This morning Jane and I returned to Central University Hospital of Kigali (CHUK) for Rounds and then to give lectures on Event Medicine, MCI and START triage. Here in Kigali SAMU is often called upon to staff everything from high profile international business meetings to football matches with 50,000 fans. They are challenged by short notice for the events, which sometimes leaves little time for planning. Fortunately everyone seems to recognize that Rwanda is growing and becoming more high profile, and with that the need for Event Medicine management increasing.
Dr. Noah and the team see patients on RoundsCoffee and tea at the ready in the SAMU office – a sign of a well-prepared EMS agency
The lectures were well received, probably because we started by passing out Toblerone chocolate bars Dr. Sudha bought in the Amsterdam airport. Free food at a meeting or lecture is universally well received.
USA far left, Germany back left corner and the rest CHUK ED staff, a diverse crowd discussing Event Medicine this morning.
After lectures at the hospital, Jane and I rejoined Dr. Sudha and Basil at the SAMU Trauma Course. Last week we taught this course to 25 of SAMU’s brightest providers with high potential to be great educators. Friday, Basil taught them fundamentals of medical education in the adult learner. Today and tomorrow, those 25 are now teaching the same course to 25 more SAMU staff from district hospitals all over Rwanda.
The change can be felt already. Yes, the test scores were significantly improved last week, but more importantly, the SAMU staff have already incorporated their trauma training into their regular practice. While at CHUK this morning, the residents told us that SAMU was no longer performing reductions on extremities with intact pulses. The residents asked for clarification so that everyone would be on the same page. The change in practice was apparent to the hospital staff.
Sitting back and watching these instructors teach was quite inspiring. Just a few days ago, they too were uncertain and had only a fragile confidence. The preparation they invested over the weekend was obvious. Switching between three languages to ensure they are meeting the needs of all students, they delivered the content with enthusiasm and grace.
It’s a good thing these new instructors are strong, because I can barely follow what they are saying in French or Kinyarwanda. Every few sentences I recognize words or phrases like “stay and play” or “scoop and run.” It’s amusing to discover that some of these expressions are universal no matter where you practice EMS.
One thing I’ve been asking myself is “how important is creating a culture of EMS?” What does a star of life patch signify? How do awards and recognition of heroic calls help motivate providers? In a line of duty death, the traditional funeral exercise that follows…
Are these traditions specific to EMS in the US, or are they something universally necessary to growing and sustaining a productive EMS system? Would SAMU of Rwanda benefit from connecting with other International EMS agencies? How can we help SAMU grow without imposing too many of our own values that may not be what’s right for SAMU. It will be interesting to watch the SAMU staff grow and develop over the next few years. I’ve seen them grow so much just this short week.
The very first class of course organizers and instructors
I had a patient last week brought into the Pediatric ED for an allergic reaction. The child had known allergies, and by the EMR, had been prescribed an EpiPen by the Pediatrician – but mom said she didn’t have one at home to use. “We have insurance, but when I tried to fill the prescription, they wanted $620! I just can’t afford that,” she apologetically told me. I sat there in disbelief, assuming she had crappy insurance.
Flash forward three days later when the news hits the mainstream media:
AEMTs and Paramedics, better check that drug box twice for your 1:1000 epi vials because you’ll be using them more often for anaphylaxis as parents and patients increasingly forgo the EpiPen. With a $400-$650 price tag (with insurance), and a 1 year expiration date, can you blame them? I certainly don’t. So brush up on your local protocols, and stay vigilant. For a good review on anaphylaxis, check out this post.
Emergency Department (ED) Implications
As with prehospital providers, we too need to be ready with the IM epinephrine. It’s always been recommended after EpiPen administration for patients to come to the ED to be observed for 4-6 hours in case they need a redose of epinephrine. As patients increasingly skip that first dose, we should expect more potential for respiratory distress and need for difficult airway management.
EpiPen Alternative
Thanks to the Facebook Group EM Docs, I learned of AdrenaClick, a reasonable alternative we can prescribe for patients with severe allergies. The mechanism of delivery is slightly different than the EpiPen (two caps to remove instead of one), but given that it’s 1/4 the cost – it’s what I’ll be prescribing moving forward. AdrenaClick has a good training video on their website with detailed instructions for use. With a coupon from GoodRx, AdrenaClick is available for as low as $141.67 at Wal-Mart. It’s still more than the original $57 cost of an EpiPen when acquired by Mylan, but better than current EpiPen prices.
