MD Roundtable – Controversies in EMS

Controversies In EMS

If you can switch that so that we see you. No, because it’s tied to your login and I’m on your login. Oh, that’s true.

Okay. Well, that is not Dr. Phillips picture that’s talking about. But Dr. Phillips is our associate medical director here in Texas, and he helps Dr. Frayn with quite a bit of the workload that it takes to be a medical director in a paramedic program.

And this is one of his specialties that he does for us. We’re really good lecturers and good interaction with students. So remember that you have to keep yourself muted unless you’re answering a question or jumping in and have a question, but then please unmute your microphone, ask, do whatever you’re discussing, and then remute yourself so that noise in the background doesn’t bother everyone else.

About five minutes in or so, I will be securing the room. So if you dump out and can’t get back in, that’s fine because the room will be locked in a few moments to keep other people from coming in late and wanting the same credit that you’re getting or disturbing everybody with the ding, ding, dings that come through. So that having been said, it looks like Dr. Phillips has a topic of controversies in EMS.

I’m going to mute my microphone and monitor from here. Go ahead, Doc. Okay.

So actually, initially, I was also going to throw in some myths in EMS and we’ll end up doing that as a separate lecture later on. And most of this comes from an article that was in a journal. I’m trying to remember the exact title of the journal, but it’s by the American Association of Physician Specialists.

And they’ve had somewhat of a bad rap in the past. They’re a certifying organization. They’re not recognized, but they’re producing some really high quality literature.

And so, you know, I would tell you, you know, be open to look at anything, but look at it with a skeptical eye. So let’s jump in here with this. First off, this one is one that I think has very interesting past.

And I know that Jane probably remembers hearing about the golden hour. It was originally said that it was one hour from the time of the traumatic injury to the patient arriving at an operating room. And so that was the original premise of this.

And that was by R. Adams Cowley. He is noted for starting the Maryland Shock Trauma Hospital and that system there. Very innovative man.

He’s passed away since then and they renamed the Shock Trauma Center as R. Adams Cowley Shock Trauma Center. But there’s some skeletons in most closets and his is probably one as well. So another version of this was that it was one hour until any intervention.

And so it’s an interesting thing to note that that was from World War I that the French noticed that from the time of an injury until something was done and it was said that the person who puts on the first bandage saves the life in World War I. So interesting to see how it kind of has been changed. And now we’ve actually got the golden hour for stroke, the golden hour for MIs, golden hour for sepsis. Everything has become a golden hour anymore.

So it’s kind of lost some of its luster. And it’s actually a variable time. And that’s what makes this actually more of a myth and a controversy is that for some conditions and injuries, you have way more than an hour.

For some others, you don’t even have but a few minutes. So it’s really something that was found initially to be something that was useful. And the other interesting point of this is that there has never been any peer-reviewed literature proving that this is actually the case.

So I’ll share with you a rumor about how the golden hour got started. And that was when Cowley was first setting up Shock Trauma. And they were trying to figure out a way that they could become known and basically market themselves.

And of course, as most things in medicine and EMS occur, this was thought up at a bar. And he was having some drinks and somebody wrote down the golden hour. And he picked that up and ran with that and began to market Shock Trauma as you need to get the patient to us within that golden hour, because we can do the life-saving surgery.

So it’s interesting because it’s one that really has no good scientific basis, but we still are using it. And in fact, it’s being broadened to even more conditions. Now, I know that we have talked about helicopter EMS in the past.

This remains a controversial topic. And there is more and more peer-reviewed literature that comes out all the time regarding helicopter EMS. And really, as I see it, and as I read the literature, mostly this is not something that has a lot of utility in urban areas.

But where are the helicopters? Mostly in the urban areas. Now, part of that is because they may be staffed by hospital personnel in the facility that’s going to be receiving the patient. And then also though, it’s where the money is.

So it’s one of those where you’re kind of damned if you do, damned if you don’t, because it’s really expensive to support these. They have to have a certain number of calls every month, or they’re not going to make their budget. One helicopter, depending on the equipment and everything, can cost anywhere from $1.5 to $7 million.

And that’s just for the vehicle and all the supplies. Then you’ve got, of course, the cost for staffing it, and for fuel, and for maintenance, and any number of different things. It has become largely commercialized.

And with one service in particular that goes by multiple names, having most of the units, and they have become big business, and they make a lot of money. There’s also been criticism because some of the trauma centers and even university centers will set up these programs as a way to try to gain more income because they will be called about a transfer, and they will offer, hey, we’ll send our crew to come and pick up the patient. Now that in and of itself isn’t necessarily a bad thing because part of the golden hour says when they arrive at the facility is really when the golden hour stops.

Well, it’s seen in the literature that if you take specialized crews, and trained crews, and crews that are good at doing those jobs, you can actually extend the reach of those tertiary care centers out into the rural areas. So there is some utility to it, but the problem really becomes one of it’s now a moneymaker more than it is a service. There needs to be strict guidelines for use.

And so one thing that I read said if the patient in the pre-hospital environment would warrant a level one or level two trauma activation at the hospital that would be receiving them, then it’s probably appropriate to fly the patient there. I’m not so sure about that. I think it depends on the distance as well.

Keep in mind that this is very expensive. We’re talking for most it’s going to be a minimum of $17,000 to $20,000 for the flight, and that’s doing very, very little in the way of interventions. It’s also a very dangerous proposition.

2010 was the deadliest year as far as crashes go, and those are loss of life, loss of the equipment, potentially loss of life on the ground as well. So just keep those in mind that you’re spending a lot of people’s money. You’re also endangering people.

