-1-1 requests is the “check welfare” call where a friend or family member has not heard from an elderly parent, college-age son, or friend with an extensive medical history in several days.  Most of these concerned callers are living in another city or state and can’t just drive and check on the individual.  Or, a home medical alarm company contacts EMS for an elderly person who has fallen and is unable to stand back up.  These encounters are usually not a safety threat and we prefer to preserve our law enforcement resources for more pressing needs. 

There is something unique about Texas though, and particularly in the western part of the state: It seems that just about every man, woman, and child owns a gun.  Yes, even in Texas, a child can legally own (but not purchase) a gun.  Most individuals are responsible gun owners, and it’s not uncommon to walk into a home and see a locked steel gun safe weighing hundreds of pounds sitting in a corner of the bedroom.  But, Texas paramedics and EMTs don’t suddenly run out of the house screaming, “scene safety!” --- in contrast, it usually spurs a conversation about the gun collection and an exchange on the latest wisdom about hunting rifles.  Having trouble with small talk for assessing decisional capability?  Start with a few words about the upcoming deer season or wild hogs tearing up the farm fields and you won’t have to say a word.  Your patient will do all of the talking.

So, going back to body armor: Are these hunters trying to kill our paramedics?  Absolutely not.  Instead, the ballistic vests find their value in the unexpected encounters.  For example, we responded to a “check welfare” call where the out-of-state son was concerned about his father with recently-diagnosed mild dementia.  His father is highly-functional and lives at home with occasional visits from friends and community health partners.  The son frequently calls his father to check up on him, but this time he did not answer the phone so the son called 9-1-1.  We arrived on scene and knocked on the door, which happened to be unlocked --- another west Texas behavior.

While entering the residence, we announced ourselves as EMS and heard no response, so we cautiously continued into the home.  As we entered the hallway, a frail elderly man was found frantically rolling his wheelchair down the hall.  His eyes were fixated on the doorway behind us and he wouldn’t respond to our questions.  He didn’t seem to understand our role or purpose and instead was intent on pushing past to the door behind us.  As I glanced behind me, I saw exactly what he was driving towards: A double-barreled shotgun resting on the door post.  He was exerting every effort towards getting his hands on that weapon because in his mind, two intruders were in his home and they were the threat. 

Dementia is a horrible disease.  His case was supposed to be mild, but when coupled with an acute urinary tract infection that altered his mental status, he was doing exactly as we should expect him to do.  He was protecting his life and his home, responding instinctively as any normal Texan would confronting a home invasion.  I was able to secure the weapon before he reached the doorway and eventually calmed him, but what if his hands got to it first?  What if shots were fired just as we entered the doorway earlier?

Another response involved a call for diabetic complications out in a more rural area of the county.  In this case, we arrived to find the front door wide open and obtunded patient sitting in the hallway.  His blood glucose level was 30 mg/dL, and while occasionally agitated, he didn’t appear to be an immediate threat.  Just your standard-issue hypoglycemia call near the “passed out” stage with a known diabetes history.  While administering the IV dextrose solution (D10W), I noticed that house was in disarray, in need of a lot of repair, and it looked like candy was scattered across the floor --- he must have been aware that his blood glucose was dropping but couldn’t fix it on his own soon enough.

My partner was looking for a medical history or medications list in the house, and he stepped out of the nearby bedroom saying, “You need to see this”.  We changed places and as I walked into the bedroom, I saw well over 80 bullet holes in the ceiling, walls, and furniture.  Handguns and rifles were strewn across the bed and floor.  I immediately requested law enforcement and as they arrived, the patient regained most of his mental status.  He was calm, confused about our presence, but then remembered: He knew his blood glucose was dropping and dropping fast.  Decades of his difficult-to-control diabetes also taught him that he’d soon lose his ability to make sound decisions and didn’t want to harm anyone.  He emptied his weapons, but by that time, his brain chose the most unconventional method. 

Guns and other weapons are not the only threat.  The human body is a formidable weapon in itself.  The ballistic vests have protected our personnel from injuries that previously were once accepted as “part of the job”.  Physicians, nurses, and emergency center staff know these risks and injuries well.  Hypoglycemia, stroke/brain injury, medication effects, or drug/alcohol abuse can turn an otherwise pleasant individual into a kicking, screaming, biting, fighting weapon of pain.  Trying to bathe a cat would be a breeze in comparison.  The ballistic vests perform remarkably well in blunting the kicks, fists, and even bites towards our core.  These are the potential injuries that can be most disabling for us on scene and risk our safety. 

I offer the experience and scenarios not to boast on “war stories” or to instill fear towards every patient encounter.  But as we’re taught in our EMS classes and usually soon forgotten, every response has a potential for violence – intentional or not.  Complacency can be fatal, but at times we also face situations where the risks will never be discovered until it’s too late. 

The individual decision to use body armor is a personal one.  Some of our personnel see it as important as donning gloves with every call.  Others bring their vests into the ambulance every shift as required by policy, but only wear them during known weapon-involved calls.  While every paramedic or EMT is entitled to their own decision to use or not use their vest, it must be an informed one.  Body armor’s role is more than protection from bullets and knives during a targeted attack.  It’s the everyday calls: The daily hypoglycemia response, substance abuse, brain injury, or even delirium from untreated acute illness. 

As experienced providers and mentors, we should instill a culture of safety that embraces the wisdom offered by author and speaker Simon Sinek: “Leadership is absolutely about inspiring action, but it is also about guarding against mis-action.”  The action is convincing decision makers that body armor investment for EMS personnel is necessary, while mis-action leads us to assume it’s only valuable for known weapon calls.  Consider alternative scenarios to protect yourself and your partner from preventable, disabling injury that in just a moment of time, could destroy your career and livelihood if not life itself.

 

Response & Commentary

Mark Philippy, EMT-P

I read with great interest the article regarding the wearing of ballistic and protective vests in EMS.  This is something of a timely topic, as one of the committees I serve on in New York has this on our agenda as an item of discussion.  We have wrangled with the notion of creating a best practices document to help EMS agencies in our state address the need for, and deployment of, ballistic vests.  Some areas of the state have been able to move ahead in various ways to provide partial deployment, mostly of threat-level four plate-carrying vests for tactical environments, but few have delved, officially, into daily-wear vest systems.

First, I’d like to be transparent about some of my own biases and experiences. 

Among the proudest and happiest days in my life were the first day I put a bullet-resistant vest on – my first day out of the police academy, and the last day I took it off – the day I retired from police work.  For 23 years I wore the vest religiously, even though, at the time I started in 1990, it was not required for daily wear as a police officer.  There were those in my department who resisted mandatory vest wear, despite the fact that they carried a firearm into every single encounter they ever had with a citizen – a weapon that could potentially be turned against them.  Yet by the time I left, it was not even a second thought – the vest went on before the uniform.

Having said that, I hated it, too.  It was hot, bulky, stiff, and any time I got into any kind of tussle, I spent a good 20 minutes trying to get it seated right and getting my uniform tucked back in (I’m a bit challenged in that regard, I admit).  When agencies such as the Chicago Police Department first started testing the outside vest carriers that looked like uniform shirts, I cheered, hoping it would someday make it to my department (it didn’t, at least not before I retired).  I worked bicycle patrol for a number of years and I lost more weight from sweating than I did from the exercise.

Now look at the EMS side of things.  In the time that I worked in the City of Rochester, my ambulance had been shot at twice, I had been punched, kicked, bit, and threatened with stabbing, all the while (stupidly, I agree) walking right in with the local police on things that today, we’d stage down the block for until cleared into the scene.  At the same time, I scoffed at those medics who wore bullet-resistant vests.  Why?  Because it was my observation that those who did, immediately seemed to get into more trouble than they had before.  Likewise, it seemed the people who got into trouble were the first ones to put a vest on. 

By trouble, I mean those few (and we all know them) who managed to rile up every patient with a mental health issue, seemed to draw crowds around themselves at inopportune times, and got more than their fair-share of personnel complaints.  These were often the folks whose chest seemed to puff out a little too much, and who seemed to feel they could take on the world single-handedly.  I worried for them, and about their partners, all the time.

Fast-forward to 2019.  I cannot agree more with the author that things are violent and dangerous.  I don’t know that I would agree they are any more so than 30 years ago, when crack cocaine was rearing its ugly head, and excited delirium was still called “cocaine psychosis.”  But we are more aware, and we are busier, and so are our law enforcement partners.  So the danger may be more visible, in-your-face, not to mention we may be much more aware of it through social media and information sharing.  So where is my concern?

First of all, what is the purpose of wearing ballistic or edged-weapon protection?  I’m loath to bring up what events transpired in my region some not-so-distant years ago (particularly since it involved a friend and colleague), but in that instance, ballistic vests would not have been of benefit.  Yet immediately after that incident, fire departments around the region and the country started talking about buying ballistic vests.  My question then as now is, why?  When will you wear them?  Will you put them on under your turnout gear?  Will you wear them on every call all the time?  If you’re a career firefighter or EMS provider will you wear it all the time, over or under your uniform?

What does that mean for you, and for your practice?  Because I see a good number of people (and police officers now, which irritates me to no end) wearing outside-carry vests festooned with pockets and carry points.  So the uniform is no longer the first thing a patient sees.  It’s the ballistic vest.  We might no longer present the image of primary caregivers, but perhaps be easily mistaken for police.  They are bulky, catch on things, and yes, you can take them off, but they still get hot when they’re on, which for practical purposes, should be most of the time.

Let’s talk about under-uniform vests then.  For threat-level II or III (and their progeny, IIA and IIIA) vests, under the uniform wear makes sense.  It is less intrusive, less visible, and depending on what style is purchased, can be integrated with stab-resistance and water repellency.  They are also hot, stiff, and make movement about inside an ambulance, or incident scene, challenging.  Uniforms will be untucked and it will be annoying, but you can work through that.  The thing to watch out for is the feeling of increased protection morphing into a sense of improved invulnerability.  And thence, potentially, increased risk-taking.

What else?  Cost.  Who bears the brunt of that?  The author was fortunate to have a hospital system than was progressive and financially positioned to purchase these, but what about municipal, commercial, not-for-profit, and volunteer agencies?  Medicare reimbursements being what they are, we are all holding on by a thread just to upgrade aging cardiac monitors and keep ambulances running.  While taking care of our people should be foremost in company leadership’s mind, does that extend to providing this level of protection?

In the law enforcement world, the National Institutes for Justice realized early on that the benefit of protective bullet-resistant vests warranted federal subsidy.  For every year that I was on the job, my vest was partially, and in some cases wholly, funded through federal grants.  Are those same grants or funding streams available for fire and EMS personnel?

The author points out that it is important for people to make informed decisions about wearing vests.  So let’s talk about some limitations and considerations.  If you have to buy a vest, I return to the question of what threat level?  What are you protecting against?  Small arms, rifles, close range, far away?  Of much more concern to me is, frankly, edged weapons.  However most bullet-resistant vests do not protect adequately from stabbing, thus Corrections’ use of SpectraTM and similar materials in stab-resistant vests.  There are those manufacturers who incorporate both (I had one for Bike Patrol) but they are increasingly expensive.  So cost and type of protection are key factors in this decision.  And I submit few EMS providers, let alone agency leaders, are knowledgeable enough to make these choices, so if you are considering it, best do your research or find yourself a subject matter expert to help.