If you want to learn more about the skyrocketing prices of the EpiPen and the not-so-coincidental tie to congressional mandates requiring EpiPens (like AEDs) in schools, check out this article on Bloomberg.
<Disclaimer> And, of course, I do not endorse the efficacy of, nor am I paid by AdrenaClick. They just happen to be the only other comparable epi auto-injector on the market right now. <Disclaimer />
In April, 2016, Richmond became the first city in Virginia to partner with the CPR crowdsourcing app PulsePoint, bringing their technology to our city. Across the US the incidence of sudden cardiac arrest is over 300,000/year, and survival rates are generally less than 10%. Early CPR and defibrillation can triple that number. Other municipalities have had success with the technology, with early data showing it to be an effective way to get a bystander’s hands on the chest prior to the arrival of EMS units.
While neither Steph nor I have been alerted by the app yet, one of our interns has had it go off not once but twice in just three months. I spent a while picking his brain about it last night so we could share his experience.
Amir: Ok Mike, you were telling me a couple of weeks ago that your PulsePoint actually went off. Could you just explain to anyone who maybe hasn’t heard of PulsePoint exactly what it is and why you have it?
Mike: Sure, PulsePoint is an app that’s tied with the local EMS dispatch. Whenever there’s someone nearby who needs CPR, people with the app get a notification and can respond to help. Essentially trying to do for CPR what tinder has done for online dating.
Amir: Perfect. Except preferable not to wait for the other person to swipe right as they have only moments to live. Got it. So it’s on your phone, just monitoring the EMS dispatch, waiting for some unsuspecting person to drop – and that’s where your story starts. Lay it on me and the rest of the English speaking world.
Mike: When the alert went off I was enjoying my day off watching Game of Thrones. I had received one alert previously that I didn’t respond to (that one was while I was in the hospital), so I recognized the alert. It was a nearby address, and “CPR Needed,” no other information. I threw a shirt on (always don appropriate PPE first) and ran out the door. When I got there, I identified myself as a doctor (liability much?) and was let in. The victim in question didn’t actually require CPR; I did a jaw thrust to keep the airway open, and literally 45 seconds later an EMS crew made their way in. And from there, EMS basically was running the show.
Amir: Ok so most importantly, have you seen this season’s finale? It was amazing.
Mike: I can’t believe they killed off [insert character you’ve only just finally felt an emotional connection to]. So unexpected.
Amir: Speaking of killing off, back to this maybe-dying person. How did you even know where to go?
Mike: Pulse Point has a pretty clean interface. When the alert came up it has a Google Maps type street grid.
Amir: How far away was the spot?
Mike: Just a block or so, looking into it the app will typically alert a provider within 1/4 of a mile, depending on the agency.
Amir: So pants on, shirt on, out the door – leisurely stroll down the block? Or were you hoofing it?
Mike: I think I had a decent clip going. Not a full on sprint.
Amir: You live about 1/4 mile from us. If that app ever puts a pin on our house I expect you to transform into Usain Bolt.
But ok so you’re keeping it cool, it’s their emergency not yours after all, and you show up. What kind of place? Apartment? House?
Mike: House; one I had biked past many times around the neighborhood.
Amir: What’s the etiquette here? Politely knock on the door or charge in like Superman? I imagine the latter comes with the risk of being, you know, shot to death. But for all you know it’s an innocent baby dying in there, and you’re literally the only person who can save her, right?
Mike: Yeah, the thought crossed my mind. There’s definitely a can of worms to be opened here: how do Good Samaritan laws apply to physicians, was the correct address sent through the app, the list probably goes on. But I knocked and was let in, so cross at least one of those concerns off the list.
Amir: Did they ask who you were or how you knew what was going on or what you were doing there? I mean no uniform, badge – you’re Joe Schmo for all they know.
Mike: It was pretty hectic and everybody just seemed to accept that I was there to help. No other questions asked.
Amir: What did you find in there?
Mike: Respiratory distress, cause unknown. As somebody who doesn’t have a background in EMS, approaching this in the field is definitely a different thought process than undifferentiated respiratory distress rolling into the ED. Differential diagnosis isn’t too important when your treatment options are limited to what you bring with you, which in this case was nothing.