You want to be sure that it’s really needed. I still recall very vividly the medical director for MedStar a few years ago that’s now retired, Dr. John Griswold, saying the last thing that I want to have to do is to go to a bunch of funerals for people that died when the patient didn’t really need that service. So we need to kind of keep those things in mind, but they are sexy and they look really great in the newspaper.

So, you know, those are some of the things that we have to fight against because, hey, you know, it is kind of cool to see the helicopter come and land on your scene. I ordered that. So just kind of keep those factors in mind.

They are useful. They have a place, but we need to use them wisely. Lights and siren.

So Chris weighed in and said that his flight, three flights averaged $57,500 each, $57,500 each. That’s a lot of money, especially if your insurance isn’t going to cover it. And unfortunately, the largest company has now taken the tactic of filing to get the payment from people any way that they can, sending them to collections and suing them.

So, you know, just keep in mind that you’re spending somebody else’s money. Lights and siren. This is one of those that is, it refuses to die.

In 1994, there was a study in Pennsylvania. Before the study, 58% of the time, we’re talking about transports to the hospital, 58% of the time they were using lights and siren. After they did an intervention where they talked about where it was appropriate, they had only 8% use and no adverse outcomes.

So in other words, the criteria that they use to say you need to run lights and siren to the hospital works and it doesn’t change outcomes. In Minnesota, they showed that lights and sirens saved on average 3.02 minutes. Three minutes.

Is that really going to be a make or break sort of thing? In North Carolina, they did a study and trips less than eight miles, lights and sirens only save 43.5 seconds. It’s not even a minute. There is also this thing known as the wake effect.

So you’re driving down the road, code three, lights and siren. You’re going through intersections. You’re having people moving off to the side.

There is this concept of wake effect and wake crashes. These are crashes that happen behind you as a result of you busting an intersection or somebody moving out of the way and then trying to pull it front and then getting hit. So it is a dangerous proposition.

MedStar in Fort Worth actually has a policy now that if they are going to transport somebody that’s cardiac arrest, they will not drive lights and siren to the hospital. They will take them code one and they will obey all traffic laws, stop at every stop sign and get the patient there because the quality of the CPR is what matters. So there’s a lot of changes about this and so the other thing that has helped and has minimized lights and sirens for a lot of services has been medical priority dispatch.

So those are all good things. So now I thought that this was an interesting little project. 293 EMTs at East Carolina University, they took a test.

The test was five knowledge questions on ambulance operation. Does anyone want to venture a guess on what the average score was? Just one point per question. So how many questions did each one get right on average? Let’s go ahead and wait.

Given that the national registry says that most people do worse in operations than anything else, I’d say two out of five is all they got right. I’ve got a two, I’ve got a five, I’ve got another two. I’d say about three.

Okay, so can we have the drum roll? One. They got one right. Now, some of the questions are state specific.

Okay, and they only gave me four of the questions. So yielding, so in other words, you’re driving lights and siren, cars have to yield to you. Okay, do regarded lights.

So in other words, if you’re coming to a traffic light, you have to treat it with some, they called it in North Carolina, do regard. So in other words, you have to slow down, you have to look, you have to see if people are going to enter the intersection following distances. So how close can a vehicle follow you? I thought this was an interesting answer in North Carolina, one city block, they have to be that far away.

Chris, I’ll definitely get that to you. In North Carolina, they say that there is no speed limit with lights and sirens. For the people that are here in Texas, you’re only allowed to go 10 miles an hour over the posted speed limit.

So you do need to know the laws within your state. Any questions on that? When it comes to like here in Texas with the speed limit 10 over, how many times have you actually seen an ambulance or any kind of emergency vehicle actually going more than the allowed speed over the speed limit? I mean, I’ve seen numerous, I’ve even seen where ambulances will just turn on the lights to go through an intersection and just turn them off and casually keep driving. Yeah, and that’s not really something that should be done.

I would say that unfortunately, most of the time my crews that I’ve observed, they definitely go more than 10 miles an hour if they’ve got the space to, you know, with the heavy diesel engines and everything, sometimes it’s hard to get up to that speed. So interesting to see the differences there with David and Martin. So any questions on lights and siren? To me, that’s a very interesting topic because recently I was doing some field response and I was at a station and there was a call that was maybe three to five miles away from the station.

And so I followed the ambulance and the supervisor. Ambulance got way ahead of us because they got into their vehicle quicker and we had to go out to the parking lot to get into ours. And then I’ll let the supervisor go ahead of me since he’s got lights and sirens.

I don’t, not on my private car. And I got there about a minute or less after the supervisor. And we actually got on the scene at the same time as the ambulance because they were driving so fast, they had to go down and turn around because they missed the turn.

So, you know, interesting little personal experience. I’m sure Jane will know Azle, Texas, the fire chief there, he and I were doing some response together and he did not turn on lights and siren. This was going to an active structure fire.

And he got there about a minute and a half after the engine. So, you know, the lights and sirens really don’t make that big of a difference. Yeah, I like getting the cattle out of the road.

Yeah, usually, usually when I’ve had something like that, the cattle, they don’t even pay attention. They don’t even look up. So pre-hospital analgesia.

This is one that is rather interesting. They have a great quote at the start of this. We must all die, but that I can save a person from days of torture.

That is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself. And I think that if you’ve ever had a chronic pain situation, you can probably understand that.

That was from Albert Schweitzer. If you don’t know who that is, let me know and we’ll assign you to write a paper on. See, everyone’s going to say, yeah, I know exactly who that is.

It’s like Google it. So in EMS and pre-hospital patients, up to 70% have pain as part of their presenting complaint. And 20% have moderate to severe pain.