What about moisture?  KevlarTM and TwaronTM fabrics, which make up the bulk of bullet-resistant vest manufacture, are susceptible to becoming soaked through, at which point they lose some or most of their ballistic integrity.  This was one reason I chose to use a combined Spectra/Twaron vest for bike patrol.  EMS providers are often in the rain, and sweating in cramped, semi-conditioned environments, so how effective will your protection be when the time comes?  As a police officer, I had the luxury of being able to go back to my station and swap carriers, keeping my car air conditioned, and making darn sure I wore a raincoat when I was outside for a period of time (most of the time, anyway).  That has not always been the case as an EMS provider.

What about training for the intended user?  How much training do EMS providers have in the limitations, care, and replacement of bullet-resistant vests?  I was acutely aware of the fact that I had a huge open area under my armpits that was not protected.  It was never so apparent as when I wore a short-sleeve shirt in changing weather, and could feel the cold air rush up my arm while in a standard bladed stance addressing a potential adversary.  Do EMS providers know how to stand to maximize their ballistic protection?  Do they know how far down the vest goes, or doesn’t go, to protect their abdomen, and their sides?

Up to this point I’ve somewhat danced around the issues of why we should wear the vest, and written about the challenges and considerations.  I don’t think anyone can argue, with any kind of standing, that there is not a place for bullet-resistant and edge-weapon protective vests in the EMS environment.  I do believe that there are a good number of considerations that must be addressed before anyone lays a hand on one, or picks up the thread to start obtaining them.  The author makes excellent and valid points about the ancillary protective benefits of the vests, from blunt attacks to motor vehicle crashes.  I know of a friend who avoided a serious spinal injury during a crash because his ballistic vest acted much like a KED.  But when we talk about “lightweight ballistic vests,” let’s make sure we’re talking apples and apples, and not Kevlar and Spectra.

Finally, I agree with the author that there is a particular lack of situational awareness (Oh, how I hate that term!) in EMS today.  It is getting better, and there are a number of good programs across the country trying to improve not only provider safety awareness, but EMS defensive tactics (shout out to Kip Teitsort and the folks at DT4EMS).  I posit that we should be spending our hard-won funds in this area before we invest in protective vests.  Then, and only then, can we fully understand the threat, and address the use of protective equipment effectively.

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EMS MEd Editor, Maia Dorsett MD PhD (@maiadorsett)

Trouble in Thin Air: Responding to Inflight Medical Emergencies

By Mark Liao, MD, NRP (@EMSFellowMark)

Peer Reviewed by Jeremiah Escajeda, MD (@JerEscajeda)

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Clinical Scenario:

As you settle into your seat on a cross-country airline flight to yet another Emergency Medicine conference, you hear the familiar Hi-Low tone signaling an announcement. Suddenly a pressured, yet professional, voice booms overhead: “If there is a medical professional on board the aircraft, would you please contact a member of the cabin crew?”  You pause for a moment and do a mental size up – what exactly would I be able to provide? Am I protected legally? What equipment is on board? The uncomfortable realization that you may be on your own – at 35,000 feet – quickly settles in as you unbuckle your seat belt and walk to the nearby galley.

Review:

Legacy Emergency Medical Kit prior to the 1998 Aviation Medical Assistance Act

Legacy Emergency Medical Kit prior to the 1998 Aviation Medical Assistance Act

Medical professionals such as EMS providers and physicians have always been aware that they may be called upon to respond as Good Samaritans in the event of an off-duty emergency. Aviation in-flight medical emergencies are uncommon events, with estimates ranging widely from 1 event every 40 flights to 604 flights or up to 10-40 events every 100,000 passengers [1-3]. The variation in estimates are due to the lack of a central registry with most studies relying on proprietary company data from either the airlines or a ground-based aeromedical consultation service.  Common in-flight medical events include syncope/near-syncope, GI complaints, respiratory problems and cardiovascular emergencies. Cardiac arrest is rare, with one review showing it represented only 0.3% of all inflight medical events [4].

Fortunately for potential first responders, the United States 1998 Aviation Medical Assistance Act provides generous legal protections for American air carriers:

Current emergency Medical Kit that meets minimum FAA Part 121 EMK requirements

Current emergency Medical Kit that meets minimum FAA Part 121 EMK requirements

An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct [5].

 The same law also updated required equipment on board commercial civil aviation aircraft in the United States. A scheduled air carrier – which the FAA calls a Part 121 Operator – is what most passengers fly in the United States. If a Part 121 aircraft has at least one flight attendant on board, the aircraft is required to have an Emergency Medical Kit (EMK), Automated External Defibrillator (AED), general first aid kit, bloodborne pathogen spill equipment and oxygen for first aid (if the aircraft operates above 10,000 feet) [6]. All Part 121 cabin crew in the United States are required to receive first aid and CPR/AED training, with demonstration of CPR/AED skills every 2 years, in addition to being familiar with the location of equipment on board the aircraft [7]. However, cabin crew education on obtaining vital signs or performing a physical exam is not required by regulations.   

 

Preparing to Respond

Above: An example of an in-flight patient care form

Above: An example of an in-flight patient care form

Each airline dictates their own policy on identifying potential medical volunteers and may request professional identification. Some international airlines – such as Japan Airlines, Lufthansa, SWISS and Austrian Airlines – maintain a registry of physician passengers who can be called on to render assistance if needed [8,9]. Medical volunteers, such as physicians who choose to respond should not have consumed alcohol prior to rendering care or otherwise be impaired [10]. Many airlines across the globe are contracted with an aeromedical ground support service, such as MedLink (located in Arizona) or Stat-MD (located in Pennsylvania) that provides physician consultation and helps the flight crew determine if diversion is necessary and assists cabin crew and volunteers with passenger medical care. They also perform ground based medical evaluations of patients if there is a concern that arises as to whether the patient is medically suitable to fly on a commercial flight. The ultimate decision for diversion rests with the pilot-in-command who will use the ground-based physician service and possibly inflight medical volunteers to assist in making the decision. Diversion is very costly and airlines attempt to avoid medically unnecessary diversions. Given the unique considerations of the aeromedical setting, suitable airports and local available services, medical volunteers should defer to the recommendations of the ground physician. Communication with the ground physician may take place with in-cabin headsets, telemedicine equipment or relayed through the flight deck.  Some airlines – particularly those flying long-haul routes – have also elected to equip their aircraft with patient monitors that integrate voice communication, video, EKG, pulse oximetry, temperature and other parameters that can be transmitted to the ground physician, though these are rare to find on domestic US operations [11]. Airlines will ask that volunteer help complete documentation for care that is rendered.

 

Vital Signs

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The only FAA required vital signs equipment in an EMK is a stethoscope and blood pressure cuff. Auscultation of breath sounds and blood pressure can be challenging due to engine noise and vibration. As such, blood pressures may need to be palpated. Pulse oximeters, while not required by regulations, are sometimes added to EMKs, although providers should be aware that the effects of altitude may cause normal changes in oxygen saturation. While oxygen saturation at sea level is approximately 97%, decreased oxygen tension at altitude will reduce this saturation value. Most civilian airlines are pressurized to maintain a cabin altitude of approximately of 6,000 to 8,000 feet: at 8,000 feet a normal oxygen saturation will be approximately 93% [12]. 

 

IV and Medication Administration

 

Figure5.jpg

The EMK is required to stock a limited amount of parental medication equipment and includes one IV tubing set with Y-connectors, 500cc of normal saline, 5cc and 10 cc syringes in addition to medication needles. As many EMKs utilize vial or ampoule epinephrine instead of an epinephrine autoinjector, 1cc syringes are also included. Curiously, the FAA did not specify the type or quantity of intravenous catheters to be equipped, thus leaving the decision up to the airlines or their EMK vendor. The author has seen as few as two 16-gauge IV catheters to a more generous set of one 18, 20 and 22 gauge IV catheters.

 

Airway and Ventilation Support

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 Basic airway adjuncts are included in the kit and at a minimum must include a bag-valve resuscitator (regulations do not specify what size), 3 sizes of oral airways and masks (pediatric, small adult, large adult) and CPR masks of equivalent sizes. The EMK presented above met these requirements by providing three mask sizes that could be either used with the adult bag mask resuscitator or a one-way CPR valve. Oddly, there is no requirement for the equipped bag-valve resuscitator to have oxygen tubing that is compatible with the aircraft portable oxygen bottle outlets.

 

Portable aircraft oxygen bottles, unlike those found in medical settings, are generally equipped with only two settings, low (2 liters per minute) and high (4 liters per minute). For these types of bottles, applying the mask adapter into the appropriate rate connection outlet will determine the flow rate.

A bronchodilator is also required as part of the EMK. A spacer, which is not required to be equipped, may need to be improvised using a toilet paper roll, rolled-up magazine or plastic bottle when treating children [13].

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Syncope

Based on previous literature, near-syncope and syncope comprise the majority of inflight medical emergencies. This condition, although frightening to the crew and other passengers, rarely requires IV administration or diversion. Simple maneuvers such as laying the patient supine, with legs elevated and applying oxygen, for the most part, are all that is required [2,4].

 Nausea/Vomiting

 Antiemetics are not required to be equipped in the EMK despite nausea and vomiting being a common inflight medical event. Although carrying antiemetics while traveling is advisable, it should be noted that serotonin receptor antagonists, such as ondansetron, are not effective for motion sickness [14]. Alternatively, the EMK does carry diphenhydramine which can be used off-label as an antiemetic. It is also reasonable to request if other passengers may be carrying over the counter antiemetic medications. 

 Cardiac Emergencies

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The EMK provides four 325mg of aspirin and at least 10 tablets of nitroglycerin. There is no requirement to include a single or 3-lead EKG as part of the equipment, though some airlines include this as a stand-alone device or optional attachment to the on-board AED [15].

 


Cardiac Arrest and Resuscitation Management

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In addition to the on-board Automated External Defibrillator, the EMK provides two doses each of 1mg atropine and 1mg epinephrine. A total of 200 mg of lidocaine is also required. Despite the provision of antiarrhythmics, there is no requirement for airlines to ensure that the equipped AED has a screen that permits the user to see the underlying cardiac rhythm.  Due to space constraints within the cabin, patients in cardiac arrest may need to be moved or dragged to the galley or a bulkhead row to ensure enough space is provided to render effective CPR. Ending resuscitation can be challenging and consultation with the ground physician is advisable.

 Allergic Reactions and Anaphylaxis

Figure12.jpg

 Diphenhydramine in both oral and injectable forms are provided in the EMK, with four 25mg tablets and two 50mg vials.  Two ampoules of epinephrine 1mg/mL (1:1000) must also be equipped. Some airlines have included epinephrine autoinjectors as part of their EMKs, but this is not required by regulations.

 



Diabetic Emergencies

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A total of 25 grams of injectable dextrose is equipped in the EMK, though there is no requirement for a glucometer or lancets. If a glucometer is needed, one option is to ask the cabin crew to make a public address announcement to see if another passenger may be willing to volunteer a personal one. An alternative is to assume the blood sugar is low (particularly in a syncopal event) and to provide an oral dextrose source such as orange juice if the passenger is able to drink.