Amir: Great point. Something more docs should keep in mind when EMS rolls in with a hot mess. So not breathing, could be overdose but could also be massive head bleed, who knows? You don’t even have gloves. So you jaw thrust, trying to avoid any and all fluid leakage, and just hope the cavalry arrives soon. You weren’t up for mouth to mouth?
Mike: In retrospect, I did have my Red Cross pocket mask in the depths of my closet. Now it’s been moved to the shelf in my kitchen.
Amir: That’s a great tip. If you’re going to use this app and respond to god-knows what, be as prepared as possible. Maybe a little kit for the car and home with some basic stuff – gloves and a barrier mask.
Mike: But that does lead into another thing I’ve been considering about PulsePoint. The cavalry in this case was less than a minute away. From their website, PulsePoint costs over $10,000 to implement, and another $10k to $28k a year to maintain. So the agencies most likely to be able to afford an extra service like PulsePoint are also the agencies that are well funded, and most likely to have an EMS crew right around the corner.
Amir: Ah so you think maybe we need to see some pre/post implementation outcome data. I’d say if that guy had been in cardiac arrest though, those 45 seconds could make a significant difference.
Mike: Oh sure, it’s definitely a good idea. Especially considering that you don’t need to be a doctor to get the app. Anybody who’s BLS certified or better can join up. And unless there are some hidden costs involved, it’s still less expensive than a lot of the other “bells and whistles” that EMS agencies can add to their toolkit.
Amir: {{*cough* ACLS drugs *cough*}} Any other tips for potential heroes out there?
Mike: Just the usual things that I’m sure are second nature to EMS providers. Expect the unexpected, prepare for as much as you can, and the number one rule, first do no harm to yourself. “Survey the scene, don’t expose yourself to harm” doesn’t get drilled into us a ton as docs, but there’s a reason it’s the first step in BLS training.
Amir: Perfect. So to sum up:
Get Dressed.
Don’t show up empty handed.
Watch your back. And your front.
Have a good lawyer, just incase.
Mike: Couldn’t put it better myself.
Amir: I love it. Thanks for sharing the story. I can’t believe it’s gone off not once but TWICE for you. I’ll let you have the last word to your now adoring public.
Mike: Flarhgunnstow.
I had to look up that last word. Apparently it’s this:
If you know CPR and are willing to help someone whose life depends on it, go to PulsePoint.org and see if your city has partnered. If you don’t know CPR yet, the American Heart Association website can help you find a CPR course.
~Amir
Michael Billet, MD is now a PGY-2 in Emergency Medicine at VCU Medical Center in Richmond, VA. He attended the University of Virginia for both his undergraduate and medical school training. He likes long walks on the beach, Settlers of Catan, and is definitely the guy you want on your trivia team.
Yesterday I attended the 17th Annual Rao R. Ivatury Trauma Symposium hosted by VCU Health. I took away multiple “nuggets” to incorporate into both my prehospital and ED practice. The conference is geared towards anyone taking care of trauma patients – not just doctors but nurses, social workers, nutritionists, therapists and EMS providers, too. I highly recommend checking it out next year. Save the date: Wednesday, March 29, 2017.
Always a leader in EMS advancement, members of the Richmond Ambulance Authority (RAA) presented a poster on delivering “Good Medicine in Bad Places.” To the credit of RAA, they have developed a council with their partners in Police and Fire, to address regional response needs to unique and dangerous situations (i.e. active shooters, bombers, terrorist attacks). The data they presented is accurate – the number of incidents is rising, and the fatalities climbing.
Tactical Combat Casualty Care (TCCC) is specialized training that originated in the military. TCCC is currently being tested and studied in the civilian public safety setting. The TCCC conversation is an important one. Specialized training for these situations is an unfortunate necessity in the United States. A little background info on how these things are currently handled – most cities have specialized SWAT Medic teams comprised of talented, elite individuals adept at not only the delivery of prehospital medicine, but also in things like shooting, hand to hand combat and law enforcement. These providers are a special breed – in most cases considered the best of the best in their public safety organizations. I’ve been hearing the rumble and chatter over the last year, and it was again echoed by RAA yesterday. There is current shift in conversation towards training 100% of EMS providers to enter the warm and hot zones, to render care to patients while under fire.
