JEMS EMS TODAY CONFERENCE

I went down to Baltimore, Maryland to attend the annual JEMS EMS Today Conference. This is the second time I have been, and I was very glad I went. The speakers are always absolutely first rate. It is good to surround yourself with people who are on the leading edge of EMS. I always like finding out what the latest is, both in research and technology.

This years’s conference was dominated by the new AHA guidelines. The message was Compressions, compressions, compressions. Allow full chest recoil when doing CPR and NO hyperventilation. Ventilate your codes at 8-10 times a minute.

Here are some of my notes:

Studies show half the time in CPR compressions don’t get done.

When you stop compressions, all blood flow ceases.

Studies show paramedics, doctors and nurses all ventilate at rates from 30-40 a minutes.

High ventilation rates screw up the intrarthoracic pressure preventing effective blood flow.

Normal people breathe through negative pressure. We ventilate people with positive pressure. Too much positive pressure inhibits blood return.

Our ventilations should be fewer and less both in terms of volume and duration.

Studies showed uninterrupted compressions increased survival by 300%.

Anything that interrupts compressions is bad.

You can delay intubation for patients in vfib. They should have a good supply of oxygenated blood in their body that will last for five minutes or so. You could monitor their status by using a nasal end tidal CO2 cannula while using a bag mask.

When you do intubate try to keep compressions going while you pass the tube. If you need to stop compressions, stop only for a brief moment

In a study when pigs were put into arrest, 6 of 7 pigs survived when they were ventilated 6 times a minute, only 1 of 7 survived when they were ventilated at 30 times a minute.

Keep tidal volume to 400 on ventilations.

There are two ways to hyperventilate: Too many respirations and too much volume in a single respiration.

Most pulses that emerge after a shock don’t show up for 60 seconds. So keep doing compressions.

One speaker joked “Keep doing compressions until the patient wakes up, grabs you hand and insists you stop.”

There are fewer v-fib codes today than several years ago because of the better cardiac care people receive from their doctors. Most codes are sicker people.

Epi has a IIb rating because they cannot do a study where epi is used against a placebo. No ethics board would allow it. Without such a study, there can be no Level I rating. Its one of the quirks of the evidence rating system.

One of the reasons, cardiac arrest discharge from hospital rates are so low is because the post resuscitation care at the hospital is so poor — it often consists only of trying to make a person a DNR.

Other notes:

On cardioversion — if the patient can remember what you look like after you have cardioverted them, don’t cardiovert because they probably don’t need it.

I asked the Dr. responsible for the tachycardia algorithm about the new phrase “Seek Expert Consultation,” and he said, it means if you don’t have to give a patient drugs, don’t, wait for the hospital.

On Intubation, a doctor said the FDA would not approve intubation today based on existing studies that show how badly it is being done and its negative effect on patients. A group of doctors said for people to keep intubating, their program needs a solid QI program and people need to go to the ER if they are not getting enough tubes. One doctor said, “a misplaced tube is a travesty. It means, your patient would have done better in a Yellow Cab.”

They said never intubate a child unless you absolutely have too.

The adult IO is great for cardiac arrest, it may not have a place in trauma.

Studies have shown that morphine actually helps the surgeon do an abdominal evaluation. We should be giving morphine to patients with abdominal pain.

In trauma, we should practice permissive hypotension – the BP can be kept around 70 for trauma patients and fluid should only be administered if the pressure gets below 40.

Gunshot wounds to the head without neuro deficits, do not need cspine.

Magnesium is great for severe asthma — 2 grams in 100cc over 1-10 minutes.

Instead of doing one breathing treatment followed by another, do a continuous treatment, which is basically dumping two treatments in the neb to begin with.

CPAP for CHF is outstanding.

Be very cautious with lasix. Never start with Lasix and never give it unless you are also giving nitro because lasix’s initial action is as a vasoconstrictor.

For anaphylaxis, give epi IM in the thigh

Everyone intubated should have end tidal Co2 monitoring.