 

 Upcoming Developments

 The EMK was primarily designed for adult medical emergencies and lacks pediatric appropriate supplies and equipment. In 2018, the FAA Reauthorization Bill was passed which included verbiage from the Airplane Kids in Transit Safety Act and directed the FAA to revise the EMK to meet the needs of children [16]. The FAA has yet to provide guidance in response to this bill.


 International Regulations and Equipment

 

Figure 14

An EMK that meets European AMC1 CAT.IDE.A.225 regulatory requirements

An EMK that meets European AMC1 CAT.IDE.A.225 regulatory requirements

Internationally, wide variations exist for on-board medical equipment. In Canada, an AED is not required by regulations and an EMK is only required on civil aircraft carrying more than 100 passengers [17, 18].  In Europe, defibrillators are not required, although are recommended if an aircraft has 30 or more passengers with at least one member of cabin crew [19].  One 2014 paper found that many German airlines did not carry AEDs and one carrier did not have any CPR equipment on board [20]. In contrast, some airlines on their own initiative, such as British Airways, far exceed these requirements, carrying an extensive array of medications and equipment including benzodiazepines, buprenorphine, antibiotics and suture equipment [21]. These optional enhancements have led to several remarkable stories of innovation and improvisation, including a 1995 case in which a physician volunteer improvised a chest tube for a passenger suffering from a tension pneumothorax using a urinary catheter found in the British Airways medical kit [22].

 Conclusion

 Despite the perceived austere clinical environment a commercial aircraft might present, US airline carriers are equipped with emergency medical supplies that a physician volunteer can effectively utilize. Whenever possible, the medical volunteer should consult with ground based medical support.  Familiarity with what and what is not carried will enhance a volunteer provider’s ability to respond to in-flight emergencies. For further information, an excellent review in JAMA is published at https://jamanetwork.com/journals/jama/article-abstract/2719313

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References

[1] Epstein, Catherine R, et al. “Frequency and Clinical Spectrum of in-Flight Medical Incidents during Domestic and International Flights.” Anaesthesia and Intensive Care, vol. 47, no. 1, 13 Feb. 2019, pp. 16–22., doi:10.1177/0310057x18811748.

[2] Peterson, D. C., Martin-Gill, et al.  (2013). Outcomes of Medical Emergencies on Commercial Airline Flights. New England Journal of Medicine, 368(22), 2075-2083. doi:10.1056/nejmoa1212052

[3] Kesapli, Mustafa, et al. “Inflight Emergencies During Eurasian Flights.” Journal of Travel Medicine, vol. 22, no. 6, 2015, pp. 361–367., doi:10.1111/jtm.12230.

[4] Martin-Gill, C., Doyle, T. J., & Yealy, D. M. (2018). In-flight medical emergencies. JAMA, 320(24), 2580-2590. doi:10.1001/jama.2018.19842

[5] U.S. G.P.O. Public Law 105 - 170 - Aviation Medical Assistance Act of 1998 (1998) (enacted).

[6] FAA. (2006). Emergency medical equipment (121-33B). Retrieved from

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-33B.pdf

[7] FAA. (2006). Emergency medical equipment training (121-34B). Retrieved from https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-34B.pdf

[8] JAL. (n.d.). JAL DOCTOR Registration System. Retrieved from https://www.jal.co.jp/en/jmb/doctor/

[9] Lufthansa. (n.d.). Doctor on Board. Retrieved from https://www.lufthansa.com/de/en/doctor-on-board

[10] Nable, J. V., Tupe, C. L., Gehle, B. D., & Brady, W. J. (2015). In-Flight Medical Emergencies during Commercial Travel. New England Journal of Medicine, 373(10), 939-945. doi:10.1056/nejmra1409213

[11] Doyle, A. (2010, December 7). MEBA: RDT demonstrates Tempus IC telemedicine system. Retrieved from https://www.flightglobal.com/news/articles/meba-rdt-demonstrates-tempus-ic-telemedicine-system-350616/

[12] Gradwell, D., & Rainford, D. (2016). Hypoxia and hyperventilation. In Ernsting's Aviation and Space Medicine 5E (pp. 55-56). Boca Raton, FL: CRC Press.

[13] Zar, H. (2000). Are spacers made from sealed cold-drink bottles as effective as conventional spacers? Western Journal of Medicine173(4), 253-253. doi:10.1136/ewjm.173.4.253

[14] Gradwell, D., & Rainford, D. (2016).Motion Sickness. In Ernsting's Aviation and Space Medicine 5E (pp. 794-795). Boca Raton, FL: CRC Press.

[15] JAL. (n.d.). Medical Supplies and Equipment on Board. Retrieved from https://www.jal.co.jp/en/health/medicines/

[16] Kraft, C. (2018, October 3). AAP Applauds Passage of Bill That Will Keep Children Safe During Air Travel. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAPStatementAirplaneKiTSAct.aspx

[17] Transport Canada. (2018, April 5). Advisory Circular (AC) No. 705-010. Retrieved from http://www.tc.gc.ca/en/services/aviation/reference-centre/advisory-circulars/ac-705-010.html

[18] Transport Canada. (2019, March 18). Part VII - Commercial Air Services. Retrieved from https://www.tc.gc.ca/eng/civilaviation/regserv/cars/part7-standards-725-2173.htm#725_90

[19] EASA. (2018). Carriage and use of Automatic External Defibrillators (2018-03). Retrieved from https://ad.easa.europa.eu/blob/EASA_SIB_2018_03.pdf/SIB_2018-03_1

[20] Hinkelbein, J., Neuhaus, C., Wetsch, W. A., Spelten, O., Picker, S., Böttiger, B. W., & Gathof, B. S. (2014). Emergency Medical Equipment On Board German Airliners. Journal of Travel Medicine, 21(5), 318-323. doi:10.1111/jtm.12138

[21] British Airways. (n.d.). BA Medical Kit. Retrieved from https://www.britishairways.com/health/docs/during/Aircraft_Medical_Kit.pdf

[22] Wallace, W. A. (1995). Managing in flight emergencies. BMJ, 311(7001), 374-375. doi:10.1136/bmj.311.7001.374

 

 

Article Bites #11: Measuring the Impact of a Telehealth Program on Ambulance Transports

Article Reviewed:

Champagne-langabeer T, Langabeer JR, Roberts KE, et al. Telehealth Impact on Primary Care Related Ambulance Transports. Prehosp Emerg Care. 2019;:1-6. [PMID: 30626250]

Background & Objectives:

Prior studies have confirmed what is known by many of those who work in EMS: a high proportion of patients that are transported have non-emergent conditions. Several studies have demonstrated that between 33 and 50% of all ambulance transports are for non-emergent causes. These transports often times result in signifiant resource utilization from EMS systems that are stretched very thin.  Furthermore, these transports may often be linked with ED overcrowding problems and increased healthcare costs. The role of telehealth has already been shown to be a cost effective and beneficial approach to many aspects of healthcare, including tele-ICUs and within EMS as part of trauma, stroke and cardiovascular care. The primary objective of this study was to investigate the impact of a large-scale telehealth program that utilizes non-ambulance based transportation (i.e. taxi) and paramedic triage of non-urgent complaints on overall EMS transports.

Methods:

The investigators conducted an observational study from January 2015 to December 2017 for patients triaged by the Emergency Telehealth and Navigation Program (ETHAN) program developed by the Houston Fire Department. According to the study protocol, EMTs and paramedics were tasked with enrolling patients with non-life threatening conditions or mild illnesses. To be formally included in the study, the following criteria needed to be met:

  1. full history and physical exam with no obvious emergency

  2. age >3 months

  3. English speaking

  4. Normal vital signs; afebrile if chronically ill or over 65 years of age

  5. ability to care for self

  6. ability to be transported in a passenger vehicle. 

Patients who did not meet all inclusion criteria or who had other high risk features of their presentation suggestive of an emergency condition were excluded from the analysis. For those who qualified for the study, enrollees were connected via tablet to a board certified emergency physician who determined if the patient could be referred for follow-up with a primary care facility via versus requiring transport via ambulance. The primary variable that was studied was whether patients were transported by ambulance. Patients who were not transported via ambulance were offered transport to the ED or a primary care facility via taxi. 


Key Results:

During the study period, the investigators enrolled 15,067 patients in the telehealth program (equivalent to 2% of the overall EMS volume during this period). The key results from the study were as follows:

  • 11.2% of patients in the telehealth program were transported by ambulance

  • 75.6% of patients were transported by taxi instead of ambulance (5% of these patients were transported to a clinic instead of the ED)

  • 13.2% of patients transported themselves or were not transported at all

  • Patients were more likely to be transported by ambulance in the telehealth program if the chief complaint was abdominal pain (19.6%), low-risk chest pain (8.3%), shortness of breath (5.2%), or dizziness (3.7%)

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Takeaways:

  • Over the course of the study period, a telehealth program to identify patients with non-emergent conditions was successful in helping avoid unnecessary ambulance transports

What this means for EMS:

EMS agencies are faced with increased demand of services by the public with decreased available resources and higher costs. Telehealth in the prehospital setting is a novel approach to identify patients that may be suitable for transport via taxi and allow for EMS units to stay in service and serve other patients who present with other time critical conditions. This study did not show a significant decrease in the number of patients that were ultimately transported to the ED (only 2% of overall call volume participated & the majority of patients were still transported to the ED via taxi) and did not provide patient outcome data regarding accuracy of triage as non-emergent. However, it does demonstrate that a telehealth program is feasible within a large EMS system and highlights a promising avenue towards matching healthcare resources with patient needs and thus represents an important advancement in the field of EMS medicine.

Article Review by EMS MEd Article Bites Editor, Al Lulla MD (@al_lulla)

ET3: Perspectives of a Paramedic and PA

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As both a Paramedic and an Emergency Medicine Physician Assistant I commend those who made the announcement of the Emergency Triage, Treat and Transport (ET3) payment model a possibility.  This is by far, one of the biggest steps in the advancement of modern EMS.  This historic payment model could finally bring an end to the “you call, we haul” motto that has plagued EMS since its inception.  One of the most beneficial sections of this new payment model is that it allows current EMS providers the option to transport to hospitals, urgent cares, primary care offices, or, when necessary, to “stay and play”, allowing EMS professionals to provide treatment in place with qualified healthcare providers, via telehealth when necessary.  While I feel this is beneficial to the EMS community as a whole, it begs the question what does this mean for the day to day provider?

As a paramedic, I am thrilled that this may curve the overwhelming amount of calls that do not require trips to the emergency room.  I can recall many trips for simple requests, such as  prescription refills, cast removal, cold and cough symptoms, or suture removal that would be placed in triage and often still be sitting in the same seat when I returned with the next patient.   I often thought to myself that there has to be another way - that trips to the ED were not always the answer, but if only we could take them to their primary care office, or utilize technology to communicate with their provider.  Then there were the many calls I would run that would end without any transport at all.  Often there would be treatment provided on scene, but then would come the refusal of transport.  For paramedics, these are also some of the highest risk refusals, but that’s another topic on good documentation.  I feel that the lack of access to healthcare was the basis of many non-transport calls, people whose only reliable way to see a provider was to call 911.  A perfect example is the underinsured patient with diabetes.  Patients who needed their blood sugar checked, were hypoglycemic, received treatment and when alert again, would sign the refusal of transportation form.  These trips would often end with a call to a medical control provider but would yield no payment to the EMS service.

