My conference started with a day-long Difficult Airway class, taught by members of the Maryland State Police Aviation Division, and by staff from the R. Adams Cowley Shock Trauma Center in Baltimore.

Some of the highlights:

•      Hyperventilation can cause an increase in intrathoracic pressure, which can actually create a compartment syndrome in the chest, compressing the vena cava (and decreasing pre-load)
•      An anesthesiologist said that using Vecuronium as a de-fasciculating dose does not affect the Potassium release from Succinylcholine (contrary to what I've been taught).  Will have to do some more research on that.
•      Learned about the 4 D's and the 3-3-2 rule in assessing potentially difficult airways.
•     The cadaver lab at shock trauma was very valuable.  We had 7 cadavers, and practiced different skills with different equipment.  We did intubations with multiple blades & techniques, chest decompressions, needle crics & tracheostomies.  We used Gum Elastic Bougies & the Glide Scope.  I was very impressed with the Glide Scope, but at $10,000 per unit, don't think we'll have it any time soon.  The Bougie appears to be a very inexpensive tool to assist in securing an airway, & I hope to arrange to have them in our units soon.

    The class was very well put together and had some impressive instructors.   Thanks to the Maryland State Police & Shock Trauma for some valuable education.

The actual conference got underway the next morning with a presentation by Dr. Paul Pepe, a nationally recognized ED physician from Texas.  His focus was on disasters.  He spent quite a bit of time talking about New Orleans and Katrina.  He was asked to respond there by the State of Louisiana.  The highlights:

• Consider alternate means of communication, such as text messaging
• Plan on taking care of your own people first
• Conventional disasters only have 5-10% 'criticial' patients, he expects more with unconventional disasters such as dirty bombs, etc
• There were major problems with people cut off from their day-to-day medical needs (dialysis, medications, etc)
• Traditional triage is designed to sort trauma patients, but some sort of unconventional trauma needs to be considered (I found this during our Earthquake drill several weeks ago - we had a non-traumatized patient with a respiratory rate that was high enough to make her a critical patient.  She had chicken pox & had been isolated.  I decided not to transport her as a critical patient.) 
• There were no medical records available, and patients were unaware of their history and medical needs.  (I see this everyday, but certainly would be worse in a disaster)
• And the "Standard of Care" could become "Sufficiency of Care" in a disaster.  Interesting topics to consider.

Asthma & Ventilatory Care -

• Confirmed the growing use of CPAP for asthma use to stent airways open & improve medication delivery
• Discussion about the ResQPod to enhance a negative intrathoracic pressure during CPR
• Discussion about permissive hypothermia following successful resuscitation from cardiopulmonary arrest

Differentiating COPD from CHF

This was a good talk.  The physician who presented it basically told us that our diagnosis can be made solely from the history & physical.   He went on to tell us how.  What I wanted to know was the use of Capnography, and whether you could use the waveform as a basis for diagnosing one from the other.  When the lecture was over, the questions started.  One question (not from me) brought up capnography.  The doc stated "I was hoping to avoid this" and did not really answer my questions.  I waited until the thing was done and asked my question.  I was told that we should be able to diagnose simply on the history and that he wasn't going into capnography at all.  Oh, well.  The highlights:

• Nitro is great for CHF
• Lasix is bad
• CPAP is excellent
• Morphine is bad - never been proven to work
• Scene survey - if the patient smokes, it's 90% COPD
• CPAP for both CHF & COPD
• He did say if their history includes both, then treat for both

Delivering High Quality CPR

Dr. Thomas Aufderheide is well known in the ACLS circles.  He does quite a bit of study and had some interesting points to make.

• Increased ventilation = interrupted CPR, increased intrathoracic pressure (which means decreased pre-load & cerebral flow)
• Infrequent ventilation (less or about 2 ventilations per minute during CPR) was studied (if more is bad, what about less?), and the study 'showed poor outcomes'
• Seems the answer is somewhere between 6 & 12 ventilations per minute with CPR
• Compression rates - EtCO2 rises with correct rates (this is good), and that higher save rates have been associated with higher CPR compression rates (also good)
• Fatigue - During the first minute of CPR, compressions are 80% correct, but after doing CPR for 5 minutes, only 20% is correct.  (I got a Zoll t-shirt for doing 2 minutes of CPR, with a 92% correct rate.  The shirt says "Occasionally I shock people".  Heh)

Medical Implications of Tasers, & Excited Delirium, Positional Asphyxia & Restraints

This was actually 2 classes, led by a physician and researcher from San Diego.  These topics have interested me for some time, and I was glad to see them presented.

• Most people injured/killed after a Taser use are injured/killed from falls, etc
• There are no studies about repeated energy cycles, or about rising ICP
• Taser use can ignite flammable liquids (ouch)
• There are studies trying to figure out why these people who get tased are dying - dysrhythmias?  electrolytes?  respiratory?
• Studies show no cardiac effects
• There are short events of ventilatory increase, but no EtCO2 changes
• There are no changes to pH
• The underlying reason for why the patient got tased is critical for proper assessment & treatment

So, on to the second class.