It’s well known and proven that the current model of Fire/EMS waiting to enter scenes causes treatment delays that increase patient morbidity and mortality. In the December 2015 issue of the Journal of Emergency Medicine, Peter Pons of the Hartford Consensus commented that “fire/rescue and EMS personnel must work with law enforcement agencies to enter these scenes earlier than has been traditionally performed, intervene promptly to stop ongoing external hemorrhage, and incorporate basic concepts of tactical combat casualty care/tactical emergency casualty care into their education, training, and practice.” I don’t disagree with that, but I’m not sure it makes sense for us to immediately assume ALL Fire and EMS personnel should be entering scenes with active shooters – as if it’s simply one more bullet point we can just tack onto the job description.
If you think about our existing public safety system, some firefighters enjoy both patient care and fighting fire, while others if given the choice, would only ever fight fire. Similarly, some Fire and EMS providers might be part cop/soldier at heart – both capable and interested in taking on TCCC. I can assure you that not everyone on an ambulance has that police/soldier side that wants to run into an active shooter scene. Yes, EMS is a dangerous job; I’ve been punched and had a knife drawn on me in the back of the ambulance (no one tell my Mom please). Of course you can never predict what may happen and need to be ready for anything. That’s not what I am talking about in this instance. What I’m saying is that if a call goes out for an active shooter, it might not be wise to require 100% of the Fire and EMS personnel to be able to enter that active scene. Here are just a few reasons I think that could be a bad idea.
Figure 1: Crossover of skills/interests in various professional fields
Negative Effects on Recruitment
As I mentioned, not all EMS providers want to take on the police/military type role of being armed with a weapon, entering dangerous scenes and providing care under fire. I don’t know how big of a chunk of people that is, as it hasn’t been surveyed yet to my knowledge. I can say personally, having been in a building with an active shooter, I have zero interest in doing so again, even with the most state of the art training. How many of the 840,000 certified EMS in the US might we lose if that bullet point gets added to the job description? Additionally, 22% of those 840,000 certified EMS personnel are volunteers. Some volunteers might want to play a part in TCCC, but if you have a family and derive no paycheck or medical benefits from your volunteer EMS gig, can you really afford to enter that scene? And what will become of all the career providers who want to do patient care, but don’t want to risk their lives. Perhaps we will we see them shift into the hospital in ED Tech, CNA and RN roles.
Distraction Away from the Medicine
Even right now, EMS education has two large components: 1) the medicine, taking vital signs, deciding what drugs to give and when and 2) operational aspects, entering a scene safely, driving an emergency vehicle, operating a portable radio, etc. As an ED Physician, I admit my bias towards the importance of #1. We’ve all had the trainee who wants to drive lights and sirens before he’s mastered taking a blood pressure. With only ~160 hours of instruction in the current NREMT course, I worry that adding the required training for TCCC will shift focus away from the medicine and negatively impact patient care, potentially leading to more morbidity and mortality across all patients, improving outcomes for those victims requiring TCCC, but leading to a net decline in overall care. Perhaps the solution will be increasing the course length. I’m not saying it can’t be done; I just hope someone studies and considers that before implementing blanket curriculum changes.
Are EMS Providers Physically Fit Enough?
Sadly, three quarters of active emergency responders in the US are overweight or obese, and 75% have been diagnosed as hypertensive or prehypertensive. All in all, we are not a healthy bunch when compared to our counterparts in Police, Fire and the military. How many EMS providers will meet the physical demands required for TCCC? Even if people want to take part in TCCC, will they meet the physical requirements to do it safely, or perhaps be pushed out of a job they love, despite providing excellent medical care.
Would it actually improve care?
To justify the risk associated with TCCC, you must be able to prove that more lives would be saved than lost, and not just during active TCCC situations, but across prehospital care as a whole. It just hasn’t been studied yet. Perhaps once studied, it will prove to be net beneficial, but right now we just don’t know.
So those are my thoughts; I’m curious to hear yours.
On July 4, 2013, Dr. Paul Aravich joined TeamLouka on the ambulance as an observer. He was asked to jot down a few thoughts on his experience. His essay is shared below.
~Steph
Reflections of a Virginia Beach Volunteer Rescue Squad Lay Observer, July 4, 2013.
Paul F. Aravich, PhD Stephanie Krebs and Amir Louka are two VBVRS volunteers and EVMS medical students who are “social change agents and leaders for the greater good of the community.” They invited me to run with them at Station 8 on Independence Day, 2013. I saw 2 other EVMS students that day who I also admire: an exceptional paramedic who is a new medical student, and a Navy veteran and physician assistant student who is as gentle as he is tall. I witnessed great respect between VBVRS, fire department and ED personnel in almost every instance. And I saw cutting-edge wireless technology and state-of-the-art equipment—although I am still not sure if it the ambulance is a box or a truck.