For years, we have fought to be recognized as a valued part of the medical team, and this new service model has the possibility of being a giant leap for EMS kind.  Not only does this require the implementation of quality metrics for EMS service but provides paramedics a platform to shine.  EMS providers are now able to highlight their mastery of pre-hospital medicine, human pathology, knowledge of medical protocols, and dedication to patient care, no matter where that care may be delivered.  This is our chance to prove to the world that paramedics and EMTs are capable of quality, evidence based prehospital medical care, and not just basic transport.  With increased power comes greater responsibility and thus the responsibility of advanced education now falls onto the shoulders of my EMS family.  Advanced education, in the form of college degrees or specialty certification, is paramount for providers making definitive decisions for patients, and as professional healthcare providers, we should not fear this change.  At this time, paramedics are faced with the ability to be valued members of the medical community, it is time we seize this moment to bear the responsibility, to ourselves, our patients and our communities.

 As a PA, the ability of alternative (more appropriate) destinations brings the obvious benefit of a decompressed ED waiting room.  Many of my patients are there because they have no other avenues to see a provider.  This new payment model is a way to allow for a more efficient and effective pre hospital triage, and subsequently improved treatment of the 911 patient.  Paramedics in the field would now be able to utilize urgent cares and primary care providers to facilitate the most appropriate level of care, while having the ability to be paid for the services they provide.  It also allows for a closer collaboration opportunity between in-hospital providers and pre-hospital providers via additional resource utilization, such as telehealth.

 Overall I think this is a great leap in the right direction for EMS and the future of our profession.

This new reimbursement model creates standardized benchmarks for the EMS providers.  The goal of which is to improve the quality of care, while decrease the overall cost of healthcare.  It is our responsibility as EMS providers to show that we are worthy of this opportunity and seize it with overwhelming care, compassion, and efficient care for our patients.  It is also our responsibility to make assure we have the education, knowledge and the skills to advance the EMS profession and allow ET3 to be the giant leap forward EMS so desperately needs.  This may also allow for new relationships between EMS providers and hospitals in the region to be formed. It is my hope and belief that this announcement will improve the effectiveness and efficiency of prehospital medical care and allow the continued growth of MIH programs nationwide.

 

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Can ET3 push the field of medical direction to where it should be?

by Melissa Kroll, MD and Hawnwan P. Moy, MD

 Introduction

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The Center for Medicare and Medicaid Services’ (CMS) passage of the Emergency Triage, Treat, and Transport model (ET3) not only recognizes EMS as part of the health care system but is a significant step in developing a mature EMS system.  But what does this mean for the EMS medical director?  It is unlikely that we will be notoriously ignored like the 1973 EMS System Act of old. But will it help propel the office of the EMS medical director from an often unpaid (or underpaid) position struggling to fulfill the needs of the EMS system to a widely recognized and valued component of the healthcare system? Before we attempt to answer these questions, let’s review what the ET3 model hopes to establish.

What is ET3?

A new model for prehospital care that allows for increased flexibility and efficiency.

 The ET3 Model is a voluntary, five-year payment model aimed at increasing the flexibility and efficiency of prehospital systems. Essentially, with this trial period, CMS has agreed to pay EMS services for the following:

 1) transport an individual to an emergency department or other destination covered under the regulations

 2) transport to an appropriate destination (such as a primary care doctor’s office or an urgent care clinic)

  3) or provide treatment in place with a qualified health care practitioner, either on scene or connected using telehealth.

ET3 hopes this model will encourage cooperative agreements between local EMS systems and surrounding dispatch systems, hospitals, clinics, local governments, etc. This system also allows for increased accountability of systems through monitoring of programs through specific QI/QA metrics.

 

Feb 14, 2019. Emergency Triage, Treat, and Transport (ET3) Model. https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model

Feb 14, 2019. Emergency Triage, Treat, and Transport (ET3) Model. https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model

 What does this mean for the Medical Director?

Not just a “sign here Doc” system.

 If we ask any lay person what a good fire or police chief can do for their community, they may not answer with specifics, but they implicitly understand the role of such leadership positions.  If you ask them what a good EMS medical director can do for their community, you’re probably going to get a blank stare. Perhaps we have been too complacent in advertising what it is that a good EMS medical director can do for the EMS service and community.  Let’s take the opportunity now to highlight what a good medical director can do to ensure the success of ET3 and improve community health.   

  1. At the heart of it all, a medical director is a physician first.  Physicians have duty to ensure that the patient remains at the center of the system -an active medical director ensures that the patient is always number one.

  2. With the ET3 expansion of EMS systems there needs to be increased involvement and oversight by medical directors. As experts in the medical direction and having an intimate knowledge of how hospital systems operate as physicians, medical directors are a required leader for connecting the hospital, EMS systems, local governments, and other entities in a collaborative partnership.

  3. Many systems will be creating new processes, such as 911 triage, processes for determining optimum patient destination and who can best be treated in the home. New protocols requiring in-depth physician input will need to be developed, trialed, updated, and re-trialed.

  4. Constant quality improvement and quality assessment will need to be completed.  Continuous quality improvement, quality assessment, and timely feedback by the EMS Medical Director are required to ensure the safe medical care of the patient.

  5. Results will need to be published, presented, and discussed allowing for programs to learn from each other. Medical directors will need to be present, both in discussions at a higher level, but also on a ground level where practical application occurs to ensure a smooth maturation of the EMS system for the safety of our patients and still receive valuable data.

  6. ET3 allows for treatment to occur in the home in coordination with a qualified healthcare practitioner. Behind every prehospital provider that completes an in-home evaluation, there is the medical director who has provided focused, up to date education, training, and consistent quality assessment.

  7. In order to provide treatment in place, there will need to be a conversation with a qualified healthcare practitioner. For many systems, this will be a conversation with their medical director. This medical director will need to be accessible for consultation.  

 As a subspecialty of medicine, EMS should optimize the opportunity provided by ET3 to move EMS medical direction from “what is” to “what should be”.   We would be remiss not to recognize that unfortunately the term “medical director” currently describes a wide range of physician roles – from rubber stamp signatures on paperwork unknown personally to frontline providers to those who are involved in all aspects of patient care provided by an agency. The reason for this spectrum in medical direction is multifactorial.   EMS as a medical subspecialty is rather young, although EMS subspecialty fellowship training is working to build a larger base of involved EMS physicians.   At the state, agency or regional level, EMS medical directors are often excluded from decision-making. In addition, many medical director positions remain un- or under-funded and full time or majority time EMS physicians are few among us. Reimbursement rates for medical direction (the cost) largely do not acknowledge the value that an involved medical director can bring to the healthcare system.  This will be even more evident as we consider treat in place and alternative destinations which will better align patient needs with the current financial incentives of the healthcare market. 

 

The Future

The pilot will end. What needs to happen to make the future successful?

 Will a change in reimbursement structure such ET3 be the nidus to move medical direction to where it should be?  We think it can.   Fundamentally, systems that have relied on rubber stamp physicians will not be able to function in this expanded model.   EMS physicians will need to step up to both this challenge and responsibility.  Hopefully this new model provides a financial means to support them in doing so.

The ET3 is a 5-year pilot project. Which means it will end. In order to make this a sustainable option in the future, medical directors will not only need to be careful trackers of data, allowing for cost analysis of the impact, but leaders who demonstrate wisdom, integrity, and the expertise required to navigate the unique world of healthcare both in and out of hospitals while keeping an ever-vigilant eye on maintaining patient-focused care.  Let’s become the EMS Medical Directors we all strive to be.  

 

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Article Bites #10: Delivering Right Care and Transporting to the Right Place: Medical clearance of Psychiatric Emergencies in the Field

Article: Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA. Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "Medically Clear" Psychiatric Emergencies in the Field, 2011 to 2016. Ann Emerg Med. 2019;73(1):42-51.

Background & Objectives:

Due to a nationwide shortage of inpatient psychiatric beds, patients with psychiatric emergencies often spend long periods of time waiting in the ED for placement for psychiatric care. These long wait times are associated with more ED overcrowding, increased costs, and unfortunately sometimes inhumane conditions for patients and increased stress for staff. The vast majority of patients with involuntary psychiatric holds are brought to the ED by EMS, usually for medical clearance and evaluation for other possible non-psychiatric causes of the patient’s presentation. This study investigated the role of an EMS field protocol to allow EMS to bypass EDs and transport patients directly to a psychiatric facility. 

Methods:

The investigators conducted a retrospective review of all EMS transports in Alameda County, CA between November 1, 2011 to November 1, 2016, focusing particularly on patients receiving involuntary psychiatric holds. To assess for patients who received involuntary holds, the investigators evaluated the medical priority dispatch system code, primary impression, secondary impression and medical narrative as documented by EMS providers. According to the Alameda County EMS Agency protocol (see further reading below) patients with isolated psychiatric presentations can be transported directly to a stand alone psychiatric facility provided protocol criteria is met. Two primary outcomes were examined. First, the investigators compared “involuntary hold patients” with those patients who never received an involuntary hold to identify what specific characteristics were associated with patients receiving involuntary hold status. The second outcome that was evaluated was the safety of an EMS field protocol to screen patients for direct transport to a psychiatric facility and bypass of the ED. This measure was defined by retransport of a patient to the ED within 12 hours of transport to the psychiatric facility (AKA “failed diversion”).

Key Results:

During the study period, the investigators identified 541,731 total EMS transports (257,725 unique transports). Of the total transports, 10% (n=53,887) were for involuntary holds. The key results from the study were as follows

  • 41% (n=22,074) of transports for involuntary hold patients met protocol criteria for ED diversion and direct transport to stand alone psychiatric facility

  • Of patients who were transported to stand alone psychiatric facility, 0.3% (n=60) failed diversion and required retransport to ED within 12 hours

  • Involuntary hold patients were found to have significantly more total EMS use (24% of all encounters; n=128,003) compared to patients that never received hold status. They were also more likely to be younger, men, and have uninsured status

  • Of the patients requiring retransport within 12 hours, 54 of 60 of those patients developed new symptoms on arrival to the facility which did not manifest with their initial presentation to EMS. Reasons for retransport included traumatic injury (n=5), previously unrecognized or unreported symptom (n=13), seizure (n=8), excessive sedation (n=10), staff request for medical clearance of asymptomatic patient (n=7) new mental status change (n=5) or patient discharge from psychiatric service and self referral to EMS (n=5)

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Takeaways:

  • Over the course of a 5 year period, an EMS field protocol to screen psychiatric involuntary hold patients for direct transport to a stand alone psychiatric facility performed safely, with only 0.3% of transported patients requiring retransport to an ED within 12 hours

  • Involuntary hold patients were usually younger and often uninsured. In addition, they had significantly higher overall EMS utilization

What this means for EMS:

This study demonstrates that implementation of an EMS field protocol can allow for safe diversion from ED directly to a psychiatric facility. The implementation of such protocol in EMS systems would likely have a significant impact on ED overcrowding and length of stay. This study highlights two important points: 1) The role of EMS with respect to hospital operations, ED operations and the health care system as a whole cannot be overstated. EMS systems nationwide may be able to build upon the lessons from Alameda County and help reduce ED overcrowding concerns as well as more rapidly direct patients to the psychiatric care they need. 2) EMS utilization by patients with psychiatric illness is significant, with roughly one-quarter of all transports in Alameda County being for “involuntary holds” during the 5 year study period. This further re-inforces the importance of both federal and local resource allocation for psychiatric illness. 

