An Increase in Survival with Dr. Peter Antevy

Sa.

Welcome one and all to another recording of the EMS pod with Chief Randall. Today is another exciting day because I get to talk to one of my friends from the East Coast.

Some people know him as Dr. Antebbie, some people know of Hand TV, but I know him as a friend. Dr. Peter and Tavi. Hello, Doc. How are you?

He's great to be here with you.

Good. It's a pleasure and I appreciate your time. I know you're a busy, a busy man, you making things happen. And I would just want to get into some of those things. But first, could you just give us a little bit about your background so people kind of know who you are and where you come from.

All right. Thanks, Chief. So a little bit about my background. I'm born and raised in South Florida. I left to Los Angeles and I did my pediatric residency there. And then I knew I wanted to go into emergency medicine. So I then went to Pittsburgh, did pediatric emergency medicine at both of those places. I ended up doing a lot of ems, mainly I flew a lot. So we, you know, in la, we flew around the city, pick up kids. In Pittsburgh, we flew around the state to pick up kids. In Pittsburgh. We also did a lot of ground ambulance. I love the trauma bay, adult and kids. So I kind of found myself slowly gravitating toward the pre hospital setting. Moved back to Florida in 2005, working at a tertiary, you know, level one trauma center for kids, Joe DiMaggio. And then I again found myself going out and teaching. There's a whole bunch of different fire departments here in South Florida. And I recognized that there was some work to do. So just in my free time, I would just go out there and start teaching. And in 2009, at the end of 2009, one of the EMS chiefs who knew me, she said, you ought to apply because our medical director job is open. And I said, I said, I'm a pediatric person, no adult experience. And she said, you should apply. Anyway, long story short, I got the job and my life forever was changed. And I recognized right there that first year that the people were nicer. It was a family type of atmosphere. People cared about you. When bad things happened.

They came to your side. And it's just really fascinating to see that I knew that's where I belong, at least kind of emotionally. I felt that way. And then maybe to my surprise, I recognized that if you have a really high functioning EMS system, then that's where the lives are saved. So I didn't know that. And here I was, I was in medicine For a long time now. I see it today. I see all these ER doctors who just see when those double doors of the ER open and another crew walks in, they're just pissed, right? It's just more work for them. They don't recognize the capabilities of what could be done in the field. And that's why, with what we'll talk about here in a few minutes, there's so many opportunities that have been untouched for so many years in ems, because the academics, the people who write the textbook, have had EMS in their blind spot for so long. Now it's a subspecialty, meaning that I'm board certified now in ems. All the EMS physicians now are board certified in this new subspecialty. And now it's getting the recognition that it deserves. And now we're trying to bring the entire profession up so that the federal government on down starts to recognize how essential EMS is.

Yeah, I know that. I would tell people that. They say, well, you're one of those EMT people. I said, no, I'm not an EMT people. First of all, I'm a single. Right? But.

But we are clinicians and not technicians. And with that said, you are doing things on the east coast, specifically in Florida, that.

Some would say would be groundbreaking. It could swell from the east coast to the. To the west side. So what are some of those things that you're trying to do over there to get done?

Yeah, thanks, Chief. There are a lot of people around this country who are doing great things.

