Data-Driven Research: ‘The Way We Are Going to Progress as a Profession'

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Welcome to another episode of EMS World Podcasts Today with me, my friends, who are with me quite a bit, and we enjoy having them on. Dr. Peter and Tevy. Chief Charlie Coyle, Palm Beach County Fire Rescue. Gents, welcome back.

Thanks, Mike. Great to be here.

Hey, Mike, thanks again for having us, my friend.

Absolutely. Guys, wanted to get you back on because, you know, we speak a lot offline, and we were talking a little bit about, you know, data and research with EMS and the importance of the research, not just on the local level, you know, but on state levels, on national levels, and why this matters, what are the impacts of this? So I thought that having both of you on here, you certainly specialize in this. And again, we don't want to lose the listener when we start talking about EMS research and data, thinking it dry. Truthfully, it is the next wave. It really is the way that we're going to progress this profession. So, Peter, why don't you hop on a little bit and, you know, kind of give us a brief on where the CMS research came from, the premise of it, and why it is so important.

Absolutely. Mike, you hit it right on the head. I think that we are now surrounded by data, right? Everything we do, every time we go to a call and we're typing into that EPCR report, that data is going somewhere. Back in the day, it was on paper, and it would be impossible to actually know what happened, not only to that one patient, but how is your agency doing on the aggregate, on the whole? We have so many opportunities now to actually say, this is how we are doing, whether it be stroke, trauma, cardiac arrest, pediatrics.

With respect to the research side of the house, all we're doing is taking our data and looking at our outcomes, and we're just telling the world, hey, we made this modification, and we'll talk about some of those today. And then here are the outcomes based on those modifications so that other people could look and say, okay, we have one agency here in South Florida who's putting out this research, and we can do that because we see almost 200,000 patients a year. It's probably less than that, maybe like 160,000 patients. So the amount of patients that we can See, in our one department could really make an impact. And we can get a lot of patients in, let's say, a category of the femoral IO or double sequential. And then we can show the world that here we're a regular agency doing things that are innovative. And then they can say, I'm looking at that data, I believe their data, and I'm going to make the protocol change at my agency too.

Charlie, talk to me about the impact that this has with the crews and the organization. I mean, obviously, you know, when you hear about research and data and tracking jobs and outcomes and things like that, sometimes it's easy for the crews to say, hey, I'm just here to do my job. And whatever happens above that, you know, is not really, you know, part of, of what I'm concerned with. Talk to me about how that really isn't true any longer and how this is a new way of doing our job.

Mike, thank you for that question. That's honestly, that's an excellent question. And the reason why I say that is because the people that are out in the streets that are actually doing the job, you know, me and Dr. Antevi have a great, we have a great job, right? Our job is, I'm actually in my office now looking outside a window and Dr. Antevi is probably in Rome or somewhere, you know, his national excursions. But next week, essentially the, the take home that everyone needs to understand on this, listening to this is the people in the field that are actually doing the job, they have to know the why. So if you make a protocol change but you don't explain the why to them, then essentially it's just, wow, they're making us do this because they think that it's important or they're telling us what to do, but they're not out here doing the job. So that's too much for me to do all of these steps before I do the actual intervention. So at the very beginning of whatever you're going to look at or study, you've got to explain the why to the people and then you have to explain to them how you're going to be measuring that. So, I mean, at the end of the day, when Dr. Intevi and myself look at some of the documentation and start to, you know, sort of figure out what a publication could look like, we really have to understand that the information that we're going to be publishing is only as good as what's put into the system. So if the end user doesn't believe in that, then we're going to have a real problem and ultimately you're not going to have, you're not going to have a good sample size because a lot of the information is not going to be accurate.

I think that that's a great way of saying we need to be very transparent with our providers. You know, listen, making them part of the process is everything like, like you just said, you know, we're not going to get good data if they're, if they don't understand why we're going in this direction. But let, let me play devil's advocate here for a second and you know, step back and say, okay, well, I'm a smaller operation. Right? You know, we don't have that many resources. You know, how, how am I going to be able to, you know, make sure that I capture all of this data, tabulate all this data, you know, and follow up on everything and then even potentially publish it? You know, we just don't have the bandwidth to do that. How do you go about this in a sample size where, okay, you know, we just, we're not that big.