Further Reading: 

Alameda County EMS involuntary hold protocol:

https://www.annemergmed.com/cms/10.1016/j.annemergmed.2018.08.422/attachment/b3ec30ed-3ced-4eca-963b-82a60f05d663/mmc2.pdf

Review and Infographic by Article Bites Editor, Al Lulla MD (@al_lulla)

Article Bites #9: The Emergency within EMS - Risk of Suicide in EMS Compared to the General Public

Death by Suicide — The EMS Profession Compared to the General Public

Vigil NH, Grant AR, Perez O, et al. Death by Suicide-The EMS Profession Compared to the General Public. Prehosp Emerg Care. 2018;:1-6.[PMID: 30136908]

 

Background & Objectives:

 Suicide is a public health crisis with an estimate 45,000 individuals dying from suicide annually. Certain professions, including law enforcement and EMS are exposed to high degrees of workplace stress, therefore it is hypothesized that these individuals are more predisposed to conditions including anxiety, depression and suicidal ideation and behaviors. Survey data examined by the National Association of Emergency Medical Technicians (NAEMT) has indicated that there is very high occurrence of suicidal ideation within the EMS community. Despite this important information, the relationship between suicidal ideation and suicide attempt with the completion of suicide in EMS providers has not been well studied. The authors of this study aimed to assess the odds of death by suicide completion in EMTs compared to non-EMTs.  

 Methods:

The investigators conducted a retrospective case-control study that analyzed the electronic death registry in Arizona from January 2009 to December 2015. Only adults greater than or equal to the age of 18 were included in the analysis. Multiple variables from the death registry were examined including age gender, race, ethnicity, and most importantly for the purposes of this study: cause of death and occupation. With respect to occupation, the term "EMT" was categorized as all individuals who had EMT certification, including firefighters, EMTs and paramedics. A logistic regression model was implemented to calculate the mortality odds ratio (MOR) of suicide between EMTs (exposed group) and non-EMTs (non-exposed group). 

 

Key Results:

In total, 350,998 adults were analyzed who died during the above time period. The key results from the study were as follows:

· There were 1,205 EMT deaths during the study period

o   63 (5.2%) were attributed to suicide. This is compared to the non-EMT group of which 2.2% of deaths were due to suicide. 

· MOR for EMTs versus non-EMTs was 2.45; [95% CI (1.88-3.13)]

· Adjusted MOR for EMTs versus non-EMTs was 1.29; [95% CI (1.06-1.82)] adjusted for gender, age, race and ethnicity 

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· The most common mechanisms of suicide in the EMT group was firearm (67%), however there was no significant difference between death by firearm in the EMT cohort versus the non-EMT cohort. 

 

Takeaways:

· In the Arizona electronic death registry, there were higher odds for death by suicide in EMTs compared to the general public. 

 

What this means for EMS:

EMS providers are faced with significant workplace stressors. Whether it’s traumatic calls, poor sleep quality, poor compensation, long hours, or overall low job satisfaction, EMS remains one of the most challenging professions. These aspects of the EMS profession, unfortunately, contribute to a host of mental health issues including depression, anxiety, PTSD, all of which predispose individuals to developing suicidal ideation and behaviors. The time to act is now. The results of this study are extremely compelling and must serve as the impetus for change within the profession. Further studies that precisely characterize the risk factors that place EMS providers at higher risk than the general public should be examined as well. Despite this, the findings from this research still demonstrate the need for greater EMS education regarding the symptoms and warning signs of suicidal behavior, the importance of adequate resources for counseling and mental health, and improved work conditions to protect those individuals who protect our communities and our patients. 

Article Reviewed by Article Bites Editor Al Lulla, MD.

Article Bites #8: Reconsidering Priorities of care: epinephrine in out of hospital cardiac arrest

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018. [PMID: 30021076]

Background & Objectives:

Other than early CPR and defibrillation, there are few measures that have been shown to improve outcomes for out-of-hospital cardiac arrest (OHCA). Despite this, epinephrine has been at the crux of ACLS management of patients with OHCA given the thought that it can cause peripheral vasoconstriction, increased beta adrenergic activity and augment coronary blood flow. In turn, epinephrine increase chances of return of spontaneous circulation (ROSC). While higher rates of ROSC have been confirmed in prior studies on epinephrine, unfortunately most of what we know about epinephrine suggests that it’s administration may not improve the most important clinical outcome - neurologically intact survival. The PARAMEDIC2 trial (Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration in Cardiac Arrest) was performed to assess whether epinephrine was beneficial or harmful as demonstrated by the primary outcome of 30 day survival. 

Methods:

The investigators conducted a multi agency (5 ambulance services), randomized, double-blind, placebo controlled trial in the United Kingdom from December 2014 to October 2017 in adult patients who sustained OHCA for which ACLS was provided by paramedics. Patients were excluded from the trial if they were pregnant, less than 16 years of age, had cardiac arrest secondary to anaphylaxis or asthma, or if they had administration of epinephrine prior to the arrival of EMS personnel. If initial resuscitation measures (CPR and defibrillation) were unsuccessful, patients were randomized to the intervention arm (1mg epinephrine q3-5 mins in accordance with ACLS protocols) or the control arm (normal saline placebo). As stated above, the primary outcome of the trial was 30 day survival. Secondary outcomes that were examined included rate of survival until hospital admission, length of hospital stay and ICU stay, rates of survival at hospital discharge and at 3 months, neurological outcomes at hospital discharge and at 3 months. Favorable neurological outcome was defined as modified Ranking score of 3 or less. 

Key Results:

In total, 8014 patients with OHCA were enrolled in the study over the 3 year period of which 4015 patients were in the intervention arm (epinephrine) compared to 3999 patients in the placebo arm. Both groups were well matched in terms of baseline patient characteristics.The key results from the trial were as follows:

  • 30 day survival: 3.2% in epinephrine group vs 2.4% in placebo group (OR 1.39; 95% CI 1.06-1.82, p=0.02).

  • Favorable neurological survival at 3 months (modified Rankin score 3 or less): 2.1% in epinephrine group vs. 1.6% in placebo group (OR  1.31; 95% CI 0.94-1.82.

  • Severe neurological impairment (modified Rankin score 4 or 5): 31% in epinephrine group vs. 17.8% in placebo group

  • ROSC during prehospital resuscitation: 36.3% in epinephrine group vs. 11.7% in placebo group

Takeaways:In this multi-agency, prospective, double blinded randomized placebo controlled trial, administration of epinephrine for OHCA was associated with a statistically significant higher 30 day rate of survival compared to placebo, but no difference in neurologically-intact survival.

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What this means for EMS:This study is the largest randomized controlled trial performed to date studying the impact of epinephrine administration on survival and neurological outcomes for OHCA. While administration of epinephrine has long been the pharmacological mainstay of prehospital (as well as in-hospital) management of OHCA, this trial calls into question its influence on patient centered outcomes (i.e. neurological intact survival). While this paper will surely be at the center of debate in the upcoming years within EMS circles around the world, one thing remains abundantly clear at this point: good quality BLS Care in the form high quality CPR and early defibrillation have the greatest impact on neurologically intact survival and should be the primary focus of resuscitation for cardiac arrest.

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Changing Paradigms?  Medication Administration in Cardiac Arrest

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Case Scenario:

EMS is dispatched for a 47 year old male who is unconscious with abnormal breathing.   A double BLS ambulance arrives on scene first. The patient is at first poorly responsive and moaning, but soon after develops agonal respirations and is found to be pulseless. CPR is initiated and an AED is applied.  He is found to be in PEA at the first pulse check. The paramedic arrives 3 minutes later and establishes intravenous access.

What medications, if any, should be given and why?  Are there historical factors or rhythm characteristics that affect this decision? What if the rhythm is ventricular fibrillation?

Within the last few years, a number of studies have challenged the role of medication administration in the treatment of out-of-hospital cardiac arrest.   Have these changed your practice and how?   

Please share your thoughts (ideally with citations!) by January 15th. A summary post will be published in January.

Article Bites #7: Should Air Medical Transport administer plasma to trauma patients at risk for hemorrhagic shock?

Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock

Sperry JL, Guyette FX, Brown JB, et al. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018;379(4):315-326. [PMID: 30044935]

Background & Objectives:

Hemorrhagic shock remains the most significant cause of mortality in trauma patients. In particular, coagulopathy is a significant contributor to death in this patient population and has been a focus of what is termed “damage-control resuscitation” in both civilian and battlefield arenas. Currently, there is a stronger push for resuscitation with blood-components including platelets and packed red cells in favor over crystalloid based resuscitation strategies. The premise of early damage control resuscitation in the pre-hospital environment is predicated on intervening at the point of injury and mitigating downstream complications including coagulopathy and irreversible hemorrhagic shock. Plasma administration as part of damage control resuscitation is thought directly address coagulopathy and improve chances for survival. This trial, termed the “Prehospital Air Medical Plasma (PAMPer)” trial sought to investigate the efficacy and safety of prehospital plasma administration in severely injured trauma patients. The primary outcome was the impact of prehospital plasma administration on 30 day mortality. 

Methods:

The investigators conducted a phase 3 multi-center cluster-randomized trial involving trauma  patients (blunt or penetrating) who were deemed to be at risk for hemorrhagic shock during air medical transport. Individual air medical bases were randomized to give plasma vs standard resuscitation in 1 month blocks. The intervention arm included patients who received 2 units of universal donor thawed plasma. The comparison group received standard of care resuscitation (crystalloid based resuscitation). Patients were deemed to be “at risk” for hemorrhagic shock were enrolled in the trial if they had at least one episode of hypotension (defined as systolic BP <90 mm Hg) and tachycardia (defined as HR >108 BPM) or if they had severe hypotension (defined as SBP <70 mm Hg) at any point in the prehospital phase of care. There were several exclusion criteria some of which included patients older than age 90 or younger than age 18, individuals who were pregnant, had traumatic cardiac arrest lasting longer than 5 minutes, penetrating brain injury, or refusal by family member to participate in the trial or if the patient was wearing an “opt-out” bracelet reflecting their wish not to participate in the trial, among others. 

