Birds of a Feather Flock Together

"Are you going to Eagles?"
     This simple inquiry from a colleague initially received a quizzical look from me until he elaborated that he was referring to the EMS State of the Sciences Conference in Dallas, TX, run by the U.S. Metropolitan Municipalities EMS Medical Directors consortium. Although I had heard of this annual conclave of the nation's top EMS physicians, I had never attended. Purposefully, it's never advertised and people usually only hear about it by word of mouth.

     But the question got me thinking--how could this conference be different from other national EMS conferences? A number of well-recognized EMS medical directors regularly speak at other venues during the year. Other than having these docs present en masse, for what reason would this unannounced event receive such nationwide buzz? I decided to find the answer to this question by exploring the "not-so-secret" phenomenon that has simply become known as the "Gathering of Eagles."

On a Wing and a Prayer...
     While the Eagles assembly has gained notoriety for offering a snapshot of the most topical matters affecting EMS, it is a fairly recent invention and one that came about by chance. In 1998, Dr. Paul Pepe, the soon-to-be commonwealth emergency medical director for the state of Pennsylvania, was called on by field providers to put on a state-of-the-art educational offering that would challenge the status quo in EMS care. The goal was to create a venue where leading EMS physicians could exchange ideas regarding the state of prehospital care and system operations and let EMS personnel, managers and medical directors, plus anyone else who was interested, eavesdrop on the proceedings. Formerly an assistant to EMS medical directors in Seattle, WA, and later an EMS system director himself for 14 years in Houston, TX, Pepe called upon his network of colleagues to meet this challenge.

     By chance, Dr. Ray Fowler, the original program director of the Basic Trauma Life Support (BTLS) Program, and Dr. Jeff Clawson, the developer of emergency medical dispatch (EMD), were both coming to Pittsburgh three weeks later. Pepe had the beginnings of a faculty for his impromptu get-together. Within two days, he managed to recruit many innovative EMS medical directors from several U.S. cities, including Drs. Marshal Isaacs from San Francisco, CA, Dave Persse from Houston, TX, Jim Dunford from San Diego, CA, Ed Racht from Austin, TX, and Paula Willoughby from Chicago, IL. Within a week, Pepe had arranged the first "EMS State of the Science: Evolution and Revolution" meeting. Despite its last-minute organization, most of the blinded evaluations said the same thing: "Best meeting I have ever attended!"

     So, how is Eagles different? After researching past gatherings, I realized that this would be an experience like none other. Imagine, if you will, approximately 350 EMS educators, managers, chiefs, administrators and physicians sitting with rapt attention through two days of presentations from some of the best clinical minds in the industry. And these sessions are not for the long-winded or unprepared. Succinct and to the point, no presentation runs longer than 15 minutes.

Eye of the Eagle: Day 1
     The 2006 conference agenda departed slightly from that of previous years in that the topics were grouped into "mini-symposiums." Pepe, the program director, opened with a keynote sermon, Anachronistic Catastrophes, a thesis on why disasters have become worse and will become even more destructive in the future. This set the stage for Dr. Jullette Saussy, director of EMS for New Orleans, who opened up the first morning's mini-symposium titled The Big Blow of 2005: A Mini-Symposium on Hurricanes Katrina and Rita. Saussy gave a powerful overview of New Orleans EMS (NOEMS) tribulations. In her presentation, she detailed how NOEMS worked hard to maintain service to its community in the face of the destruction brought on by both the storm and the disintegration of the city's protective levee infrastructure. She also referenced the chaos wrought by local, state and federal agency infighting and offered advice gleaned from the ordeal to other system leaders: "If someone says, 'We are from the government and we are here to help,' check their shoes. If they are wearing loafers, they are not there to help."

     Following Saussy, some of the Eagles medical directors from nearby communities also affected by the evacuation of Louisiana residents (i.e., Fort Worth, San Antonio and Houston), described their various preparations for the onslaught of potential patients. They drilled down on the logistical issues that these municipalities faced dealing with residents whose lives had been literally torn apart by the disaster.

     This opening program was then followed by an Eagles' brand-name commodity, the "lightning round." Lightning rounds are an Eagles tradition during which the audience has the opportunity to yell out an EMS problem/topic and the presenting medical directors each have less than 30 seconds to respond. Questions in that first round focused on the fatigue factor that plagued responders and also specific roles that the various directors played, even when they were quite distant from Katrina. The answers were direct and a thunder of applause soon followed the lightning.

     In the early afternoon, mini-symposium No. 2, titled Thinking Outside (and Inside) the Bus, spotlighted special EMS operational challenges and triage concerns.