And I think that my goal had been to figure out what those things are and then try to make them very apparent to the rest of the world. You know, what I realized is that there could be someone doing some great stuff somewhere in a little pocket somewhere. But for that greatness to then be spread across the United States and around the world, it takes about a decade. So how do we shorten up the time in which, you know, something works? The research is being done along the way, which I think is an important part of it. And sometimes that research and the product or the procedure that you're trying to figure out is not fully matured yet. So when it comes out of the gate, it's a little rocky, and then you change it a little bit, and then finally you get to the point where the research ends up showing that it does, in fact, work. So the first one, what I wanted to mention was full blood. For anyone listening to this podcast, they have seen, I guarantee they have seen trauma victims die in front of their eyes. We've all seen it. And it's the most horrifying thing that you can witness when all you have is saline and you bring these people into the emergency department to the trauma bay, and they had no chance. The military has been for decades using whole blood. Actually, the first use of whole blood, Doug, was in the early 1900s. And then someone figured out that if you take the whole blood from that person who gives it, you know, they get their two movie tickets and then that blood is taken to the processing center where it's split up into three different parts, right? The red cell, the plasma on the platelet. It sold for a lot more money than that initial one bag. Right. It also can stick around for a little longer, too. Some of them can, and therefore it's a better business model. So they've swung completely over to component therapy. But the military said, no, no, we can't do any of that. We're still using whole blood. They even do something called a walking blood bank, where if they're about to go into, you know, let's say into a new front, they'll have a whole bunch of the. Of the military folks who are known to be low tight or O positive, hold out their arm. They get 20, 30, 40, 50 units. That goes pushed into the front lines. Those bags are not good for days. And now they actually have threshold blood on the front line. So that's been, that's been done for a long time. Finally, the folks in San Antonio, people like Don Jenkins, John holcomb, and then C.J. winkman in San Antonio said, hey, let's bring it to civilian folks. And now we're going through 2018. Listen, how long we're talking about. There's been EMS systems out there using whole blood successfully in EMS. San Antonio's already given over 2,000 units. So we just ripped off and duplicated what they did here in Broward County. That's that. Jim Roach and Clark, Broward Sheriff, they did it first. We then took it and did it in Palm beach county, and then we started marketing it, meaning we just started telling the world, because we saw our initial outcomes and we said, this is insane. So we then started putting all of our data into a registry. So New Orleans is in the registry. South Florida is in the registry. People in Virginia are in the registry. Now we have hundreds and hundreds of cases all going into an academic facility in Tulane. And now all the data shows that if you get the blood before you go into cardiac arrest, right? Like, in other words, if we get there, the person's already in arrest, we have a zero percent survival. So the blood doesn't work. But if they get the blood before they go into cardiac arrest, they're periorette or they're just hypotensive tachycardia. We have some criteria that we get, we get, then we have about a 90% survival, if you think about that. And the latest paper that was published from this data set shows that for every minute that you save by giving the blood sooner, that's 11% increase in survival. So it's effectively the same as an AED. For every minute earlier you give it, you save 10%.

I don't know about you, but there's nothing in my lifetime or your lifetime that we'll ever see in a civilian population that will lead to this type of outcome in trauma, period or heart stop. And that's why I think everyone's gonna ultimately, if they can carry it, even if you're out in the middle of nowhere, rural. So the way that you do that is the hospital carries the whole blood. They, they get it from their sources and their source could be the nurses and doctors who are in the community, or the EMS folks, firefighters. So they have their little stash of whole blood, EMS comes into the drive through, they open up their cooler, pop it in, and now that blood is good for two weeks, right? And after two weeks, if they don't use it, no problem, you go back to that same hospital who's using the blood in the ICU and the trauma bay, whatever, you give it back to them, and now they have a week to use that blood. So the startup costs are probably around 10 to 12,000 bucks. And if the blood is free and the hospital can give you the equipment, the consumables for the warmer and for the lifeblood, which is the rapid infuser, then technically speaking, or if CMS pays for this, technically speaking, whole blood should have zero cost to ems and it could be accessible not just to Peter Antevi in the middle of the, you know, big urban area where we have a lot of money to spend, but also in the middle of nowhere where you have a, you know, a hospital out there that's just the closest place to that where that trauma is occurring.

Wow. So you're broken down the process, right? And when people listen to this, they've already heard that this is how it can be done. But what I'm curious about is this registry. So there are EMS chiefs across the country and medical directors that will hear this and they want to know, so how do we Connect this registry. How do we get the data? How do we.

Find out that what you're saying is something that I can make tangible?