***

And here are my awards for the two best products from the EXPO:

Vida Care Easy IO

RESQPOD

***

The conference will be held again in Baltimore next year. Since EMS is now relying on evidence-based medicine, each new study will shape our direction. As one doctor said, what you are learning today, will be different tomorrow.

11 Comments

  • Stacey says:

    We just learned the new 30:2 cpr in paramedic class. It makes alot more sense than the old way.

  • KyT says:

    As one doctor said, what you are learning today, will be different tomorrow.well isnt that the truth, i havent even taken my state written yet and they are already changing things on me.

  • Aaron says:

    Great blog, I look forward to reading more in the future. I just finished reading the first 9 chapters of your latest book, and hope that the rest will be online shortly. Tomorrow I hope to order your other two books.Regards, and please continue Blogging,AaronEmt-BIsrael

  • Anonymous says:

    thanks for posting what you learned. nice to see that a lot of it has already been mentioned where i’m working, and no one that i know of went to the jems conference. this says to me that the jems conference has their finger on the pulse in terms of the information that is out there (or my agency is ahead of the learning curve – something i doubt…ha ha).was the issue of privately funded studies addressed in any lecture? strikes me that there have been changes in the past (and changes that are currently underway) that have been influenced by companies that have…well…a vested interest. i’m just curious if that topic was addressed at all.by the way, i’m the one who was interested in the dni/dnr separation – wondering if you’d gotten any time (or information) to further my education on that. :)thanks!

  • Anonymous says:

    Regarding pain relief for the patient with abdominal pain, here’s a section from the 6th edition of Emergency Medicine by Tintinalli:—-The 20th editon of Cope’s Early Diagnosis of the Acute Abdomen marks a historic change in the traditional view of pain management in patients with abdominal pain:”The realization, likely erroneous, that narcotics can obscure the clinical picture has given rise to the unfortunate dictum that these drugs should never be given until a diagnosis has been firmly established. With the numerous layers of triage nurses, medical students, residents and attending physicians in modern emergency units, and with the addition of time-consuming tests often done before an adequate history and physical examination, the suffering patient is sometimes forced to wait for many hours before any relief is offered. This cruel practice is to be condemned, but I suspect that it will take many generations to eliminate it because the rule has become so firmly ingrained in the minds of physicians.” ….Early administration of intravenous opioids has been shown to be a safe and effective analgesic in patients with acute abdominal pain in the ED and does not have adverse effects on the accuracy of the evaluation, diagnosis and management.-pp 262-263.—-

  • PC says:

    On the DNR/DNI issue, people have a menu option of alternatives. DNR is no CPR, but it does not preclude intubation if the person is still breathing. DNI precludes intubation. As I understand it now, a person with a DNR suffering respiratory arrest, should not be intubated, but a person with a DNR in respiratory distress can be. The grey area is the patient with decreasing resps with a paper that has DNR checked, by DNI blank.

  • PC says:

    Thanks for the excerpt on the morphine for abd pain. I will use this in a presentation to our regional council to try to change our protocols.

  • Anonymous says:

    back to the dnr/dni issue, i guess what i’m wondering is why on earth someone would specify dni but not dnr. i mean, “hey, you can do those great chest compressions and you can bag me till the cows come home but no way will you stick a tube down my throat”? i can understand what is to be gained by signing a dnr, but why a dni?thanks for your thoughts on this.

  • Anonymous says:

    and by the way, our dnr includes intubation, so if they have a dnr and they need help to breathe, you still don’t intubate them.i find this all interesting – don’t know why.

  • PC says:

    I agree why be a DNR, but not a DNI, but some people do it. I took this off of a web site explaining the orders:”What does DNR/DNI mean?” DNR/DNI stands for Do Not Recussitate/Do Not Intubate and is a specific physician order. Put more simply, Do Not Recussitate means that in the event of cardiac arrest no CPR or electric shock will be performed to re-start the heart and Do Not Intubate means that no breathing tube will be placed in the throat in the event of breathing difficulty or respiratory arrest. Each of these orders may be given separately, that is, your loved one may be have a DNR order but not a DNI order, or vice versa. Usually, they are ordered together.

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