Key Results:

There were 27 air medical transport bases that were recruited for the study that transported patients to 9 different level 1 trauma centers across the United States between 2014 to 2017. In total, 7,275 patients were transported during the study period, of which 501 patients qualified for the study. Of these patients, 230 received plasma and 271 received standard care resuscitation. Average prehospital time was 40 minutes (95% CI 33-51) and 42 minutes (95% CI 34 to 53) in the plasma and saline treated groups respectively. The key findings were as follows:

  • Mortality at 30 days was significantly lower in the plasma group (23.2%) versus standard group (33.0%)

  • Absolute reduction was 9.8% in the plasma group (95% CI 1.0 to 18.6%; P=0.03). 

  • Median INR was lower in plasma group compared to standard group (1.2 vs 1.3; p<0.001)

  • No statistically significant difference was found in outcomes with respect to other variables including multi organ failure, acute lung injury/ARDS, or transfusion-related reactions

  • Number needed to treat (NNT) was 10. 

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Takeaways:

  • In this prospective trial administration of plasma in the prehospital aeromedical transport setting was associated with decreased 30 day mortality in trauma patients at risk for hemorrhagic shock.

What this means for EMS:

In 2015, the PROPPR trial demonstrated improved outcomes in trauma patients receiving blood products (packed red cells, platelets, plasma) compared to crystalloid resuscitation. Little research has been done on the role of plasma administration at the point of injury in the prehospital setting. This study was one of the first to show that rapid prehospital administration of plasma products is associated with improved 30 day mortality. As stated in Article Bite #4, transfusion of blood products in the prehospital setting is associated with many logistical roadblocks, including but not limited to refrigeration, coordination with blood banks, and issues pertaining to wastage of products with a short shelf life, are all important considerations prior to routine implementation of this intervention. Given the traditional model of prehospital trauma care has focused on rapid transfer to a trauma center for definitive management, prehospital administration of plasma is a potential intervention that may lead to improved patient outcomes in some systems where distance to trauma center leads to extended prehospital times*.

Article summary and figure by Article Bites Editor Al Lulla, MD

* The COMBAT trial, which evaluated prehospital plasma transfusion for patients with signs of hemorrhagic shock within an urban system, did not find similar benefit.

Article Bites #6: Mac vs. Miller - A Retrospective review of Intubation Success

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by Aaron Farney, MD

 Citation

Alter, S. M., Haim, E. D., Sullivan, A. H., & Clayton, L. M. (2018). Intubation of prehospital patients with curved laryngoscope blade is more successful than with straight blade. The American journal of emergency medicine.

 Background/Rationale

There are two direct laryngoscope blades available to EMS: the curved Macintosh and the straight Miller.  Most providers learn to operate both blades, but tend to gravitate towards one based on personal and/or institutional preference.  Existing literature suggests the straight blade allows for better visualization, but perhaps intubation is easier with a curved blade.  However, there are no existing studies comparing these blades in the prehospital setting.  The aim of this study is to compare intubation success with a Macintosh blade versus a Miller blade as performed during pre-hospital endotracheal intubation (ETI) by paramedics.


Methods: This was a retrospective chart review of patients who underwent prehospital ETI from 2007 – 2016 by a single hospital-based suburban EMS service in/near Boca Raton, FL. This system had a 20K EMS volume, double ALS ambulances, 2-tiered system. Intubation attempt was defined as blade passing incisors. Intubation success was defined as confirmation of oxygenation & ventilation following ETI.


Outcomes and results

  • 2,299 patients had ETI attempted

  • 1,865 attempted with curved blade only (81%)

  • 367 attempted with straight blade only (16%)

  • 67 attempted using both blades (3% - added to both groups above)

  • Both groups were similar in age, weight, and gender


Conclusions: Both first pass success rates and overall intubation success rates for paramedics were significantly higher when Mac blades were used.

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Takehome

In this retrospective study,  first pass success rates and overall intubation success rates for paramedics were higher when Macintosh blades were used.  The difference of 13-15% is expected to be clinically significant. Other process measures such as perintubation hypoxia were not measured. The results of this study demonstrate correlation, not necessarily causation and are subject to confounding variables.   For example, the training backgrounds, in particular experience with different blade times, are unknown. However, this is a thought provoking study from the education and training perspective.  Should we be stressing training with curved blades or should we focus efforts to improve training with Miller blades or versatility in psychomotor skills?

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Not Your Typical Wake Up: A review of opioid related noncardiogenic pulmonary edema

by Aaron Farney MD

 Clinical Scenario

 You are called for a 25-year-old male, possible overdose, unknown if breathing.  On arrival, the patient is unresponsive on his bathroom floor.  Family reports they found him on the floor not breathing just prior to calling 911.  They had last seen him well 15 minutes prior.  He has a known history of heroin use, and you notice an empty syringe next to him.  On exam, he is unresponsive, cyanotic, with agonal respirations and has a pulse of 40. 

 You immediately commence resuscitative measures.  The airway is positioned, a nasopharyngeal airway is inserted, and positive pressure ventilations are initiated via a bag-valve mask connected to high-flow oxygen, with resultant resolution of cyanosis.  Four milligrams intranasal naloxone is administered.  About three minutes later, the patient wakes and you start to notice copious pink, frothy secretions.  You suction, but it continues, and even seems to increase.  The patient is now alert, complaining of shortness of breath and hypoxic to 78% despite a non-rebreather mask flowing at 15 liters/minute.  Your partner asks you “did he aspirate…?” 

 

What is happening, and what is the correct management?

 The phenomenon of opioid-related noncardiogenic pulmonary edema (NCPE) is not widely known in the prehospital realm.  As we are in the midst of an opioid crisis, the odds that the average field provider will encounter opioid-related NCPE is increasing.  The ability to recognize this phenomenon and knowing what to do will make all the difference to your patient.

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Background & Prevalence

The physician William Osler first described narcotic-related pulmonary edema during an autopsy in 1880 [1,2].  Its presentation and clinical course was not appreciated until the 1950s-60s.  The prevalence of opioid-related NCPE is about 2-10% of heroin overdoses [1,2].  It is most commonly seen in heroin overdose but has been reported with other opioids.

 Presentation & Clinical Course

Opioid-related NCPE typically presents as dyspnea accompanied by development of pink, frothy pulmonary secretions associated with ongoing hypoxia despite reversal of respiratory depression with an opioid antagonist (i.e. naloxone).  It often presents immediately after reversal but can be slightly delayed, up to four hours [1].  Most cases will resolve within 24-36 hours, but up to one-third of cases will require aggressive respiratory support [1,2].  If left untreated, it can progress to complete hypoxic respiratory failure, hypoxic end-organ injury, and cardiac arrest. 

Pathophysiology

The mechanism of opioid-related NCPE is poorly understood, in part because there are a variety of drugs involved, including the opioid antagonist naloxone.  There are several published theories.  Perhaps the most popular theory is increased pulmonary capillary permeability related to hypoxia and/or histamine release [1,2].  Heroin in particular is prone to causing excessive histamine release, causing leaky pulmonary vasculature.  Morphine is another drug known to do this. 

Other theories blame naloxone.  A patient who is opioid dependent, overdoses, and who is rapidly reversed with a high dose of naloxone subsequently experiences a catecholamine surge, particularly in those with concomitant cocaine use. [2] A second theory blaming naloxone is that following a prolonged period of near or complete apnea, reversal that results in inspiratory effort prior to complete opening of the glottis can result in excessive negative pressure within the lung, drawing in fluid from the pulmonary vasculature.  Administering positive pressure ventilation prior to naloxone therapy may mitigate this.  It is likely that opioid-related NCPE is multifactorial, with both the opioid agent and naloxone contributing.  Regardless of the underlying etiology, treatment remains the same.

 Management

The treatment of opioid-related NCPE is supportive and focused on correcting hypoxemia.  Initial measures include application of supplemental oxygen, preferably via a non-rebreather mask.  Patients with hypoxia refractory to high flow O2 warrant assisted ventilations.  Paramedics should have a low threshold for initiating CPAP therapy in the patient experiencing opioid-related pulmonary edema.  Hypoxemia or distress refractory to CPAP therapy may warrant endotracheal intubation and invasive ventilation to correct hypoxemia.  There has been no identified role for nitroglycerin or other medications in treating opioid-related NCPE.

 Back to the case:

The medic recognizes that this patient is experiencing opioid-related NCPE.  Only 8 minutes from the nearest emergency department, RSI is deferred in favor of immediate transport.  CPAP is placed onto the patient at a pressure of 5 cm H20.   The patient tolerates CPAP well, and oxygenation is improved to 90% on arrival at the emergency department, where care is transferred.  The patient continues to improve on CPAP and is admitted for further monitoring.

 Take-home points:

  • EMS should administer only the amount of naloxone required to reverse respiratory depression, not mental status.  Higher doses may increase risk of NCPE.

  • Opioid-related NCPE occurs in about 2-10% of opioid overdoses

  • Patients may complain of shortness of breath and will develop pink, frothy pulmonary secretions and hypoxia despite opioid reversal

  • Treatment is focused on correcting hypoxemia with supplemental oxygen and CPAP 

  • Cases refractory to CPAP may require invasive ventilation

  • All patients with opioid-related NCPE warrant transport.

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References

1.     Sporer KA & Dorn E. Heroin-Related Noncardiogenic Pulmonary Edema: A Case Series.  Chest 2001; 5:1628-1632.

2.     Sterrett et al. Patterns of Presentation in Heroin Overdose Resulting in Pulmonary Edema. American Journal of Emergency Medicine 2003; 21:32-34.

3.     Grosheider T & Sheperd SM. Chapter 296: Injection Drug Users.  Tintinalli’s Emergency Medicine 8th ed. 2016.

Article Bites #5: Pediatric Intubation - What's the first pass success rate in a physician-staffed helicopter retrieval service?

Analysis of Out-of-Hospital Pediatric Intubation by an Australian Helicopter Emergency Medical Service. 

Burns BJ, Watterson JB, Ware S, Regan L, Reid C. Analysis of Out-of-Hospital Pediatric Intubation by an Australian Helicopter Emergency Medical Service. Ann Emerg Med. 2017;70(6):773-782.e4. [PMID: 28460858]

Background & Objectives:

Adequate establishment and maintenance of a patent airway is one of the hallmarks of resuscitation. Pediatric intubation poses particular challenges, most notably lack of provider experience. It is estimated that first-pass success ranges from 66% to 85%. Prior studies have demonstrated no significant improvement in pediatric outcomes with prehospital intubation.  The intubation success rate in this study was only 57%.  [1]  Despite the difficulties associated with pediatric intubation, it remains within the scope of practice in the prehospital setting in some EMS services. The primary goal of this study was to report first-look success rate in pediatric advanced airway management in a physician-led adult out-of-hospital helicopter retrieval service. The secondary goal was to evaluate for potential complications of airway management as well as success by operator type, patient age and type of intubation.

Methods:

The investigators conducted a retrospective study evaluating patients who were treated by the Greater Sydney Area Helicopter Emergency Medical Service in Australia. This helicopter EMS service (HEMS) is comprised of a 2-person medical team with a physician and a paramedic. Physicians were usually board certified in emergency medicine or anesthesiology or residents with at least 5 years of experience. Paramedics were critical care paramedics with 10 years of experience and additional training with out of hospital care and retrieval medicine. The investigators evaluated an analysis of all out of hospital and interhospital pediatric intubations between January 2010 and April 2015. The only inclusion criteria was that the patient be younger than 16 years of age. Patients were intubated at the discretion of the team, with rapid sequence intubation (RSI) versus cold intubation (most frequently for cardiac arrest). The measures that were reported included critical timings (i.e. time to intubation), demographics, provider background, number of intubation attempts and complications. 

