Don’t Ask, Don’t Tell? Not Safe in Any Environment

1. Don’t Ask, Don’t Tell?Not Safe in Any Environment J Brent Myers, MD MPH Director Wake County Dept of EMS

7. Never put off until tomorrow What you can put off Until day after tomorrow -Mark Twain

8. Take Calculated Risks. That is Quite Different From Being Rash. -George Patton

9. Culture of Safety • We should be ashamed of ourselves • We have sat idly by while: • Response time has become our measure of success • The main purpose of medical direction was to catch people when they make a mistake • The patient and our providers have been lost in our anti-safety culture

11. Areas of Focus • Clinical Decision Making • Medication errors and adverse events • Vehicle incidents • Endotracheal intubation

12. Clinical Decision Making • Transport vs no transport • ALS vs BLS • Alternative destination

13. Evidence • Without additional training, paramedics may have some difficulties in determining who needs transport • With additional training, paramedics may be able to do this well

14. Medication Errors and Adverse Events • Use of drug dosing cards and clinical checklists can help reduce errors • One example from the literature: • Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care 2008;12:486-94.

15. Results • With and without drug dosing cards: • Accuracy 65% vs 94% • Severe errors 20% vs 5% • Ten fold error rate 6.8% vs 0.8% • Correct size ETT 23% vs 98%

21. A Distinction No Longer? Pilots Surgeons

24. The Truth About Our MVCs • 36 deaths per year in ambulance related crashes per year • More likely to have fatalities than police or fire crashes • Occur in good weather at intersections and on straight highways • Unrestrained passengers in the back most likely to have injury/death

25. We Should Wear These

27. It Is Time to Stop the Madness • EMS providers are much more likely to be injured in a crash than our other public safety colleagues • There are ultra-time critical emergencies but we can tailor our response to these • We need to develop evidence-based responses and stop allowing the public to think that fast = good

28. If All You Have is a Hammer . . .

32. The Take Home Message • As a profession, we should: • Create an environment where near-misses and true misadventures can be shared – the so-called “just culture” • Follow the lead of the airline industry – there is no place for math in medicine but there is every place for a checklist • Never tolerate an injury to our providers or the public

33. Do Ask, Do Tell

35. Now That’s A Cool Idea – Hypothermia in Non-Traditional Cases J Brent Myers, MD MPH Director Wake County Dept of EMS

36. Case #1

37. Case #1 • 60 year old male collapses in a parking lot • Bystander notices patient on the ground with blood from back of head • Bystander compression initiated • 9-1-1 is activated

40. Case #1 • EMS arrives to find the patient in ventricular fibrillation • Compressions are continued • Patient is a “one shock” save with only one epinephrine and one vasopressin administered • Cold IV saline is used both during and after the resuscitation

41. Case #1 • En rte to emergency department, patient has spontaneous respirations assisted with BVM • Patient has no purposeful movement but does have some non-purposeful flailing of the arms/legs

42. Case #1 • Is this patient a candidate for continued hypothermia treatment? • ROSC post v. fib with spontaneous movement • Laceration to the head with fall onto a parking lot • What helps with the decision?

43. Case #1 – Post ROSC 12-lead

44. Case #1 • Cold IV saline is continued while en route • Versed IV 5 mg required to keep patient on the stretcher • Patient continues with flailing but will not follow commands • Secondary survey reveals extensive third degree burns on the back/posterior legs

45. Case #1 – Emergency Dept Arrival • 60 year old male arrives with the following conditions: • S/P V-fib arrest • Induced hypothermia in progress • STEMI • Head trauma • Severe burns

46. Panel of “Experts” Assembles

47. From theory to practice • Immediate life threat • Known – STEMI • Potential – head trauma • Critical clinical issues • Known – burns • Potential – ischemic brain injury • Now ain’t this a mess. . .

48. So What Happened? • RSI due to patient being too restless to go for cardiac cath, but we lost our neuro exam • CT scans deferred until after cardiac cath, but who was going to the OR with an active STEMI anyway? • IV cold saline was continued, if he lives, don’t we want to maximize outcomes?

49. The Case for the Heart • Measureable decline in survival for every 30 minutes of delay to the cardiac cath lab • Can’t argue that no other interventions will be done until the vessel is open

50. The Case for the Brain – s/p Ventricular Fibrillation Arrest • Class I evidence from AHA • Clear recommendation of AHA and ILCOR • “Strongly recommend” from many national and international groups