Quick Hits from the Gathering of Eagles

If you’ve attended past conferences of the Gathering of Eagles—the leading conference of the EMS medical directors of the world’s major metropolitan jurisdictions—you’re aware that the information comes at you at a rapid pace. Most talks last 5 minutes, so you’d better have your recording device charged and ready.

Below are only a few snapshots that were presented in Hollywood, Florida during the Eagles’ 2022 conference.

Monkeypox

“I’m pretty tired of these infectious diseases,” said Portland, Oregon Fire-Rescue EMS medical director and infectious disease expert Jon Jui, MD, to introduce his lecture on monkeypox. As COVID-19 has begun to subside in many parts of the world, monkeypox is taking over the headlines and responders are concerned about exposure.

Monkeypox is a double-stranded DNA virus, making it stable and less likely to mutate, Jui explained. The term monkeypox is actually a misnomer, as the research casts doubt on whether monkeys are the primary hosts. It’s not currently clear where the disease’s main hosts are, according to Jui. The disease’s place of origin is West Africa and Congo, depending on the strain.

Fortunately, overall mortality is less than 1% depending on the strain, Jui said, adding that monkeypox will not be “another COVID.”

However, “This is a long-term disease,” he said. “This disease doesn’t go away.”

The bottom line: EMS clinicians should be aware that transmission is via direct contact. It’s not necessary to furlough exposed individuals, but close monitoring is required. Those with a smallpox vaccine are fairly well protected. Remember your PPE, Jui said.

Hennepin EMS Ridealongs

An initiative of Hennepin EMS in Minneapolis is exposing local elected officials to the realities of working as an EMS responder.

Nicholas Simpson, MD, chief medical director of Hennepin EMS in Minneapolis, explained that legislators are expected to be experts on everything, which is not feasible. Because hearing about EMS stories is starkly different than experiencing calls first-hand, Hennepin EMS invites elected officials to spend hourlong immersive encounters with EMS to learn how the 9-1-1 system functions and how police, fire, and EMS work together on complex calls.

Thirty-two elected officials have gone on ridealongs so far.

Don’t worry if no calls come in during an official’s visit, advised Simpson—use the opportunity for open dialogue on current concerns facing the industry. “We had deep conversations on difficult issues,” Simpson said.

“Each of these rides was extremely impactful,” said Simpson, adding that many politicians promoted the visits to their constituents, therefore leveraging positive publicity to the agency. “The relationship is key. We’ve been tremendously happy with how this has turned out.”

Florida’s Resuscitation Centers

Resuscitation centers are a step closer to becoming formalized throughout Florida as one such effort is being launched this month in Orlando at AdventHealth, noted Kerry M. Bachista, MD, a board-certified emergency medical physician in Jacksonville.

Bachista—credited by Eagles course coordinator Paul E. Pepe, MD, MPH, as one of early champions of the idea—updated attendees at the Gathering of the Eagles 2022 conference of the efforts taking place.

“The question is, are you taking your ROSC patients to the right place?” Bachista asked attendees. “Those of us involved in EMS systems of care may have noticed that certain hospitals have better outcomes than other hospitals.”

While the idea of resuscitation centers is not new, certain factors are driving support for more widespread establishment.

“Some high-performing EMS systems are routinely getting ROSC rates of 40%–50%,” says Bachista. “We’re bringing these patients to the hospital. There's still a defeatist attitude when it comes to cardiac arrest in a lot of places.”

Case in point: microhospitals.

Bachista recalls a recent conversation in which he told someone affiliated with a microhospital that “We’re probably not going to be bringing you a cardiac arrest in ROSC, and he said, ‘We have 5 ICU beds—does that make you feel better?’ There’s this idea that all the ROSC cardiac arrest patient just needs is a bed to sort out the rest of their days. We don’t have that attitude with other things.”

And like other aspects of specialized medical care, primary and comprehensive resuscitation centers can be evidence-based and streamlined in a tiered system, noted Bachista.

The centers provide equity in care, preplanned pathways, and a team approach to patient care, he added.