And I thought that this was interesting. They did a survey where they looked at 1,073 suspected fractures and looked at the EMS charts. Only 1.8% got analgesics, 17% got ice packs, and 25% got air splints.

And this is in ALS crews. This is rather interesting as well. When you think about it, if we’re giving the analgesics before they get to the hospital, then that kind of takes some of the pressure off of the ED.

But understand that there are quite, especially these days with electronic medical records, we can’t even access the medicines until they’re in the computer. Then depending on the way that the system is set up, a lot of times they can’t access the medicine until the physician goes and actually puts an order into the computer. And sometimes then it has to be reviewed by a pharmacist before they’ll release the medicines.

So as a result, if it’s given pre-hospital, it’s 28 minutes on average. If you’re waiting for us in the ED from the time that they hit the door, it’s 113 minutes on average. And I think that that’s unconscionable for a lot of reasons.

So what are some of the hurdles that we have to get over to begin to actually start treating pain and treating it appropriately? Well, first off, it’s been said, well, if we give you this and you won’t be able to provide consent for your surgery, no, that’s not the case. There has been noted that there is definitely biases towards ethnicity. So, and it’s not just black and white.

It has also been noted in Los Angeles that Latinos are less likely to get pain medicine. So it’s not just one race. And women are less likely to receive analgesics than men.

And I think that that’s alarming. It’s also been noted that socioeconomic status. So poorer people tend to get less pain medicine as well.

And I think that all of those are barriers that need to come down. Addiction fears. One dose of an opioid in the back of an ambulance or three or four doses in the ER for an obviously painful condition are not going to make anybody an addict.

Addiction is a very complex problem. There are a lot of factors to it, but please understand that us treating painful conditions in the back of an ambulance are not going to cause addiction. And then of course there’s safety fears.

I mean, who has not had this fear that, oh my God, I’m going to turn around, my patient’s going to be blue because they stopped breathing. And while that is something that is somewhat recognizable as a risk, it’s also something that monitoring our patients properly and doing evaluations of them on a repeated basis can mitigate that. So let’s talk about what would be an ideal agent.

So an ideal analgesic agent would have a very short onset. So it’s going to work really fast. It’s going to have a short time to its peak, which means that very quickly we’re going to see that actual effect.

We’re not going to have to wait 15 or 20 minutes for them to either be as sedated as they’re going to be or as out of pain as they’re going to be. We also need something that really has a short duration. And the main reason is how do you like doing a BVM alone in the back of the rig? I mean, I don’t.

So you want something that’s not going to last a long time so you don’t have to bag them forever. And you also want minimal effects that cause hypotension, respiratory depression, and nausea. You also want it to be cheap because especially if we’re not given enough of it now, don’t you think that we should probably be given a lot more of it? So let me see.

Amanda posted a question here. Well, Amanda, you ask a really good question. And there’s a lot of factors in that.

There is a factor that is related to one’s training, one’s personal experiences, your own biases. It’s hard to not see the patient that was being really crappy to you, that was trying to hit you and all those sort of things that might have had some addiction problems and feared that you’re going to cause some of those things. So there are a lot of things that we individually bring to the table.

There are also, of course, some systemic things such as concern that you’re going to be seen as somebody that gives way too much of this medicine, that your director is going to call you in to talk about the use of narcotics that your medical director is going to. And I would say that most of those fears are totally unfounded. And I think that it’s probably something that we all bear a burden to take to management, to take to our medical directors and have an honest discussion with them.

Hey, listen, do you think that we’re giving enough pain medication to some of our patients? I think that that’s a reasonable thing to discuss. And if needed, take something like the statistics that we gave you earlier and show them that perhaps we could be doing a better job with that. So David, why did y’all get rid of fentanyl? So why did they get rid of fentanyl and replace it with ketamine? Why not have both? And Amanda, you’re absolutely right there.

There are a lot of benefits. Well, the medical director, we all come into this with our own biases and everything. And certainly, there’s regional differences.

There’s even within the Dallas-Fort Worth area, there’s probably differences from one side of the area to another as far as opioid use and those sort of things. I would say that if your protocols are written appropriately and the dosing is appropriate, that really there is not going to be a real problem with opioid epidemic sort of things. Those are generally due to prescription writing.

And we’re not going to be having a part in that in the EMS arena. You know, Chris, you bring up a good question. And really, the literature is mostly towards traumatic type pain.

But I think that if we researched it, we’d find that it’s on the medical side as well. Traumatic pain is easier for the researchers because, you know, it’s there, it isn’t. At the same time, you know, somebody coming in with chest pain, was it due to an MI? Was it due to pleurisy? Was it due to some other conditions such as pneumonia? And trying to control for those factors makes it very difficult in some cases to really do a controlled study.

So I think the data would actually show that it’s probably there for both medical and traumatic, but most of the data that’s out there is on trauma. Well, I’m not sure why that would be the case, Amanda, because ketamine and opioids are all controlled substances by the DEA. And they, I’m sure that part of it comes down to a Schedule 2 versus a Schedule 3 drug.

But, and we’ll see in a little bit. I actually like ketamine. I think that it is a good pain medication.

And I think that it’s got some merits. There can certainly be some problems with it. But we’ve been using it more and more for pain and the sub-dissociative dosing.

And it’s actually worked very well in our experience in the ER. We’re giving it some in my EMS agency, but we also do have fentanyl. And so they tend to lean on that.

Testing pain ASAP. I’m not sure exactly what you mean. If you mean asking the patient to grade their pain on that one to 10 scale.

