Having attended the 2009 Conference of U.S. Metropolitan Municipalities EMS Medical Directors Consortium (a.k.a. "The Eagles Coalition"), it became immediately apparent this was not "your father's EMS conference"...   

Second, the format of the conference was unique in that each presenter was given 600 seconds (i.e.: 10 minutes) to present his or her 'insight' into the advancement of pre-hospital care - gosh, it has taken me longer than that to write the last paragraph!   For some, that was a real challenge, right Dr. Fowler, but it allowed for over 50 formal presentations about current EMS innovations around the world.   Interspersed throughout the 2-day conference were also several "lightening rounds" in which the Eagles Coalition took the stage and had 1 - 2 minutes each to answer questions from the audience.  

This facilitated incredible sharing of knowledge unlike any of the 40 or so EMS conferences I've attended in the past 30 or so years in EMS.   In this author's opinion, here were the "Top 5" insights from the Eagles...

#5 - If you don't manage your patient's pain, they won't like you!

Dr. Marc Conterato from Minneapolis reported on an Ohio study of 1,073 encounters of patients with extremity fractures and only EIGHT were given analgesics for pain management.   He continued in his presentation to dispel the five myths associated with why pain management is not generally used more liberally.  As a patient who suffered a comminuted tri-malleolar fracture as the result of a sky diving accident, I can tell you 1^st hand the value of pre-hospital pain management in patient satisfaction.   Failure to adequately address your patient's pain is not only mean, it borders on malpractice (and they won't like you!).

#4 - Do we really take the right patient to the right facility?

How do we know the hospital we transport the STEMI or Acute CVA patient to can provide the best treatment for the clinical manifestation?   Dr. Donald Locasto from Cincinnati reported on a survey instrument they used to verify the services available at the 26 hospitals in their service area.   They used some rather interesting tactics to assure the hospitals actually participated in the survey, including publishing the preliminary list to the community that included the statement "The capabilities of hospitals that have not responded to this survey are unknown."   Shortly after that publication, the hospitals that had not previously submitted information did so.   From this information, the EMS system was able to implement protocols to assure the right patient is taken to the right facility.

#3 - We are human and humans make mistakes, but super-humans admit mistakes!

 Dr. John Gallagher from Phoenix provided sage advice concerning medication errors.   He suggests reducing look alike and sound alike drugs, and segregating drugs based on actions.   He also advised that good medical directors create a culture where it is 'safe' for paramedics to admit medical errors without fear of unrestrained reprisals.   Doing so helps to identify necessary quality improvement initiatives.   The more earth shattering discussion came toward the end of his presentation.   When we DO make mistakes, the patient deserves the right to know and in many cases, if the patient knows a mistake was made, and what steps are being taken to avoid similar mistakes in the future, they are less likely do engage in hefty lawsuit.   This is rather controversial, but there have been several reports of increased patient satisfaction and decreased litigation when we admit we're human.

#2 - EMS Pre-Alert of STEMI patients is essential to meeting the 90 minute door to balloon time!

Dr.'s Fowler (Dallas) and Slovis (Nashville) debated the issue of 12L ECG acquisition and transmission for reducing door-to-balloon times for STEMI patients.  In this lively session, a few pearls of wisdom were uncovered.   In a study published in the May 2005 edition of the American Journal of Emergency Medicine, 12L ECG interpretation accuracy was highest in cardiologists at 95%, emergency department physicians were accurate 93% of the time and paramedics were accurate 94% of the time.   Further, in a study published in a 2008 edition of the American Journal of Cardiology, 80% of the patients made the door-to-balloon (D₂B) time goal of under 90 minutes if the EMS team pre-alerted the hospital, but only 10-25% of the patients made the D₂B time goal without EMS pre-alert.   After the debate, it was agreed that paramedics, E/D docs and cardiologists independently do a very good job of diagnosing STEMI patients, but all three together are nearly perfect!   Work together!!

#1 - The future of EMS lies with modified response configurations for the most and least serious patients!

Dr. Brent Myers of Wake County, NC provided outcome results from his innovative approach to using Advance Practice Paramedics (APPs) in their EMS system.   The concept of community health paramedics and sending the right resource to the right patient at the right time has been the holy grail of EMS agencies (and this author) for some time.   Wake EMS seems to have finally got it right!   APPs complete additional training consisting of a seven week academy focusing on public health issues, critical encounters and alternate destinations.   They also participate in clinical rotation in OB, infectious diseases, psych and other specialty area.   Once completed, the APPs respond to the highest acuity, or most difficult calls, and visit 'frequent fliers'.

Although in its infancy (started in January 2009), the initial results are encouraging.   APPs have conducted 54 well-checks have responded to 99 Cardiac Arrest calls.   Dr. Myers presented a few specific cases:

Case Report  - 60s year old diabetic male

-          In the 4 weeks prior implementation of the program, patient called EMS 3 times (70 calls in 5 years)

-          Homes visits were scheduled

-         On first visit, the patient's hypoglycemic episodes were all noted to be in the late afternoon

-          Subsequent visits thus timed

-          2nd home visit - patient was found alone in the home, disoriented, with blood glucose of 28

-          No ambulance was needed

-          APP started IV, remedied blood glucose, and evaluated the patients medication

-          Follow-up visit with PMD scheduled

-          Medications were adjusted

-          Patient has not called for 9-1-1 in 28 days

Case Report  - 30s year old psychiatric female in a local hotel lobby

-          Ambulance responded and per protocol considered pharmacologic intervention with Haldol/Versed

o    Would require ambulance transport and E/D evaluation prior to psych admission

-         Psych intervention trained APP summoned to the scene

-          Through conversation and further communication, pharmacologic intervention not needed

-          Patient transported directly to psych facility

-          Average E/D hold for psych patients is 14 hours

o    i.e.: kept an E/D bed open for 14 hours

Congratulations to the Eagles Coalition for a very educational and "insightful" two-day conference!

To learn more about the Eagles, review the specific presentations, AND register for the 2010 Gathering of Eagles, visit http://gatheringofeagles.us/