Yeah, well, I can tell you that first of all, anyone can research, anybody can do it. Even if you're an agency that runs, you know, 150 calls per year, you can easily do it. But I think the key is you have to identify what it is, what, you know, what are you trying to achieve in the research. So, you know, I think it's very easy for us to look at papers and say, okay, you know, this is a big, prolific study and it makes total sense to us. Now let's take it and put it to play. Now if you put it to play, you really, you have an obligation to measure it, to make sure that it's working. So I think the first part is understanding what you're studying. And then, you know, as you go to implement the change, you need to be thinking about the research aspect of it before you implement the change. So whether it's by a spreadsheet, whether it's by just, you know, looking at certain reports, you know, for our, for us, our EPCR system based on, basically has all these tags and flags in it. So, you know, if we wanted to look at, we'll, we'll say whole blood administration, anytime whole blood is used, we would be able to get immediate notification of the whole blood usage. Now as soon as we look at that whole blood usage, I already have a backup spreadsheet that's basically we're going to go ahead and pick apart that call and we're going to pull everything that we want out of that. We're trying to look at and measure. We're going to pull it out and we're going to extrapolate it and put it in the spreadsheet. And. And it could go by mechanism, it could go by age, it can go by, you know, basically initial vital signs before blood, initial vital signs after blood. So if you had it all laid out prior to implementing the change, it really makes things easier as, you know, the time goes on. And then you're going to be able to look at all of that and say, wow, that mirrors exactly what the national statistics are, or that mirrors exactly what that publication is that we tried to replicate in our system.

Okay, but are you utilizing one individual? Like, do you have somebody specifically dedicated to looking at, you know, or following these cases?

There has to be, at least in my opinion. And I'll defer to Dr. Antevi because he's obviously done a lot more research than I have. But I will tell you that there has to be one clearinghouse. So basically, you know, for us in our system, at Palm Beach County Fire Rescue, we're a big organization, and I have a lot of EMS supervisors that are out in the streets. So the EMS supervisor will be the first one to look at the information and make sure it's accurate. Then whether it's myself or somebody that's in the medical services team, they will review it for accuracy. Because there has to be a layered approach. You can't just have one person looking at everything. And then ultimately, we've been blessed. Some of the publications that we've worked on or that, you know, we're currently working on now, we have a great group out of Mount Sinai, Dr. Farsi and his group, you know, Dr. Pepe has also been a part of that. They're the ones that are digging in and asking all the really difficult questions. Because when you have somebody from an outside agency looking inwards, they're going to ask a lot more questions because they don't understand your agency. And that's a good thing. That's what you want. The questions are difficult. You really have to get in there and just scrub all. Every piece of information out of the report. But that's what you want, because ultimately what you might find out is what you're doing might not be working for sure.

Now, Peter, we were speaking a little bit, and you said, listen, that information already exists, right? So a lot of people may not know that. We do have national information, right. And research that's available to Us and that's through the CARES path. Right. So maybe speak a little bit about that.

Yeah. So first I'll talk about. There are several data elements that everyone should know about. I would assume most people who are listening today, Mike, are not on paper. And if you're on paper, then this is a whole nother conversation.

But that's a whole nother podcast.

So as far as everybody else is concerned, you know you have ESO image, trend, EMS charts. All those folks are able to give you the data that you're putting into your system on your. For your agency, whether you're seeing a thousand calls or you're seeing 200,000 calls. And you should have a dashboard. So, for example, you ought to be able to go up and say, and start to pull reports today on patients who overdose, on patients who are in cardiac arrest, patients who had a stroke. And usually they'll give you some sort of dashboard if you don't have that right. Most agencies who are in a state where they are participating in cares, and for those who don't know cares, it's a cardiac arrest registry. What is a registry? It just takes every single patient in that state that's had a cardiac arrest and then it actually tries to take that data, send it back to the agency and say, this is how you are doing compared to the agency next to you, the agency in the northern part of you, the agency across the country from you, so you can compare yourself apples to apples. So if you're in a care state today, all you have to do is go to your EMS chief and say, hey, chief, can you print out our CARES data for our agency? And they'll print out your data. And in the next column over, it'll say the state data. And the next column over, it'll say the national data. So you can go for an example just to kind of. Let's peel away cardiac arrest for a minute. There are several survival numbers that everyone should know. Number one is your ROSC rate, which is. That's what we call survival to the emergency department. How many patients do you see in your agency that end up with a pulse after you found them dead? That's number one. And you can see your agency, state numbers, national numbers. Okay, great. How about survival to hospital admission, meaning they left the er, they went to the. They went upstairs to the icu. Great. That's the second type. Then the third one is survival to hospital discharge. Did they leave the hospital alive, yes or no? And you can look at your data comparatively. And then lastly, which is the Number we look at mainly is did they leave the hospital neurologically intact? And Mike, if you ask most people today what is your neuro intact survival for cardiac arrest, they should know that because they're in a care state.

So you have to do nothing as an EMS chief, All you have to do is ask for that report, you get the data and I would use that as a baseline. Right. So if the national number, so for example 2023 is about 8%. So if you saw 100 cardiac arrests, eight of those people would walk out of the hospital nationally. But if you're an agency who's riding at 2, 3%, well, you know, you have a huge problem. And that's where I would start. If you have never done research or collected data before, it's a simple email, get your cares data and start from there.

See, I love that, I love that explanation, right. Because it's very, very easy and I'm talking about the administrators as well to get into this mentality that this is what we do, we just go, you know, we provide the service and then we're on to the next call. But don't you want to know if you're making an impact and whether you're making the impact that is supposed to be there or you're below par or you're above par, that's the only way that you're going to change the way you do things. Right. I mean, listen, we cannot be stagnant. We know we can't be stagnant in this industry. Right. If we want to progress ourselves, we need to be very proactive. So I love the explanation.