But I wish that we had a very objective measure for pain, but everything is subjective. You mean, I think what you’re meaning is that they’re looking at whether or not you’re treating pain. And I think that’s a good thing.

Treating, not testing. Okay. Jane, excellent question.

I have to admit that in my own practice in the ER, I tend to use Dilaudid more. And I think it works better. I think that it has an excellent safety profile.

The problem for pre-hospital is that it actually has a pretty long onset and long duration. So I know that’s why I don’t have it at life care. At least this ideal agent should also be reversible.

And it should be able to be given by multiple routes. Ketamine, for example, can be given IM. It can be given IV.

You can squirt it up their nose. You know, pretty much anything except for rubbing it on their forehead will work. And there are some other examples as well.

So at least according to the authors of this article, fentanyl actually is probably the number one option because it’s ID, intranasal, transmucosal, and transdermal. Now we’re not going to start curing fentanyl patches, but they do make them. They also make fentanyl lollipops.

Once again, we’re not carrying those. I can just see my crews showing up on scenes with popsicle hanging out of their mouth. But it is available to be used IV or intranasal, and it also will work intramuscularly.

The problem with intramuscular anything except for epinephrine is that the absorption is so erratic. Excellent point, Kim. However, if somebody’s having a history of chronic pain and they have a dergizic patch on them, that’s a brand name for fentanyl patch, is dergizic.

If they have a fentanyl patch on and they’re having acute pain, say from a fracture that’s open, you’re not really going to have to take the patch off. In fact, you should say, okay, maybe I need to cut my dose in half, see what the effect is, wait a shorter amount of time, and then I can give another dose. But just keep in mind, if you’re taking away what they’re already getting on a chronic basis, you’re going to have to replace that plus some if they’re having true acute pain.

And I’ve seen all the stuff about, oh, if they have a patch on, you can’t… No. The truth of the matter is that you need to remember that you’re going to have to replace that same chronic dose that they’ve been getting and go above that to treat acute pain. Good question.

So some others that they think are really great, nitrous oxide, I’ve not really been that impressed with. I’ve used it several times and it doesn’t seem to work as well as we thought. Methoxyfluorine, that is actually an anesthesia gas.

And there is an inhaler that you can get. You can’t send a prescription for it, but you can get an inhaler that has methoxyfluorine and that is an anesthesia agent. So that’s going to, just like ketamine, it’s going to help to disconnect their brain from the pain.

Morphine, tramadol, butorphanol, or nubane, ketamine, and alfentanil. Now, I’m not sure that I would have put alfentanil on this list. And the reason is that fentanyl and alfentanil, but especially alfentanil has an occasional, it’s a rare side effect, but you can get a thing called a wooden chest syndrome when you give this.

And in that case, their muscles in their chest all spasm and they cannot breathe and you cannot ventilate them very easily. So it is something where I’m like, nah, I would not put alfentanil in the field. Um, I think that it’s a great anesthesia drug and we’re going to let the anesthesiologist play with that wherever I’m at.

I’m not going to be the one trying to use that. And then there’s also non-pharmacologic interventions, ice, splitting, elevation, heat, and I should have put a comma between heat and breathing, uh, breathing exercises. They talk about doing biofeedback and things like that.

That’s a, that’s a little too out there for me at this point, but there, there is some utility in coaching the patient into square breathing is one term for it or a tactical breathing. They’re all the same thing. It’s four seconds of breathing in slowly, holding the breath for four seconds, breathing out for four seconds, and then holding the breath out for four seconds.

So it’s completing a square. Um, and I like the Lieutenant Colonel Dave Grossman was where I first heard about this and, um, excellent book on killing and on combat. And one of the things that he points out is that of all of our autonomic functions, the things that we don’t have to think about breathing, circulation, sweating, all of these other, other things that are all autonomic breathing is a one thing that we can control.

And if we can get our breathing under control, a lot of times everything else will calm down as well. So it’s actually a useful technique for providers. Um, I have found myself in stressful situations in the ER doing tactical breathing without realizing it just so that everything stays calm.

So, um, there, there are some useful non-pharmacologic interventions and ice, in my opinion, is probably one of the best. It works quick. It works right where you put it.

Doesn’t have any side effects. They’re not going to stop breathing from the ice of one, if you ice their whole body and get them hypothermic. Um, so I, I think that ice is a wonderful thing.

I like that, David. That’s, that’s excellent. I haven’t thought about that.

Um, one thing that, that I have thought about doing with residents, especially, but I think would be useful, um, and has been shown to be useful in pre-hospital is what’s called stress inoculation. So, you know, taking a simulator, taking a room that’s dark, have the simulator set up in there and have lights and sirens that are blaring in the room, um, and giving you a scenario that is stressful. So that basically you get over all those fears and everything while you’re there doing that.

And then when it comes time for you to be in the real situation, you’ve also been given tactics such as tactical breathing to help to bring yourself under control and stay out of, as Colonel Grossman calls it, condition red or condition black and being able to get that all under control. Now, if somebody wanted to do a study, there would be a good study showing, you know, stress inoculation with things like tactical breathing and stuff and have your counterparts hooked up to monitors while they’re, they’re doing stressful work and give them the interventions later on to show, okay, now look at, look at them doing the scenario and how much better they are. So I’m glad that you had that experience.

That’s definitely, definitely a good thing. And I appreciate you sharing that. So bottom line is analgesia is humane and good medicine.

So keep that in mind. You know, it’s, it’s not nice to keep people hurting, even if you don’t like them. Airway management.