• Dr. Jon Jui (Portland, OR) led off with a discussion called SARS du Jour, detailing the various phases of a likely pandemic and the role of EMS in such a public health crisis.
  
• Dr. Eric Ossmann (Atlanta, GA) reviewed discussions with CDC officials about the relatively uncontrolled prehospital environment with regard to biocontainment and the types of precautions that need to be taken (standard, contact, droplet and airborne). He concluded with an overview of the Toronto SARS experience and its impact on EMS.
  
• Dr. Paula Willoughby (Chicago, IL) took the stage with an overview of MCI management, specifically looking at a recent train accident and a plane-off-the-runway incident in the Chicago area, discussing the challenges faced (access issues, weather, traffic accumulation, accurate patient count), as well as the solutions implemented.
  
• The session was rounded out by a duo of presentations by Drs. James Dunford (San Diego, CA) and Marshal Isaacs (San Francisco, CA) on approaches taken by their respective municipalities to address the effects of public inebriates' overutilization of 9-1-1 services.

     The second lightning round led to great discussions on such diverse topics as: diversion/loss control issues on narcotics (which actually educated me on the fact that San Antonio, TX, does not utilize narcotics in prehospital care); the utilization/deployment of the Impedance Threshold Device (ITD); thoughts on the National EMS Scope of Practice project; the need for a lead federal EMS agency; treat-and-release/non-transport programs; and the prevalence of LMA utilization. p>     A potpourri of general EMS systems issues were explored later that afternoon:

• Elizabeth (Libby) Char (Honolulu, HI) discussed her island's challenge of integrating two divisions of responders--lifeguards and field EMS--under her office while handling the usual staffing and union factors.
  
• A new director/medical director in a new system, Neal Richmond (Louisville, KY) presented a one-year update about his experiences in an innovative model for an EMS system. He delineated the challenges of attempting to implement evidence-based interactions, both medical and operational in nature, as well as new staffing and scheduling patterns along with an aggressive hiring/training program--all in 15 minutes!
  
• Randy Loflin (El Paso, TX) offered a unique perspective in the categorization of "medical" (non-traumatic) patients into various levels correlating with severity of signs and symptoms (similar to our practice with trauma patients) which has resulted in a decrease in lights-and-siren transport.
  
• White House Physician and Director of Training Dr. Jeffrey Kuhlman discussed the White House Medical Unit (WHMU), including its roles and responsibilities, and protective medical support, as well as caring for high-level government officials.

     As the first day wrapped up, the topics posed in the third lightning round addressed the future of adult intubation, the U.S. Department of Transportation (DOT) curriculum, therapeutic out-of-hospital hypothermia for resuscitated cardiac arrest patients, implementation of National Registry requirements for field providers, waveform capnography and adult intraosseous (I/O) as well as the utilization of rapid sequence induction (RSI) in the prehospital environment.

Eye of the Eagle: Day 2
     Though events weren't grouped and titled as the previous day's agenda had been, clinical practice quickly appeared to be the connecting theme on the second day.

• Corey Slovis (Nashville, TN) offered a well-researched presentation on not missing the true signs of acute coronary syndrome (ACS) and then defined the acute myocardial infarct (AMI) standard of care for EMS. He reviewed the prevalence of missing signs of AMI, the importance of the "basics" (including a 12-lead on all chest pain patients) and the critical need for aspirin administration in applicable chest pain patients.
  
• Brent Myers (Raleigh, NC) pushed providers to get "Beyond Utstein: EMS Performance Measures" and began by advising the audience that cardiac arrest save rates alone should not be used to "sell" a system. Paramedic-level interventions on cardiac arrest calls are not a part of performance measures trended for his system and intubation is de-emphasized on these calls. He argued that ALS interventions make a difference on certain critical patients (i.e., S-T elevation myocardial infarction, stroke, trauma and acute pulmonary edema), but are not the prime factors in cardiac arrest resuscitation. He provided a recommended outline of BLS and other basic EMS performance measures and he shared what was working in Wake County.
  
• Crawford Mechem (Philadelphia, PA) discussed the clinical and operational decision to return his city's fire department EMS to a tiered ALS-BLS system from an all-ALS system. Mechem outlined the reasons for this strategic transformation, including call volume and population shifts, as well as serious ALS staff shortages. He went on to delineate some of the other measures his system will be taking to increase the pool of paramedics, and touched on the safety, feasibility and palatability of this fundamental change.
  