The effort does entail tracking and metrics, which is what hospital administrators already do, said Bachista, adding there are “minimal to no costs” in establishing resuscitation centers.

“In Florida we've built a public-private model with champions from throughout the state to move this effort forward,” said Bachista.

The idea is drawing more interest from hospitals and regulatory agencies, said Bachista.

“AdventHealth has 8 hospitals in the area and 1 tertiary-care center downtown,” Bachista noted. “They’re just starting out an overall community effort from top to bottom to start this as a true systemic effort.”

Bachista believes it will inspire others to follow suit. "Everybody agrees with the medicine," he says. There's really no discussion of money. It's mainly about process—who's going to be on call, what's going to be our process to wake this person up."

Sepsis

Establishing a sepsis screening tool and administering antibiotics can improve patient outcomes in managing sepsis early in the prehospital setting, noted Paul Banerjee, DO, EMS medical director of Polk County, Florida. Banerjee cited data from his own operation’s program.

Among his many roles, Banerjee also is assistant professor of emergency medicine at the University of Central Florida College of Medicine.

Polk County Fire Rescue has achieved positive results since starting the screening and antibiotics program in January, having brought mortality rates down in 58 cases of patients presenting with sepsis to 6.8% from 15.98%.

“For people with sepsis, that’s unheard of,” Banerjee said, pointing out that every hour of delay of antibiotics to patients diagnosed with sepsis increases mortality by 7.6%.

Banerjee points out the data shows that more people die of sepsis than of cardiac arrest, stroke, myocardial infarction, and trauma.

“We really should be aware of this, and everyone should have some kind of sepsis screening,” says Banerjee. “The quicker we recognize this, the better outcomes we're going to have.”

There are 4 stages of the sepsis continuum, starting with a suspicion of infection and leading to septic shock.

In the case of Banerjee’s operation, antibiotics are administered if a mean arterial pressure (MAP) score is less than 70.

“The earlier you recognize it, the better the outcomes are going to be if you start treating these patients,” he says.

Banerjee says while a broad spectrum of antibiotics can be given, he recommends choosing what is best for the case. His operation chooses Rocephin “because it basically covers most of the bugs we would be encountering.”

CAP protocols also inform that decision, as does a calculation of a shock index (SI) and modified shock index (MSI), he said.

Mass Shootings

Among the most powerful and emotionally evocative sessions at Eagles centered on the topic of mass shootings. A panel comprised of EMS physicians who have responded to mass shooting scenes—such as Aurora, Colorado and Parkland, Florida—along with law enforcement and the parent of a young victim of the Parkland school shooting spoke of the difficulties and the raw emotions of working these horrific calls.

Whenever there is a great tragedy, there is an expression of guilt, said panel moderator Pepe, which can erupt in various forms such as anger, regret, blame, extreme melancholy, or the unrelenting feeling that mistakes were made and more could have been done. It’s important for responders to understand that these feelings are normal and expected as people work through the grief process, Pepe stressed, sharing details of conversations he had with panel member Peter Antevy, MD, who responded to the 2018 shooting attack at Marjory Stoneman Douglas High School and experienced difficulty processing the event.

“I was very angry," said Antevy of the Parkland shooting, frustrated at not being allowed in to the school to assist victims in the critical minutes following the shooting. Pepe replied that extreme frustration of not being able to "do something" is a classic and common emotional reaction to caregivers on the scene.

“Sometimes it’s hard to predict what triggers it,” said Christopher Colwell, MD, who still has flareups of post-traumatic stress from responding to the Columbine school shooting more than 23 years ago. While some triggers are expected, such as news stories of other school shootings, others can be more subtle and difficult to predict.

“It’s not if, but when,” said Juan Cardona, division chief of the Coral Springs-Parkland Fire Department. “The question is, are we ready?”

The panel members expressed a mutual feeling that sharing their perspectives was valuable both professionally and personally. If family members and responders of large-scale MCIs wish to engage with each other, it can be an important piece of the grieving and healing process, said Pepe.

"My heart goes out to all the folks I work with," Antevy said, adding that "microtrauma" can be as progressively damaging as one major tragedy. "It’s been valuable for me being up here."