Now, we’ve touched on this over and over, and I’m sure that you’re going to get sick and tired during your career of hearing airway management, which probably also going to realize is that the pendulum on this one swings and it swings a lot. So Pennsylvania studied severe head injury patients. They had 4,000 patients, 44% had pre-hospital endotracheal intubation.

That’s what ETI is. The other 56% had ED intubation. The odds ratio for death in the pre-hospital group was 3.99, or almost four times more likely to die.

Now they, I would need to read the whole paper to really say for sure that, okay, did the intubation really do that? Were those patients more severe? They didn’t say whether or not they were matched for severity. So there, there are some problems with that, and that’s where learning to read the literature is definitely going to be a plus in your career. They also said that 18% or 18.2% had worse neurologic outcome, or it was 18.2% higher in the pre-hospital intubation group compared to the ED intubation group.

And worse functional outcome, 15.5%. So I think that there’s probably a lot of factors that go into that particular study. And, you know, I wouldn’t say that this is the paper that you would ever want to say, well, we shouldn’t be doing intubations anymore. So Chris, excellent question.

First off, I would tell you that if they’re in the ED and they’re being intubated, it’s going to be a physician doing it 99% of the time. We may occasionally have a medical student, we may have a resident, we may have a paramedic student, but most of the time, and especially if it was a known study, those would be the attending physicians that would be doing that. Um, and certainly, you know, one could extrapolate on there that from that, that the fact that the emergency positions generally have a lot more experience with doing those just because of volume, that it would be a better outcome.

So, you know, certainly those are all the sort of questions that when you’re reading a paper, you need to go and you need to read that section on methods and you need to understand all the different factors that they’re trying to control for. So there was even a best evidence topic report from the emergency medicine journal. They actually looked at eight papers that had a total of 17,000, let’s just call it 18,000 patients that were either endotracheally intubated or a BVM was used.

In the endotracheal intubation, they had longer pre-hospital times. It was noted that they had higher mortality. And so once again, the question is, was this an open study? Was it, you know, a convenient sample of looking just back at charts later on? Are the patients sicker in one group than the other? There’s a lot of information that needs to be fleshed out from these.

And generally, something like that, where they’re doing a meta-analysis, they do try to control for those. But, you know, we all have discussed the thing that, you know, you do an IV, you add five to eight minutes to your scene time. Do an intubation, typically you’re going to add at least five minutes and probably more like 15 to 20 minutes.

So, you know, the longer scene times, I get that. The higher mortality, once again, I want to know if they’re controlling for the severity of injuries. You know, is it that more patients that had more severe injuries were intubated versus, you know, patients that weren’t as sick that were in the BVM group to begin with.

So there are some factors that without actually reading the actual paper, you need to kind of flesh that stuff out. Now, Maryland Shock Traumas did a study in 2003. Obviously, this is on trauma patients.

191 severe head injury victims surviving the first 48 hours. So to get into the study, they had to have already survived the first 48 hours. 59% of them were BVM, 41% endotracheally intubated.

In the endotracheal group, they had longer mechanical ventilation, longer hospital stays, and higher risk of pneumonia. Zach, I’ll come back to that in just a second. And overall mortality was 12.4% for BVM group and 23% for endotracheal intubation.

And this is in the patients that were treated pre-hospital. They didn’t start counting them until they had survived 48 hours. That’s actually a pretty good study.

So Zach, actually no, there isn’t anything like that. And part of the problem is how do you do those studies, especially in a rural area? There are many questions to be done or that have to be answered, such as how do you get informed consent? How do you do the study? Is it going to be on odd days we do endotracheal intubation, on even days we do a BVM? Is it something where they’re going to have to call in to get a randomization and they’re told on the phone, okay, well, you intubate this one. So the other problem is in the rural setting, the sheer numbers are hard to get.

I would love to see there be a clearinghouse where kind of like the Resuscitation Outcome Consortium or the ROC coordinates a lot of pre-hospital studies in a lot of different areas. And I would love to see that. But I remember when I was talking with Dr. Idris, who’s one of the principal investigators, and he’s at UT Southwestern, because I was wanting to see if we could get life care involved in that.

And he looked at our numbers and he said, no, you don’t have enough calls. You don’t have enough, in that case, cardiac arrest. So the numbers is a big problem because they want to get the study done.

They have a schedule that they have to stick to. And if you don’t have enough numbers, then your study’s not powered high enough or strong enough. So there’s a lot of factors into it.

And unfortunately, the rural areas tend to get missed. And I think that that’s a shame. And I wish that there was an organization that would take the lead on doing those sort of things.

I know that Minnesota and, it’s not Michigan, maybe one of the Dakotas, that has actually done a lot of stuff towards rural areas and trying to study the rural areas. But they’re just hard. I live in a rural area too, Kim.

I understand that. And it makes me mad. And that’s one of my passions has been for the rural areas.

Well, David, you bring up an excellent, very, very good question. And the way that they do that is that they go into these areas. Fort Worth was one of the study sites for the rock and where they were talking about placebo or epinephrine.

And they have to do quite a few things. They have to have some public notices. Those can be in the forms and billboards.

They can be newspaper articles. They have to have town halls where people are invited to come and hear about the study there. And what they end up doing is that you have the option to opt out of it beforehand.

So let’s say that you decide, hey, I don’t like that particular study. There is no way that I want them, if I go into cardiac arrest to not do the standard care, then you have the option of obtaining consent where you basically say, no, I’m not consenting to this. You’re given something to identify you such as a wristband that you have to wear all the time during the study period.

And usually dispatch also is notified that you’re a non-participant. So there are ways around that. And it is considered ethical provided that you do the proper steps to get that pre-hospital investigational review board to sign off on your consent process.