• Ron Pirrallo (Milwaukee, WI) proposed a "lean and mean" approach to resuscitation medications, highlighting perfusion, electricity and epinephrine as the truly "essential drugs," along with I/O circulation access, capnography trending and the "lowly" BVM as essential for resuscitative efforts.

     As a perfect segue, the next mini-symposium, "ROSC--Return of Spontaneous Circulation," focused on revisiting some CPR technologies for EMS.

• Joseph Ornato (Richmond, VA) conducted an in-depth discussion on his system's experience with a non-randomized observational study of the AutoPulse device that, based on historical results, had led to some improved outcomes following the introduction of the device.
  
• David Keseg (Columbus, OH) offered another perspective of the AutoPulse, based on his system's participation in the ASPIRE trial, a clinical trial of the device. Keseg outlined the logistical difficulties of getting the equipment onto the fire apparatus, as well as the training of personnel, establishing data collection positions and other related issues.
  
• A panel on the AutoPulse and other CPR adjuncts was held regarding the varied experiences in San Francisco, Columbus, Richmond and the ASPIRE trial. It was noted that a critical factor was the ability to put the machine on the patient in a timely manner that would avoid significant interruptions of chest compressions. Also recommended was the need for further randomized studies to better analyze this technology's overall impact on ROSC and survival to discharge.

     The fourth lightning round started off with a question regarding common issues seen with fire-based EMS systems, which touched off a whole discussion related to advancements in cardiac assessment--which systems were utilizing prearrival instructions, the value of transmission of ECGs from the field to the ED, and diversion to cardiac centers for cath lab utilization--and wrapped up with a question on termination of failed resuscitation efforts in the field. But it would not be the Eagles without some spontaneous "OTR" (off-the-record) antics. In the middle of the session, presenters took out a CPR quality analyzer and pulled out audience members randomly and demonstrated why such devices are extraordinarily useful, especially for training--all in 30 minutes!

The Home Stretch...
     The last mini-symposium of this year's conference offered a look into issues affecting medicine and police: Cops and Docs: EMS and Medical Direction in Law Enforcement.

• Nelson Tang (U.S. Secret Service/Immigration & Customs Enforcement) spoke on the various models of law enforcement medical support (e.g., ALS vs. BLS, dedicated vs. non-dedicated personnel, in-system or stand-alone services), the unique aspects of such medical support, related challenges and controversies (scopes of practice, protocols, etc.) and future directions and prospects. He stressed the need for development of law enforcement medicine and stated that it's "not just tactical anymore."
  
• Kathleen Schrank (Miami, FL) presented a soon–to-be position statement from the Eagles on conductive electrical devices (CEDs) such as the Taser. She also delved into the general principles of these devices, some basic statistics, EMS calls for assistance for victims (including what they should assess), deaths attributed to CED use, as well as a review of recent cases and outcomes.
  
• A panel regarding interfacing law enforcement and EMS issues followed and this included a live Taser demonstration by a master trainer from the Dallas Police Department.

     In the homestretch presentations of the day, Marc Eckstein (Los Angeles, CA) and John Gallagher (Phoenix, AZ) offered differing perspectives on digital capnography. Eckstein introduced the audience to the concept of digital capnography as the sixth vital sign and delineated its various uses in 2006, as well as its usefulness as a predictor of patient outcome. At the same time, in Suit Yourself: When the Sixth Vital Sign Is Not Enough Courtside, Gallagher counter-argued that there were practical limitations to field capnography that needed to be considered, particularly in the litigation arena.

     Closing out the conference were two of its veterans, Dr. Ed Racht (Austin, TX) and Dr. Pepe. Racht presented an insightful challenge about pain management that was a class-act presentation, even in the late hours of the last day. Pepe then presented an inspirational finale regarding the success of a new 30-minute CPR-Choking-AED course that, using very elegant scientific methods, was proven to be just as good as the standard three- to four-hour offerings, even in terms of retention at six months.

Flying High...
     On the flight home, I was amazed that I had truly experienced the width and breadth of U.S. medical leadership in just two scant days. With more than 30 state-of-the-art and provocative presentations in less than 16 CE-accruing hours, the 2006 EMS State of the Science: Gathering of Eagles VIII proved to be a whirlwind encounter with the most experienced clinical minds in EMS today. Touching on operational, clinical and a multitude of other system issues, the Eagles conclave lived up to its reputation as one of the most engaging and illuminating prehospital symposiums. For more information, visit www.GatheringofEagles.US.

Raphael M. Barishansky, MPH, EMT-B, is executive director of the Hudson Valley Regional EMS Council in Newburgh, NY, and a member of EMS Magazine's editorial advisory board. He can be reached at rbarishansky@gmail.com.