That's a great question. There's two things that we're doing. Number one is we created a four hour academy that we're now converting to completely online called the Spark Academy.

It's basically selective pre hospital advanced resuscitative care. Spark. This is the brainchild of a small committee of us led by Dr. Juan Duchesne. He is not just a practicing trauma surgeon in New Orleans, he, but he's also a big academic researcher, big publisher. When he saw what was going on in New Orleans, he said, we have to start a registry. We then said, we want to send you all of our data so that we don't have to do any of the publication. And we figured out an easier way even for ems. As you know, I have a big research team and we have the way of researching, but not many people have that. So what we said was when EMS gets the patient and they go to the trauma center, the trauma center has to participate in a registry. It's by law.

So we just added the questions that we needed answered. You know, the vital sign shock index, all of the EMS data to be added into that registry. So once that trauma person is typing into the registry all of the data, then that information just gets sent right over to Dr. Du Chesne in Tulane. And so from an EMS perspective, all you have to do is convince the trauma hospital.

It's not too hard to convince because they're all academic people. You say you sign this form, this agreement form, it's probably like a BAA just to make sure that everything's HIPAA compliant. And then you just send your data from your trauma registry into their red Cap database. It's basically just the computers talking to each other. From an EMS perspective, you have done nothing because all the data being collected from EMS in the hospital is being done by the hospital trauma registrar. And then sending it to the registry.

We have a number of agencies now already signed up, agencies in their hospital already signed up. I predict that in the coming years, we're going to end up having thousands and thousands of patients coming through that registry. And it will be no secret as to what the answer is. Meaning how fast you need to get the blood on. I think it's within 15, 20 minutes of the incident. This whole golden hour thing, throw that out. You throw it in the window. Out the window. It's not true. You have to get the blood on within 15 to 20 minutes for the life to be saved. And for the people who are listening saying, well, I live right next to the trauma center, that doesn't work either. Why New Orleans is an eight minute ride to the trauma center. But they calculated that from the moment they arrived at the trauma center, if the patient didn't get blood yet, it took another, I think 16 to 20 minutes for the trauma center to get their act together, to get the band on, open up the whole blood refrigerator, to scan it, to get the infuser on, all that kind of stuff took a long time. And they have proven and they just published the paper that even if you're minutes away from the trauma center, EMS is where the blood needs to be delivered. That's a very powerful statement. And if you read we just published an article in Gems, myself and Bryony.

Gilby, who basically she and I wrote this article talking about why the pre hospital system needs to be the one carrying the blood, not the trauma center.

Wow.

I mean this is going to shake some stuff up, right?

It's going to piss some people off. Steve, I'll tell you that the trauma surgeons are, were very upset with us when we started this thing. Now they're all on board. But if you're sitting there in a place where either the state doesn't allow it, there's only a few states left, or I think the rest will come on board, there's a very good likelihood the trauma surgeon is not going to like this idea either. So we're now making presentations around the country. We have the American association of Blood Banks now on board with EMS blood delivery. And there is a bill that's actually going through Congress right now. That's one of the asks is for blood to be paid for. So if the hospital can't just give it to you, the EMS system will have a CPT code. And you could say like for example, blood costs anywhere from about 475 bucks and some people are paying up to 650 per unit, depending who your supplier is. Well, that's way too much. Right? I know that where you are, I'm sure that.

You'Re not collecting those kinds of funds. We only bill $800 per transport and we only collect about 400 the blood. If you add up the blood and all the consumables, it's about a thousand bucks a patient. And so for right now we're eating the cost. But that cost should not be eaten. It cannot be eaten up by EMS systems. Someone else got to pay for it.

Okay, very Good. Yeah. This is exciting. I know people that are listening are going to dig in for more information on this topic and find out those places like they are, like you have in New Orleans and in Florida, Broward county area that are doing it. So.

God speed to those people getting this done. So fantastic.