Excellent question. If you want to look into something like that, there are certainly a lot of people that are interested in doing pre-hospital research and people that are a lot smarter than me that can walk you through that process. Even if you just wanted to learn about it, go and see what that entire process is from start to finish with somebody like Dr. Ahmed Idris.

He was one of the, he’s actually a cardiologist, but he was one of the principal investigators from UT Southwestern on the resuscitation outcome consortium. Contact David Purse, who is the medical director for Houston Fire Department. They’ve done a lot of studies like this.

So, you know, and as it turns out, placebo is probably better than epinephrine for cardiac arrest anyway. So this is really, this was a landmark study. It came out around 2003, I believe it was.

Gauche, Marian Gauche and colleagues at Los Angeles did a three-year trial where they had a total of 830 pediatric patients and they compared survival and neurologic outcomes. And they embarked on a very intense training for all of the paramedics in Los Angeles County and Orange County, California. And it was a very well-done study.

And what they found was that there was no difference in outcome in pediatric patients between the BBM and endotracheal intubation. And what they did find though, was longer seen times and overall times for endotracheal intubation and 8% fatal complications and dislodged airways in 14% of the cases. Keep in mind, they have a very short airway.

A lot of the times in PEDS, you’re using an uncuffed tube. So it is easy to dislodge those. So, you know, I still remember sitting next to Brian Bledsoe at a Governor’s EMS and Trauma Advisory Council meeting when the EMS for Children came in saying that every ambulance in the state should be required to have pediatric intubation equipment.

And Dr. Bledsoe, if you’ve never met him, look him up at one of the EMS conferences. He sat there and he said, now, hold on here. Do y’all even read your own literature? And the woman looked at him and he said, yeah, there was a paper that came out just three years ago that said that we should not be intubating any kids.

And she was like, but what if there’s a pediatrician on scene? It’s like, they’re not going to do anything. So anyway, you know, if you’re still intubating pediatric patients, you know, you may want to consider whether or not you should be doing that. And, you know, once again, I think it’s a reasonable thing to go to your medical director and go, yeah, listen, I’m not saying that what we’re doing is wrong, but, you know, how do you, how do you think, how do you feel about this particular paper and stuff and give them the paper and let them read about it? And, you know, I think that that’s actually something that we all should be doing with each other all the time.

So I’m reading Amanda’s question here. So, or SGA, Superglottic Airway, also BIAD is another term for it. And I will tell you that I think that if you look at the data that has come out and actually Dr. Bledsoe was one of the authors on an article about some of the BIADs.

And I think that we probably need to consider moving more and more to those sort of devices. And so that’s, that’s something that you’re probably a little ahead of the curve in thinking that way. And in fact, I’m trying to get my crews to not necessarily intubate cardiac arrest, put a BIAD in, it’s faster, you achieve the same thing and the outcomes are similar.

You know, do we even need to be ventilating those patients is another question in itself we’re coming to. So, but excellent question. I don’t, I wouldn’t, I would look up Brian Bledsoe with a Y in Brian.

And, and I believe that they were specifically using the iGEL, King Airway. Yeah. So, and so there are so many studies showing that endotracheal intubation may not be the best option in all cases.

And I think that that’s really where critical thinking processes come in is us being able to look at a patient and say, okay, that may not necessarily be the best thing. Maybe I need to just, you know, maintain what we’ve got. I don’t want people to be lazy and say, well, I’m now I don’t have to do that, but I do want them to look in and also look at yourself critically and think to yourself, there may be a potential problem with this one for whatever reason, you know, body habitus or, or I had had one yesterday that he was crashing and his blood pressure was 70 systolic when we started the intubation and realizing that I needed to give him push dose epinephrine before we did the intubation because realizing that the paralytic is going to knock out his, his sympathetic response.

And so, you know, sometimes realizing, Hey, this may be over my head. It takes a lot of courage and a lot of insight into your own thoughts to be able to say that. So I think that, that ultimately what I want every paramedic to be able to do is to think about those things critically.

I have absolutely no problem at all calling anesthesia or somebody and going, yeah, I may not need you, but I may need you. Can you come down here? I’m going to do this intubation, but just in case I’ve got a problem, I’d like somebody else here. When I got done with this intubation yesterday, and it took me three tries to get in, by the way.

So that happens. The other ER physician, he said, Hey, how’d that go? You know, you can call me if you need anything. And, you know, it’s, it’s being collegial, it’s being willing to work with others and also to realize your limitations.

So now let’s talk about CPR and ACLS. So first off, most cardiac arrest drugs don’t make a difference. They really don’t change anything.

Airways don’t really make a difference. And most studies show that what does make a difference is three things. Yeah, the problem, David, is more and more, they’re not doing intubations, even in the, even in the OR.

And if they are, it’s usually a specialty surgery, like they’re going to do a thoracic procedure where they have to ventilate one lung, but not the other. I agree completely with you. And the problem, the problem that I see is it’s kind of interesting because when I was a paramedic, intubations were pretty much just on the dead.

And so they didn’t really seem to make a big difference. And they were very few. As time has gone on more and more, especially with RSI and facilitated intubations, we’re doing these more and more.

But now the indications for them seem to be dropping off to less and less. And so it’s, it’s kind of a situation where you’re between a rock and a hard place because so few are being done in the OR anymore. Almost everything is an LMA or another blindly inserted airway device.

But yeah, I agree with you. I wish that we had the ability to send the medics to do more, more intubations. So what does make a difference? Well, the legal implications, yeah, those may get somewhat tricky.