At the station I hung-out with a volunteer from York County who served at the World Trade Centers and Katrina, a new EVMS graduate student, a senior volunteer who is a builder of persons as well as of homes and barbecues, a critical care nurse from Chesapeake, and an accountant. We talked about abandoned older persons, defensive medicine, how to read an ECG, challenging behaviors, not getting T-boned at intersections, altruism, family, political turmoil in Egypt, and who catches a baseball better, the bulked-up waiter at IHOP or a nerd like me who, like Winnie the Pooh, is actually a “bear of little brain.” We also wondered if we heard the dispatcher correctly that a person got stabbed in the cheek with a fork. At one point Stephanie bravely gave me her humerus (which is pretty funny) and Amir gave me his stethoscope and cuff so I could learn the proper way to take a blood pressure. Thankfully, Stephanie’s paresthesia lasted only a few minutes. At the nearby Oceania Fire Station we laughed with an Army veteran who has seen more than his fair share of tragedies, discussed the merits of Cheryl Crow as a History Channel commentator, and had a surprising conversation about the nutritional problems of hot dogs that made me worry that firefighters may someday eschew donuts. I saw camaraderie being built during the down times as well as during the calls. And, I talked with a squad member and former court official about the ones that were saved, the ones that got away, and an aging parent with dementia. I was reminded that all of us have to hold on to our victories, let go of our defeats, and understand that we’re in this together.
Dr. Aravich & us outside Sentara Virginia Beach General Hospital
Throughout the day I was humbled and inspired by consistent displays of commitment and professionalism, humanism and compassion, and collegiality and mutual support. I saw a successfully aged person with a rare and serious injury that causes significant pain in others but did not in her and wondered if it would steal her independence. I saw an isolated older woman and cancer survivor with depression and abdominal pain and hoped that her GI cancer was not coming back. I saw a frightened young mother fighting addiction and hoped that today will be the first day of the rest of her life. I saw an injured skateboarder who should have known about helmets. I saw a scared older person with breathlessness and fatigue and a family history of heart attack who should not have been cutting grass in the middle of a hot day. I saw the basic life support team immediately recognized the severity of this situation and calmly and effectively take precautions before the paramedic arrived. I saw the paramedic take an ECG in the truck and learned later that it showed the more severe type of heart attack called a STEMI (ST Elevation Myocardial Infarction). I saw the paramedic taking care of this person inside the moving and turning ambulance by, e.g., drawing blood, giving nitroglycerine, sending ECG telemetry to the ED, and offering words of encouragement. Finally, on the 4th of July I saw a crying spouse, caring neighbors, and engaged citizens volunteering to help others when almost everyone else was relaxing.
If, in the Jeffersonian tradition, the pursuit of happiness importantly involves pursuing the greater good, then the VBVRS is full of happy people. And, if people are not distinguished by doing what they have to do but are distinguished by doing what they don’t have to do, the VBVRS is full of very distinguished people. Thank you Stephanie, Amir and the VBVRS for allowing me to see the important volunteer work you do without charging patients. Lives do indeed need saving, both physically and emotionally. All of you saved lives today. Is there any greater compliment? Meantime, a few words about hot dogs: it is OK to bad-mouth hotdogs—but not on the 4th of July.
Dr. Paul Aravich is a behavioral neuroscientist and Professor of Pathology & Anatomy, Internal Medicine, and Physical Medicine and Rehabilitation at Eastern Virginia Medical School (EVMS). He is the former of the Virginia Brain Injury Council and its Ad Hoc Neurobehavioral Committee. He also chaired the Virginia Governor’s Public Guardian & Conservator Advisory Board and sits on the Boards of the Mary Buckley Foundation for brain injury survivors & their families; the I Need a Lighthouse Foundation for suicide awareness; and Alternatives, a nationally recognized youth empowerment organization. He won an AOA Glaser Distinguished Teacher Award. It is the highest award for medical education in the United States and Canada and is presented at the annual meeting of the Association of American Medical Colleges. He also won a Virginia State Council of Higher Education Outstanding Faculty Award, which is Virginia’s highest award for research, teaching and service.
Stephanie Krebs and Amir Louka are two 
TeamLouka 