I'll send you, if you want, I'll send you a link. We created a YouTube channel. It's the Florida NAEMSP, which is a national association of EMS physicians. So I'm the Florida chapter president. We created a YouTube channel and one of the playlists is called Florida Whole Blood Coalition. It's got videos that pretty much explain everything, the why, the how. And then I'm happy to send people a Dropbox of all the SOGs, all the protocols. If someone's listening out here, they don't have to create anything. We'll just give it to you. And then we're working with Prodigy EMS to then put on this entire four hour course so people from their own office can actually go. And we're going to go through every single step of how to set up a blood program from soup to nut so that someone can actually go out and figure it out. So we don't want people to have to go and reinvent the wheel.

Fantastic. Thanks for the info. I'm looking forward to watching those, watching for those links.

One more topic I want to get into with you before you have to continue your busy day is a little word known as sepsis. What are you doing with that?

Yeah, so sepsis is the, is one of the leading killers in, in the United States people focus on cardiac arrest and they focus on all this other stroke and trauma. But if you look at sepsis, there's a lot more people dying from sepsis than all of those other things. And the reason is, is because you can be young and have sepsis, you can have a middle aged and have sepsis and you can be older and have sepsis. And if you become septic and you have an episode of hypotension, period, septic shock, your mortality in the United States today, 20, 24, is 40%. Whoa, just think about that. 40% of people who receptive shock die. And.

For a long time it was the federal government focused in on the hospital. And they said right, when you get to the hospital you need fluids and you need antibiotics and pressers. Okay, think fluids, pressers, antibiotics. Why can't we give those?

There's not one mention of EMS or the pre hospital setting in any of those documents. Right? And you have all These foundations and everything, and they give the hospital 60 minutes. Think about that. They give antibiotics. So we said, do that. We're going to go ahead and we're going to give the fluids, we're going to give the antibiotics, we're going to give the pressure. And they got so upset with us. You're not doing blood cultures. And we said, listen, when. When 40% of these people are dead anyway, we bring them to you and you send them Back to room 85 in the back, and there's no one there to address it. And the antibiotics don't get on for a whole nother hour because you have an hour. We're not going to tolerate that. That's the first point. The second big point is that.

About a decade ago, there was a paper that was published in the New England Journal that was done in Africa saying that children. Well, at least this what they say, the children in shock, if they got fluid, they did worse. It was a study that did not look at that at all, but it confused a lot of people, and therefore a lot of people started saying maybe for sepsis and septic shock, we shouldn't give fluids at all or we should restrict them. It was called the Feast trial. What they didn't tell people is that that study was done on children with malaria and dengue. Both of those basically make you severely anemic. So your hemoglobin was like 3 when it should be 13, 14. So think about it. If you give someone with a severe anemia a lot of fluid, they die because you're diluting them even more.

So even though it was not a sepsis study, it should have been called a malaria study. A lot of people in the United States in EMS stop giving fluid. We said, you have it all wrong. Once we got the lifeload device, that infuser device for the blood, at one of my agencies about a year ago, we said, let's start giving the full 30 cc's per kilo to the adult. So a 50 kilo patient times 30, that's a liter and a half. We said, if a patient's in septic shock, let's give them at least a liter, and we'll try to give them up to a liter and a half.

So we just presented our data on a recent webinar, and we have a mortality in that patient population of about 6 to 8%, not 40%.

And all we did was get the fluids done in EMS early. Then in my other agency, we decided to do not just fluids, but antibiotics, Rostephin and Gentamicin in the field. Our data that we're looking at now looks like we can get the antibiotic in within 12 minutes of.

The 911 call.