And certainly credentialing is a, is an area of concern. Well, legal implications all the time for, for credentialing. So what does make a difference in CPR? Witnessed arrest, bystander CPR, and early defibrillation.

So those are really the only things that really seem to make a big difference. So I thought that this is an interesting thing. And this is from the AHA.

Defibrillation survival. So if it’s nine minutes from the time of arrest until defibrillation, survival is around 4.6%. And it goes up to 5.9, 7.5, 9.5, and 12 as the time gets shorter. So the shorter the time to defibrillation, the better the survival rate.

The, you know, where the best place in the world to have a cardiac arrest is a casino in Las Vegas, because they have EMTs with AEDs that are standing by all the time. The security personnel are trained to look for people that are looking like they’re going to have a cardiac arrest, for real, not a fake one. And they’re, they also get there, and they put the pads on, and they shock them really quick.

And a lot of times they wake up, and then they whisk them out because that’s slowing down people giving them money. So ventilation likely doesn’t matter, and especially in bystander CPR. They’re finding that we sometimes overventilate, we may underventilate, we may ventilate at the wrong time in the cycle.

So there’s, there’s a lot of literature that seems to be pointing to maybe we don’t need to really do any kind of ventilation while we’re doing compressions. And doing CPR before the first defibrillation does improve survival. 30 seconds, two minutes, does seem to improve survival.

For every minute the patient is in VF and not defibrillated, their survival drops almost 10%. So, you know, it’s, it’s a rapid progression, that was a different paper, but, you know, it’s a rapid progression and loss of life. So anybody work somewhere where they have a public access defibrillation program, and by that I don’t mean just in one building or one place, I mean a system-wide PAD.

Because those are, they’re kind of hard to find, but the NIH looked at this and this is AED installations in high risk settings was their, their definition. And that’s more than 250 people over 50 years for most of the day. That’s not a lot of places.

And so it turns out that the places like airports tend to be where people are looking for, for those or the nursing homes, places like that. So they also said places where an out of hospital cardiac arrest has occurred within the past two years. So, you know, football stadium, things like that.

So they had 1250 places. They said that 10 to 15 lives saved cost about $100 million. So they’re basically spending about $1 million per person, or sorry, $10 million per person to save their life.

So there’s a lot of expense associated with and it doesn’t seem like it really has made as big of a difference as we had hoped. And residential AEDs only gave a 3.3% survival. The problem is cardiac arrest is such a rare thing to begin with and to have it witnessed and to have it in a building, a home that has an AED is even more rare.

So it’s, it’s one of those where it just doesn’t really make a lot of sense economically and otherwise. And CPR only has a 14% survival, but it does jump up to 23% for CPR with an AED. So let’s talk about law enforcement carrying AEDs.

Pittsburgh, they had 183 versus 118 police cardiac arrest where they were defibrillated. Meantime to defibrillation in EMS group 11.8 minutes and the police group 8.7 minutes. The earlier shock was an independent predictor of survival.

The same authors 10 years later said 77% of the Pittsburgh officers had used an AED. That’s an amazing number in my opinion. 45% of them had witnessed a return of spontaneous circulation before EMS arrived and 65% said that it didn’t interfere with their police duties.

Now, interestingly enough, go here’s your, one of your rural studies, suburban rural Indiana AED arrived 1.6 minutes sooner. And the first shock was 4.8 minutes sooner, but that did not, did not improve survival. Hmm.

Wonder what the difference is. It really has not been fleshed out to be honest with you. I can believe that David, I can believe that.

The big problem is half of the police will tell that they’re not comfortable treating that. And I think that there’s something to be said for that. And I think there’s also something to be said for us as EMS, getting them comfortable with that, getting them used to, okay, you know, somebody ain’t going to be looking good and chances are they’re going to be on scene faster than we can because they’re not having to go to the truck.

They’re not having to start it up. They can get the address and just start heading that way. So there is something to be said for that.

And yes, definitely confidence in CPR training. I think also the media can help with something like that. If they are more willing to, to do stories, there was one down in Granbury, Texas, where a police officer got to a scene like five minutes before the ambulance and dash cam shows him saving this child who was choking.

So those are the sort of things that we need. So Kimberly, the, the Indiana study, there was no mechanism of injury. This was cardiac arrest.

So they just dropped, if they were trauma patients, they took them out of the study. So this was just medical cardiac arrest. Electrocution and CPR within seconds.

Yeah. You know, there, there are some that we’re just not going to be able to do anything with. Well, Martin, I think the big thing with that is training them and getting them used to, to coming on those calls.

The other question is, are they dispatched to them? That, that has actually been one of the areas that they noted in some of these studies is that they just don’t respond with EMS very often. Yeah. The response time is a big factor.

Anything else on AEDs? I’ll be honest. I’m, I’m a big supporter. I really think that the police should be carrying them.

I believe that with the proper training and introduction, they can be comfortable with them. And, you know, sometimes just simply having your medical director stand up in front of them and just go, you know, look, here’s the deal. They’re dead.

You’re not going to make them more dead. And to the police chief, this is not a liability for you because unless you’re taking the thing and using it in place of a taser, it is never going to hurt anybody. So, you know, there, there, and especially if you have the fully automatic ones where they just have to say, okay, you know, analyze, stop CPR, shock advised, stand back and it shocks them.

Well, that’s on the AED manufacturer. So, well, you know, David, I think that the liability, especially if you’ve got an agency that’s willing to give them the AEDs, give them the training, the liability would be hold on, my brother died. And there was a cop that was standing there with his hands on his belt and you had an AED in your car, or you could have had one and you didn’t.