Key Results:

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In total there were 10,856 patients treated during the study period, of which 497 (4.6%) were pediatric patients. Of these patients, 82 (16.5%) were intubated by this particular HEMS service. The key findings were as follows:

  • First look success rate: 91% (75/82; 95% CI 83 to 97%). The overall success rate was 100%. 
  • 80% of patients were successfully intubated within 1 to 2 minutes after induction
    • 69/82 (84%) were rapid sequence inductions (RSI)
    • Ketamine was the most commonly used induction agent, utilized in 63/69 patients (91%) undergoing RSI
  • The most common indications for intubation included trauma (83%), head injury (56%), combative/agitated patient (29%). 
  • Median time to intubation was 25 minutes (defined as time from HEMS arrival to intubation)
  • Complication rate including hypotension, bradycardia and desaturation was 14%
  • Difficult airway indicators were present in 77% of patients that were intubated by this service

Takeaways:

  • In this retrospective series of pediatric intubations in the prehospital setting by a physician-lead helicopter service, first pass success was 91%. Overall success rate was 100% with only 9% of patients requiring multiple attempts). 

What this means for EMS:

The role of intubation in the field for pediatric patients is extremely controversial. Prior studies have demonstrated low rates of first pass success and overall lack of significant improvement in patient outcomes. This study showed an uncharacteristically high rate of first past success in the prehospital setting for pediatric patients. The investigators of this study attribute their high rate of success to a rigorous training program for providers in the field, frequent practice and checklists amongst other mandated practices. Overall, pediatric intubation in the field is a relatively rare occurrence with limited “on-the-job” training experience, which may be what has historically contributed to its unsuccessful implementation in the field. This study highlights the importance of adequate training and psychomotor mastery to performance of critical skills, particularly those that are rarely performed.  It did not evaluate the effect on clinical outcomes. 

References:

1. Gausche, M., Lewis, R. J., Stratton, S. J., Haynes, B. E., Gunter, C. S., Goodrich, S. M., ... & Seidel, J. S. (2000). Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. Jama283(6), 783-790.

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Stroke Destination: An Opportunity for Innovation in System Design

Clinical Scenario:

In June, we posted the following scenario for comment:

EMS is called to the scene of a “possible stroke”.  The patient is a 75 yo female who was last known normal at 8 pm the night before when she went to bed with plans to watch TV before going to sleep.  She fell when she tried to get out of bed at 7 am.  Her daughter lives with her and heard her fall. When she came into the room, she noted that her mother had a right facial droop, right arm and right leg weakness. She also was unable to speak coherently.  The ambulance arrives on scene at 7:30 am and the EMT performs a Cincinnati stroke scale and confirms the findings reported by the patient’s daughter.   

The patient lives 20 minutes away from a community hospital which is designated as a primary stroke center.  The comprehensive stroke center with endovascular capability is located an hour away.

Where should the patient be taken?  What pre-notification alarm bells should be rung?  What criteria should EMS systems use to make these transportation decisions in a way that best serves patients without overburdening both the EMS system and comprehensive stroke centers?

We got many thoughtful comments on the above scenario that highlight the complexity of the systems-of-care decisions that face EMS on a local, regional and national level.

 

Background:  The Changing Landscape of Stroke care

Only incremental changes in stroke treatment occurred after the approval of IV tPA in 1996 which established a 3 hour window for IV thrombolysis.  After publication of the European trial ECASS III in 2008, the window extended to 3-4.5 hours.   But in 2015, a number of clinical trials were published that dramatically increased the management options available for the treatment of stroke patients and challenged the EMS community to change their destination protocols for stroke patients.  These 5 trials, MR. CLEAN, ESCAPE, SWIFT-PRIME, REVASCAT, and EXTEND-IA,  demonstrated that patients with NIHSS > 6 and proven large vessel occlusion by CT-angiogram may benefit from endovascular reperfusion therapy if they present within 6 hrs of stroke onset [1,2,3,4,5].   A subsequent metanalysis (HERMES) concluded that there may be potential benefit out to 7.3 hours after stroke onset [6].

Similarly to trauma centers, stroke centers are not all equivalent:

-        Primary stroke centers (PSCs) provide good stroke care and intravenous tPA

-        Thrombectomy-capable PSC can do everything a PSC does, but also has the capability to perform mechanical thrombectomy

-        Comprehensive Stroke Centers (CSC) have all of the above, plus extensive resources managing the most complicated patients with dedicated Neuro ICU, neurosurgical services, research and educational resources. 

Given the different capabilities of potential destinations, two main issues complicated EMS transport considerations:

(1)   To be eligible for endovascular therapy patients had to have a proven large vessel occlusion on CT angiogram. EMS needed to screen effectively for large vessel occlusions in the field using physical exam.  A number of scales were developed for this purpose, with varying and less than optimal sensitivity and specificity [7-14, Table 1].

(2)   Most of the patients in the above trials received tPA prior to going to endovascular therapy.  In many areas, bypassing a primary stroke center capable of administering tPA in favor of going directly to a comprehensive stroke center would place patients out of the tPA window.

Table 1:&nbsp; Sensitivity and Specificity for Prehospital Screens for Large Vessel Occlusion

Table 1:  Sensitivity and Specificity for Prehospital Screens for Large Vessel Occlusion

Above and beyond this, getting the right patient to the right place at the right time also included considerations for not overburdening Comprehensive stroke centers and excluding primary stroke centers.   Primarily in response to the above, the Mission: Lifeline Stroke was formed and  developed a Severity-Based Stroke Triage Algorithm for EMS to balance the competing demands of time to tPA, access to endovascular capability and overtriage/undertriage to comprehensive stroke centers.

While EMS was still collaboratively identifying best-practices for patients with possible LVO presenting within 6 hrs of last known normal, two other studies were published last summer which again challenged us reexamine our stroke process of care by extending the time window of patients eligible for endovascular treatment. 

The DAWN trial was a prospective, randomized, open-label clinical trial comparing thrombectomy plus standard care vs. standard care [15]. The trial included patients with the following characteristics:

  • Last known well between 6 to 24 hrs
  • NIHSS > 10
  • Imaging-confirmed large vessel occlusion (ICA or proximal MCA)
  • Mismatch between severity of clinical deficit and the infarct volume as determined by perfusion imaging.

The trial found a significant difference in functional independence at 90 days (49% for thrombectomy arm, 13% for standard care, p < 0.001) but no difference in 90 day mortality.

The DEFUSE-3 trial  was a randomized, open-label trial with blinded outcome assessment that compared thrombectomy + medical therapy vs. medical therapy alone [16].  The trial included patients with:

  • Last known well between 6 to 16 hrs
  • NIHSS ≥ 6
  • Imaging-confirmed large vessel occlusion (ICA or proximal MCA)
  • Initial infarct size of < 70 ml
  • Evidence of salvageable ischemic tissue on perfusion imaging defined as ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of ≥1.8

Similarly to the DAWN trial, DEFUSE- found a significant improvement in functional independence at 90 days (endovascular therapy 45%, medical therapy 17%, p < 0.001).

Both trials included patients with severe deficits.  Mean and Inter-quartile range NIHSS for patients receiving thrombectomy in the DAWN and DEFUSE-3 trials were 17 (13-21) and 16 (10-20), respectively   

These trials present several new challenges for EMS transport decisions:

(1)   Patients who are clearly ineligible for IV tPA are included, leading to less competition between transport time to comprehensive stroke center (CSC) and tPA eligibility for a significant proportion of stroke patients.

(2)   The time criteria are broadened and include the very important population of “wake-up” strokes which made up a significant proportion of the LVO stroke population in the above trials. While broadening the population of patients to be screened for eligibility for endovascular therapy, the criteria are actually very narrow and imaging-based, increasing the possibility of a significant amount of over-triage to comprehensive stroke centers. In one retrospective review of all patients with acute ischemic stroke presenting to a Comprehensive Stroke Center only 1.7% of all patients would have qualified for DAWN enrollment with an additional 0.6 – 1.0% meeting DEFUSE-3 criteria. [17]. Moreover, while CT angiogram may be available at many primary stroke centers, the imaging software (like was utilized for patient selection in both DAWN and DEFUSE III) to evaluate perfusion is unlikely to be.

The comments we received on this post presented a number of responses and potential solutions to these challenges.

 

Comment Review:  The Brainstorming Phase and Regional Solutions

The Right Patient

 Dr. Aurora Lybeck made several great comments on this post.  She made the very important point that the first step in patient identification starts with the EMT or paramedic at the patient’s side.  Stating that “we shall use X… “ to screen for LVO without providing appropriate education and feedback to the provider at the patient’s side will decrease the sensitivity, specificity and utility of validated prehospital LVO screens:

 I think there are a few questions to answer before considering if we SHOULD as EMS to screen for LVO strokes and bypass PSCs for CSCs. 1) Can EMS reliably screen for LVO strokes and 2) What benefit is bypassing PSCs and going straight to a CSC going to have to the patient (a small margin of benefit or a large clinically significant benefit) and 3) what is the acceptable over-triage rates at the CSCs?

With regards to training, we can gather some of the evidence that demonstrates that EMTs can successfully perform one of the screening tests (LAPSS, CPSS, LAMS, RACE, or even a full NIHSS), but the implementation of that in a real-life EMS system with not just new training and competency expectations, but also embedded in a new protocol and transport guidelines that can sometimes be confusing depending on geography etc. If you are one medical director and/or educator and have hundreds of EMTs/paramedics, how are you going to adequately train them all? Have them practice the exam? Ensure competency? Scenarios or simulation? It may be possible with a smaller service or one with robust education but in reality, it's an important skill that requires not just skill training but critical thinking and a high degree of clinical competency.” – Aurora Lybeck

 If system-design changes are to succeed, they must include plans for involvement and education of the field provider if they are to effectively improve patient outcomes.

 

 The Right Place at the Right Time

From a system standpoint, the outcome benefit of endovascular therapy for a very select group of patients must be balanced with resource utilization within the system as a whole.  While it is easy to say that every potential LVO should go to a Comprehensive stroke center, this “transport intervention” could come with a significant amount of unnecessary overtriage that may overburden already-overcrowded centers and add significant cost to the system.