And we have pressors, and we use epinephrine, we use push presser, epi. So in the field, whether we're across the street from the emergency department or whether we're 30 minutes away from the emergency department, we are now giving a lot of fluids. Antibiotic, we're giving pressors. Of course, we can manage the airway if we have to, and we have dsi, so we can manage the airway. What we don't have is we don't have the blood culture, but we don't need it because at the end of the day, those people are going to die anyway. We don't have a lactate level, but who cares? These patients are altered, they're tachycardic, they're hypotensive. It doesn't take a rocket scientist to figure out that they're septic. So we are doing everything that the hospital can do, and we're doing it in ems. And now we're going to be publishing our data, hopefully within the next six months, and we're going to start to prove to the world once again that EMS is where lives are saved. And it's not waiting until you get to the hospital to then have some random nurse. At least you have to get her attention. Hey, patient septic. I just called a septic alert in. And then until the things get done, you're just wasting precious time.

And then along the same lines, just because I want to mention it, because this is something very important to me, too, and we just submitted our manuscript, is the IO placement for cardiac arrest. A lot of people and kids use the proximal tibia. We have completely gone away from that in cardiac arrest. And we now go into the distal femur, and we have an 89% success rate in the distal femur. And it's better than we've seen in the proximal tibia. That's number one in Texas. They have switched to the distal femur for adults, because if you go to the proximal humerus, which has good flow rate and it's a good place, but the arms are very mobile. And people, if you're on a Lucas and your arms are up on the Lucas, and then you take the person off the Lucas and their arms flat backwards, that needle bends and pops right out. The distal femur is a great place, but for the adult, you need a longer Needle. Well, the Teleflex folks understood what we were doing and now they're coming out with a 65 millimeter needle. Remember, the yellow needle currently is a 45. This is another 20 millimeters longer. It's like a harpoon. Basically it's green and basically it'll allow you to get into the distal femur for any size adult, whether you live in Texas or California. So my prediction is that once people do the femur, the distal femur IO one time, they'll never go back. And I predict in the coming years you'll see many, many more people doing the distal femur IO for kids and for adult.

I think it's, it's a pretty big thing that that's coming our way. And again that, that paper, we plan on publishing it in a couple of.

It'S already been submitted, but hopefully other people around the country, many have already started to do it. We hope many more continue to do so.

Whoa.

The big harpoon. Neither. I can't wait to see that.

I, I, you know what? I heard it's going to be out in, by the end of the year, maybe October. So look out for that and get rid of the pink needle. You don't need them anymore because if you're, if you're resuscitating an infant, just take the blue needle. And just as a pro tip, if it's an infant, the easy IO needle has a cutting edge to it. You can just take your finger and you can spin it in manually.

Because it'll just kind of gently puncture through that bone. If you use the drill on an infant, you're likely to go all the way through the bone. So in the little tiny kids, just use your hand and spin that needle right into the distal femur. No matter if they just were born or if they're, if they're an older person, the distal femur IO is good for everybody.

Wow, that's some old jam shitty stuff you're talking about for these old.

Not sure some of the younger kids know what a James PD is the guest.

Go look it up. I'm not telling you.

Wow. Wow. So, I mean, you've given us things that medical directors need to be a part of. Right. When it comes to decision making administrators, when we talk about we're providing great care for our citizenry, then things like blood products and sepsis protocols and EMS need to be looked at then even for the provider when it comes to using these iOS and some of the better locations that you have found to work and your patients so this, this has been a full, and I mean full episode, like a buffet from you doctor and tv. So I really, really appreciate you, your time and the nuggets of knowledge that you gave our listeners.

Thank you. Thank you, Chief. I appreciate it. I love what you're doing and I'll come back anytime you want, my friend. You know that. Keep up the great work and let's, let's make this profession great and let's rise it up to the fact that the federal government, the academics and in the house of medicine start to recognize that we are a significant link in the chain of survival for all these patients, whether it be pediatric trauma, stroke, cardiac arrest. You cannot just simply ignore EMS when it comes to these time critical life saving interventions that we can provide in the field.

Well said. Well, I thank you all for joining another exciting thought provoking and information field episode of the EMS podcast with Chief Randall. We'll be back with you again next month. Thank you.

Sa.