I think that there’s probably more liability in that area than there is in them acting, trying to save a life. So I understand people can sue for anything. So has anyone heard the saying Mona greets all patients? So it was, it was cardiac and it was ACLS and it was for chest pain and it was morphine, oxygen, nitroglycerin, and I don’t remember the A, but most of it, if not all of it is essentially gone away for the most part, but let’s focus specifically on the oxygen.

As y’all, I think I mentioned to y’all that the board for emergency medicine that I’m on the board of directors had our oral examinations recently. And I can’t tell you how many times I would give my cases and they would have an O2 saturation of 99% and they were there for something totally unrelated to the respiratory system. And they would just, by reflex, I want an I, two large IVs, an O2 cannula put on the patient with two liters and a monitor.

And it’s like, do you want to look at my child before you start an IV on them? So, you know, unfortunately we’re taught that over and over and for national registry, if that’s one of the points that they have on, on those scenarios, then certainly even though they’re behind, you have to, you have to go ahead and say those things, but I’m more interested in how you’re going to practice when you’re out on the street. So let’s break that paradigm. And here’s the reference for this.

I would encourage you to print it off in full color and find it and it’s all one page, but I’m going to have to break it down into, into some different screens. So here’s an overview of their recommendations and they have all of the data, all of the studies to support this that are, that are referenced as well. So they’re saying the top left recommendation, recommendation one is acutely ill medical patients with a few exceptions.

We’re going to come to those. And then two and three apply to stroke and myocardial infarction. So really our goal should be to keep them around 93 to 94%, not try to get them higher than that.

And they’re saying stop oxygen if their O2 saturation is 96% on supplemental oxygen. There are a few caveats to that. If they’re on chronic home O2, don’t.

Okay. So yeah, you’re right. A is aspirin.

Thank you. So the upper limit on, on number one, once again, 96%, that’s what you want to shoot for. And they even give you the, where the, the evidence is weak and where it’s strong down at the bottom there.

And then if you actually go into the paper, that little area on the bottom, right, that says more details, you can click that and they have an expansion for that. But I think that that’s a reasonable thing to say is that if you, if they are on supplemental oxygen that we put on them and they get up to 96 to 97%, we can probably turn that down or turn it off. Okay.

There are a few things there that they point out that no, these still need more oxygen, carbon monoxide poisoning, cluster headaches, sickle cell crisis, and pneumothorax. So those are some areas that, okay, this doesn’t apply, but I like the graphics. I think it’s something that we can put up that we can get drilled into people’s head.

Okay. So recommendation two on the lower limit, that 90 to 92% for stroke and MI. So the no oxygen therapy, they both have weak and strong on either oxygen or no oxygen, but we shouldn’t apply it until they get down to 90 to 92% is really what this says.

And I think that that’s reasonable. And then the other lower limit here, 93% is the recommendation there. Now this one actually has strong evidence for no oxygen therapy.

So bottom line is go with 93 or 91 to 93%. That’s where we’re going to add oxygen to them, especially in heart attack and stroke. And then once they get up to 96 or 97%, then we can turn it down or turn it off.

So that was an awful lot of information and we’re over. Any questions you can unmute in the words of Pink Floyd. Is there anybody out there? Yeah.

Amanda put a question over there about more. Okay. Okay.

Actually, I don’t think that it decreases the absorption of aspirin. I’ve never heard that. I’d love to see the reference for that.

And in fact, morphine is still considered, morphine and nitrogen or nitroglycerin are still considered by the cardiologist to be the recommendation. And in fact, they’re one of the myths that we may explore is morphine for nitroglycerin for inferior wall MIs. Turns out that that’s probably a myth because you can drop the blood pressure with nitroglycerin from any MI.

Yeah. I’ve never seen that. Hopefully I get a cardiologist into the ER tonight and I’ll ask him a question.

So the, I appreciate the compliment, David, but one thing that I would tell you that I want you to get out of any of these is I want you to have enough questions in your head. Is he really telling me the truth that you’re going to go and you’re going to look up this stuff for yourself? And I’ll get Jane, the reference for the article that most of this came from. And it is very well, um, footnoted.

So you can, you can get all the references that they use. And I, what I want is I want you to begin to read the literature and I want you to read it with a skeptical eye and start saying, hold on here. Yeah.

You didn’t really control for this factor or this factor, um, or this is good paper because those are the sort of things. And the link for the BMJ article is actually in the presentation. Um, so that should be pretty easy to get.

In fact, uh, let me just real quick. I’ll actually cut that one and put it on the chat session right now. So that way you can just go ahead and have that one.

There you go. Yeah. It shows it’s a hyperlink.

So if you click it right now, it should go ahead and open up for they actually got a lot of criticism from the doctors in Britain over this British medical journal, because they’re like, yeah, I don’t think that our consultant is going to do, is going to approve this consultant being an attending physician or registrars and attending. Um, you know, so there there’s different terminology, but, um, so, you know, and, you know, such and such healthcare trust has tried to do this. And so, you know, it’s, it’s interesting to read the comments when they’re from other countries.

Any other questions? Looks like we’re good. Thank you very much, Dr. Phillips. It was a great lecture as usual.

And, uh, I know we, uh, everybody here, I’d like to wish you all a very, very happy and safe holiday season because we’re coming up on winter break. Yeah. It won’t be long.

So thank you again. And I’ll get this posted or get posted as soon as I can get Pat to get them posting. Well, Merry Christmas, everyone.

Y’all have a safe night. Good night, Dr. Phillips and be safe on shift. All right.

Thank you. Bye-bye. Thank you.

Bye.