Several of the commenters specifically addressed the issue of over-triage to comprehensive stroke centers.  While there was general consensus that embolectomy candidates should be taken to CSC, there was variability in what their path to the stroke center should be.  In some cases, it was felt that prehospital LVO scale was sufficient to warrant PSC bypass.  In others, there was consideration whether the role of the PSC could still play a critical role in the care of these patients by offering a “secondary screen” in which imaging criteria was used to further narrow embolectomy candidates in such a way that significant time was not lost. While in the end this will vary by region structure and resources, these comments highlight the importance of considering different solutions to the same problem, implementing effective system metrics and measuring patient outcomes:

If the patient has signs and symptoms of a large vessel occlusion than bypass the primary stroke center for the comprehensive stroke center because tpa alone at the primary may not be effective against the large clot and clot retrieval will be needed anyway, I think???” – Kyle

 “RACE LAMS or CPSSS positive for LVO need to go to a comprehensive center. These are the prehospitally validated scales for LVO. If it is to far or time intensive call the helicopter. We are happy to help because time is brain and minutes matter.” – Bill K

What criteria should EMS systems use to make these transportation decisions in a way that best serves patients without overburdening both the EMS system and comprehensive stroke centers?
- Patient time since last known to be normal
- Willingness of comprehensive stroke center to be OK with a certain amount of over triage
.” – Greg Friese

RACE LAMS or CPSSS positive for LVO need to go to a comprehensive center. These are the prehospitally validated scales for LVO. If it is to far or time intensive call the helicopter. We are happy to help because time is brain and minutes matter.” – Bill K

We have to be careful when considering this question and come to an answer in a vacuum. EMS triage and destination is critical. But those decisions need to be made in the context of the system of care in region. A regional system of care where the primary stroke center (PSC) can perform a CTA immediately on arrival and upload it to a cloud based imaging viewer that the comprehensive stroke center (CSC) can also immediately review allows the PSC to perform the critical initial function of identifying those that are candidates for embolectomy. Add that to a system where inter-facility transport can be rapidly secured or even auto-launched, the OR can be mobilized ahead of patient arrival, and the patient can be brought directly to the OR at the CSC, and the initial medical contact by EMS to CSC groin puncture time will likely be the same or even less than if the patient was triaged pre-hospital to bypass the PSC and go to the CSC. If too many patients get triaged prehospital to the CSC, then the CSC's resources (personnel, scanners, ED beds, neuro beds) may be overwhelmed and their ability to provide care to their LVO-strokes will be compromised. If there is no LVO or they have an LVO, but aren't a candidate for embolectomy based on the initial imaging acquired, they can be cared for just as well at the PSC as at the CSC in most cases.” - Chris Zammit

Great discussion!
In this patient with wake up stroke I would transport to PSC first. Although she does have a LA Motor Score/CSTAT and RACE concerning for LVO she is a wake up and would need both a primary stroke work up (CT to evaluate for hemorrhage and CTA head and neck to identify if she has LVO lesion) It the CTA is positive then perform CTP or DWMRI to evaluate if she fits the criteria set fourth by the DAWN trial or DEFFUSE 3 for reperfusion. I believe most of this can be done at the PSC if there is a prior algorithm with EMS and cooperation for door in door out transfer direct to intervention to the CSC if she has an LVO and fits criteria.”
– Rob Dickson

So, if we decide that based on the evidence, an EMT can indeed be taught the chosen LVO screening exam and can indeed implement it within a new stroke transport destination protocol and can retain the skill and demonstrate competency over time, now how is that implemented in a given service or area? Some protocols will suggest a given time guidelines (ie if there is a CSC within 30 min, or bypassing a PSC would not extend the patient's ED arrival more than 20 minutes for example). But there is little to no evidence to guide us on how to geographically on transport- not to mention the reality of time estimates that many of us recognize from practicing in the field. If you plop yourself at any given residential address within your service area, do you know exactly how far you are from the closest PSC? CSC? The difference between those sites? Are they supposed to pull up a map with estimated arrival times and calculate the difference? There is so much subjectivity there, it's worth considering all the possible scenarios before implementing a change as important as bypassing a PSC. For some areas, it's a moot point. Where I trained in residency and in fellowship, we were in major metropolitan areas, where a CSC is rarely more than 15-20 minutes away. Unless your PSC is in the complete opposite direction and you're on the edge of the city, there is likely more to gain and less to lose by choosing the CSC over the PSC- as long as that CSC is willing to accept a lot more stroke patients, knowing that EMS may just default to the "easy" decision of bringing all stroke patients to the CSC (not saying it's the right decision, but with complex decision making we know the easiest generalization is often chosen regardless of the protocol minutiae). However, I currently practice in a more rural and suburban area, where the CSC may be over an hour away. For many of our services, it wouldn't make any sense to implement screening and new protocols for LVO occlusion when their closest local facility is a PSC and transporting to the CSC would be a delay long enough to exclude some patients from receiving TPA if they are not interventional candidates- those patients are much better served being brought to the local PSC, treated with TPA if eligible, and transported to the CSC for intervention if indeed an LVO and eligible for endovascular intervention- ie the model we are currently using.” – Aurora Lybeck

 

One other consideration for transport time is patient stability balanced with the clinical skills/training of the field provider:

Where should the patient be taken?
If I am in the story as an EMT ... I am going to the nearest hospital. An hour feels like a long time to be with a patient who potentially needs ALS interventions.”
– Greg Friese

Agree with Greg as well that there are considerations of long transport and risk of airway compromise so provider level of training and capability has to play a role. Also we must consider geographic location and strain on resources from having a truck out of service for 3 hours on this transport.
Lot's depends on geography and capabilities of your particular system
” - Rob Dickson

 

In his expert review of this post, Dr. Pete Panagos (Co-Chair of Mission:Lifeline Stroke) wrote the following:

A big issue also to at least mention is door-in-door-out (DIDO) from PSC to CSC.  IF the decision is to always go to nearest/closest stroke center, then the PSC, and EMS, must be committed to rapid identification, evaluation and transfer out, literally within 30-60 minutes of arrival and/or decision to transfer.

 

Don’t Forget the Basics

 Overall, while I think the prospect of identifying LVOs in the field accurately and transporting them to the most definitive care/CSC is exciting and their expedited treatment and recovery is a clinically important outcome to focus on, I don't want to lose sight of excellent basic stroke care for all patients. For high functioning urban systems with robust education and training that can implement such new screening skills and protocols, maintain competency, and demonstrate success in patient outcomes and acceptable over-triage rates to the CSCs, I think it's great. For most other services though, I think that time in education and emphasis is best spent on excellent basic prehospital stroke care- timely, accurate, checking a glucose and performing a basic Cincinnati stroke scale, appropriate monitoring, sending a stroke alert to the nearest appropriate facility, and bringing the patient straight to CT for the ED team to jump into action. Who knows, maybe someday our more rural services will start identifying LVO strokes and utilizing our HEMS services to get them to a CSC in the future. Thank you to everyone out there putting the time and passion into researching, implementing and closely QA'ing these new clinical changes. Looking forward to the research that will come out of all the systems out there implementing LVO screening by EMS, and certainly hope to see a significant clinical benefit to patients!

For reference and example, here are some Wisconsin LVO protocols currently in use:
-Milwaukee's (using BEFAST): http://county.milwaukee.gov/ImageLibrary/Groups/cntyOEM/EMS/Standards-of-care/Cardio/Stroke2018.pdf
-Madison/Dane County's (using FAST-ED, see page 73): https://em-ems.countyofdane.com/documents/pdf/2018%20DRAFT%20EMS%20Protocols%20-%20DRAFT/DCEMS%20Protocols_%203.9.18%20FINAL%20(web).pdf
-LaCrosse/TriState (using FAST-ED, see page 28): http://www.tristateambulance.org/documents/TSA%20Medical%20Guidelines.pdf
– Aurora Lybeck

 

Last Words

 Why would it be necessary for EMS to make this decision alone? Call stroke alert and report to online medical control” – Mario

Prehospital stroke care does not exist in isolation. The advent of endovascular therapy for stroke challenges the specialty of EMS to  take innovative approaches to system design that incorporate best evidence to improve patient outcomes while balancing the strain on resources.  The best solutions will consider regional factors, focus on field provider education and value comprehensive quality improvement initiatives that acknowledge the critical role of the EMS provider in the stroke care continuum.

 

Discussion Summary by EMS MEd Editor, Maia Dorsett MD PhD (@maiadorsett)

Peer Reviewed by Peter Panagos, MD (@panagos_peter)

References:

 1. Berkhemer, O. A., Fransen, P. S., Beumer, D., Van Den Berg, L. A., Lingsma, H. F., Yoo, A. J., ... & van Walderveen, M. A. (2015). A randomized trial of intraarterial treatment for acute ischemic stroke. New England Journal of Medicine372(1), 11-20.

2. Goyal, M., Demchuk, A. M., Menon, B. K., Eesa, M., Rempel, J. L., Thornton, J., ... & Dowlatshahi, D. (2015). Randomized assessment of rapid endovascular treatment of ischemic stroke. New England Journal of Medicine372(11), 1019-1030.

3. Saver, J. L., Goyal, M., Bonafe, A., Diener, H. C., Levy, E. I., Pereira, V. M., ... & Jansen, O. (2015). Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. New England Journal of Medicine372(24), 2285-2295.

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8.  de la Ossa, N. P., Carrera, D., Gorchs, M., Querol, M., Millán, M., Gomis, M., ... & Escalada, X. (2014). Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke45(1), 87-91.

9.  Katz, B. S., McMullan, J. T., Sucharew, H., Adeoye, O., & Broderick, J. P. (2015). Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke, STROKEAHA-115.

10.  Kummer, B. R., Gialdini, G., Sevush, J. L., Kamel, H., Patsalides, A., & Navi, B. B. (2016). External validation of the cincinnati prehospital stroke severity scale. Journal of Stroke and Cerebrovascular Diseases25(5), 1270-1274.

11.  Lima, F. O., Silva, G. S., Furie, K. L., Frankel, M. R., Lev, M. H., Camargo, É. C., ... & Nogueira, R. G. (2016). Field assessment stroke triage for emergency destination: a simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke47(8), 1997-2002.

12.  Hastrup, S., Damgaard, D., Johnsen, S. P., & Andersen, G. (2016). Prehospital acute stroke severity scale to predict large artery occlusion: design and comparison with other scales. Stroke, STROKEAHA-115.

13.  Demeestere, J., Garcia-Esperon, C., Lin, L., Bivard, A., Ang, T., Smoll, N. R., ... & Parsons, M. (2017). Validation of the National Institutes of Health stroke scale-8 to detect large vessel occlusion in ischemic stroke. Journal of Stroke and Cerebrovascular Diseases26(7), 1419-1426.

14.  McMullan, J. T., Katz, B., Broderick, J., Schmit, P., Sucharew, H., & Adeoye, O. (2017). Prospective prehospital evaluation of the Cincinnati stroke triage assessment tool. Prehospital Emergency Care21(4), 481-488.

15. Nogueira, R. G., Jadhav, A. P., Haussen, D. C., Bonafe, A., Budzik, R. F., Bhuva, P., ... & Sila, C. A. (2018). Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. New England Journal of Medicine378(1), 11-21.

16. Albers, G. W., Marks, M. P., Kemp, S., Christensen, S., Tsai, J. P., Ortega-Gutierrez, S., ... & Sarraj, A. (2018). Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. New England Journal of Medicine378(8), 708-718.

17. Jadhav, A. Desai, S., Kenmuir C, Rocha, M, Starr, M, Molyneaux, B, Gross, B, Jankowitz, B, Jovin, T. (2018).  Eligibility for Endovascular Trial Enrollment in the 6- to24- hour time window: Analysis of a Single Comprehensive Stroke Center. Stroke. 49:00-00.