Positional restraint & asphyxia

• Most deaths result from drug use/psych issues/fighting with the police (never a good idea)
• 1995 study showed no effect on pulmonary function tests when hog-tied
• LAPD stopped hog-tying and found no changes in in-custody death rates
• Weight force (cop sitting on the perp) studies showed no effects
• So, the correlation between in-custody deaths and positional restraints (hog-tieing) and asphyxia does not pan out in studies

Pepper Spray

• Most in-custody deaths after use of pepper spray also involved excited delirium and drug use

Commonalities

• #1 is the subject/patient/perp
• Excited delirium w/ violent, combative behavior
• Elevated heart rate, B/P, & temperature with sweating & altered levels of consciousness
• There are possible neurotransmitter alterations
• There is a possible link with severe psychiatric issues
• There are possible dopaminergic changes in the brain

Treatment

• Recognize excited delirium
• Consider it a medical emergency
• Careful monitoring
• IV access & fluids
• Sedation with Versed
• There is a possibility of using Bicarb prophylactically, but there is no data to support

I did share our protocols with the doc and he assured me that they are right on target.  When I asked about comparing excited delirium and cocaine -vs- methamphetamines, he had no data.  However, he did mention that prolonged meth use has been associated with cardiomegaly (enlarged heart), which means that it could be associated with untimely death.

Mystery of the Medication List

This was a fun class.  It was taught by the State EMS Medical Advisor for Minnesota. 

• The average patient takes 5-10 prescriptions
• Risks of complications & interactions increases exponentially with 3 prescriptions and age
• "What medications have been prescribed for you", and "Why are you taking these medications" should be in your history-taking.
• Basically, the premise was that you can figure out a patient's medical history simply by looking at all the medications they take.  I figured that out about 2 years ago, after finding that many of my patients did not know what their history is or why they were taking the medications given to them!

Slap the Cap!

This was a great class presented by Bob Page.  He really reinforced the value of capnography in evaluating, treating & monitoring patients.

• Capnography is dynamic and proactive
• He recommends printing out the wave forms before & after every move (in the intubated patient), especially before and after the final move to the ED bed.  This proves your tube was good should you be questioned.
• EtCO2 in the early asthmatic patient will be slightly lowered as the patient hyperventilates
• In the tiring patient, it will be slightly elevated, and in the tired patient, it will be severely elevated.
• If the EtCO2 goes up with o2 application in the COPD patient, it means that you have depressed the hypoxic drive, and you should back off the o2!  He also mentioned that only 5% of end-stage COPD'ers have a hypoxic drive.
• We've all learned that a sloping upstroke (shark-fin) means uneven alveolar emptying (bronchospasm).  But, a sloping downstroke can mean a leaking endotracheal tube ( lower section of the downstroke), or a flail chest (upper section)
• He also confirmed that a normal appearing wave form in a respiratory patient would tend to confirm a CHF diagnosis, whereas a shark fin indicates a bronchospasm (and different treatment)
• You can use the monitor (displaying the wave form & respiratory rate) to coach your hyperventilating patient to slow his/her breathing.

To Transport, Or Not To Transport

This class was presented by W. Anne Maggiore, an Attorney/Paramedic.  She spoke on the risks involved in obtaining refusals, and had some great info.

• The basic question is:  how much risk are you (or your agency) comfortable with?
• A person becomes a patient only after an exam that is sufficient enough to determine illness and/or injury.
• Refusals MUST be signed by a person with full mental capabilities
• The narrative is most important to defend a call in court, as well as to adequately remember a call years later.
• You should document your efforts to convince a patient to be transported.  Documenting these efforts could be the difference between winning & losing a lawsuit (Kyser vs. Metro Ambulance)
• She mentioned that the practice of taking photographs at the scene (usually of car crashes) 1) should be supported by your agency, and 2) printed and placed in the medical record.
• With regards to the adequacy of evaluation in the field - several studies showed that of the patients said by EMS to have minor medical problems, some 10% were later found to actually have a serious medical issue, and that Paramedics are actually incapable of safely deciding who needs transport or not.  Schmidt, T. Acad. Emerg. Med. 2000 Jun; 7(6):633-9  & Schmidt, T. Prehosp. Emerg. Care 2002 Oct-Dec; 5(4):366-70 & Hauswald, M.  Prehosp. Emerg. Care 2002 Oct-Dec; 6(4):383-6 & Silvestri, S.  Prehosp. Emergt. Care 2002 Oct-Dec; 6(4) 387-90.  I presented this information this morning to my co-workers.  What a controversial topic!  It ended up dominating the conversation for some time.
• Make sure that the patient actually reads and understands the refusal form.  An uninformed refusal doesn't count.

Well, that's most of the medical stuff.  Some time was spent on the exhibit floor.  Lot's o' stuff to see there.  New ambulances, although I didn't really look at them closely.  My agency buys from one manufacturer (not present at EMS Today), and so it was a waste of my time to even bother to look at the others.  Except - I did take a look at the new safety features, such as netting at the head of the bench seat, emergency lighting, restraint systems, reflective striping, and loading/storage of large/heavy o2 tanks.

I looked at splints, some more splints, IV fluid warmers, powered gurneys, EMS helmets, and the King LT airway.  I was impressed with some of the new SAo2 sensors.  I found my new friends at Midnight Medicine and came away with one of their shirts. 

I met with several other EMS bloggers & podcasters, including Peter Canning, Dan White (inventor of the EMS Helmet, above, and the Triage Rap Tag), John Bignell, Jamie Davis, and Rick Russotti.  We shared a few drinks, cooked animals and bullshit by the ton.  I think we'll have to do it again.  I am really intrigued in the possibilities of continuing education by podcast.

I met one of my instructors from a class some 13 years ago at the National Fire Academy.  I was talking with a rep at the Boundtree Medical booth when I realized I had worked with him and even bought stuff from him some 15 years ago in Alaska.  I was able to put faces to names from people I have communicated and worked with in the recent past.  I talked with reps from the Boussignac CPAP system & EZ-IO and tickled them with real-world info on how well their equipment works.

I would like to go back to more national EMS conferences.  I was impressed with the speakers & information presented.  It was a privilege to be in the same room with some real EMS movers & shakers.  

Oh, and I found Rogue Ales Dead Guy at a pub near the convention center.