Yeah. What I do go give you one example because this is important and it kind of just kind of will button up this point where I went to a state, I'm not going to mention the state and the EMS system there said to me, we're talking to the hospital and the hospital, the pediatricians at the hospital say, don't work these kids where you find them, just bring them to the hospital. And I said, what are they basing that on? And they just said, that's what we do and you should bring them to the hospital. I said, chief, do me a favor before you go along with that nonsense, go back and do a two year review of all the cardiac arrests that you have run and then find out how many of those kids are walking, talking, playing soccer today. I got to give him credit. He spent two weeks, he came back to me, he said, Doc, 50 cases of pediatric cardiac arrest, zero survivors. And that's the moment that he knew that he had to make a change and, and so he used the data to his advantage.

Again, not doing this is.

Is irresponsible. Let's just be honest. It's irresponsible.

Yes.

Right. I mean, we need to be better. So let's get into some of the things that, you know, are basically driving change, you know, within your area, within your oversight. And again, these are exciting topics. Like, first and foremost, we know that you guys have been doing whole blood for a while and we, we incredible that has been, what a great change that has been to your service and to your service area. Talk a little bit about the implementation of whole blood. And now there's a lot of data that has come out based on, I think, what are we looking at a year, two year review at this point?

Yeah, so I'll jump in on that one, Mike. You know, we started our whole blood program here in July of 2022 and currently we're sitting in about 115 cases. And you know, on the surface it looks, it looks phenomenal. So if you look past the surface though, and you actually talk to the providers, the providers are telling me stories that, I mean, I could, we could do an eight hour podcast with the men and women that are serving in our community right now doing this treatment and they would tell you all types of coming back to life situations that they've experienced by giving the blood. So, you know, this one we're looking at a very. So if you think about from July 2022 to now, 115 cases is not really a lot of cases. So it would take us a very long time to be able to gather something, to have a statistical significance to prove. Hey, this is something that definitely changed the game. And then you're going to have your naysayers that are out there saying, well, you didn't really do a randomized controlled trial, so, you know, maybe that same patient did just fine with saline. So for this one, as hard as we're working on measuring all of the, each and every little intricate value that comes up during the interaction, what we've done is paired up with our trauma center and we're taking our data and we're putting it into a bigger, bigger data registry, which is actually up in Tulane. Dr. Duchesne, they created a data registry out of New Orleans that essentially is taking everyone's data. It's asking many questions from EMS's run report, it's asking many questions from hospital intervention, and it's putting it all into one umbrella where ultimately what you're probably going to see is a multi center trial that comes out that's really going to say the significance of using blood in the pre hospital arena. So when you ask, can it be done, yes, it is labor intensive, but ultimately you're going to have by sharing that data and believing in chasing the data and putting out a publication that really has strength, you've got to get a little help from your friends. And that's honestly something that there's, you know, there's all different types of etiology of reports that we could look at for, you know, critical care or pre hospital care. But whole blood I truly believe in. And taking our data, putting it into that registry is going to allow us to have something that's really got some strong significance from a statistic standpoint.

Peter, how did the, how did the docs help with this? How are they going to drive this? Because again, listen, EMS is EMS and the respect is getting better. But how do we take these nationally recognized docs that are going to buy into this? Because again, let's be honest, we do get naysayers and a lot of times, and I'm not calling anybody out specifically, but it does come from the trauma community, especially when we're talking about whole blood. How do we get the buy in?

Yeah, this is huge. And it all comes back to.

Publishing our data. And if you look at what we did in Palm Beach County, Mike, our first publication only had 20 patients.

Right.

And the reason that we did that is because these physicians that you're talking about at the trauma center, the surgeons themselves, they were the naysayers. So we saw our outcomes and it mirrored what we were seeing in other locations. So we immediately said, you know what, we're going to publish a paper. And on top of that, what Charlie did, which was incredible, he got the healthcare district involved and we have, on top of this Tulane registry, we now have our own tableau dashboards, which are basically a live dashboard. And every time he goes to a meeting, these dashboards, he puts them up on the screen. They're beautiful, they're interactive. And you cannot argue with an 88% survival rate if the patient received blood before they went into cardiac arrest. Nobody could argue with that. However, imagine if we just said, okay, trauma surgeons, we're doing this new thing, call it X, right? We're doing this. And then we, we don't follow that up with look at the outcomes. The trauma surgeons would have a field day. They would eat us up in these meetings and they still try to Eat Charlie up in the meetings, but he just comes and he's back with the data. And so now what's happened, and Charlie can explain better than me, but now, over time, the surgeons are starting to recognize that we were right after all, and now they want to work with us. Some of them are still kind of the laggards. They're still not, not there yet. But there's no doubt in my mind that based on the registry, you see what Atlanta is doing, you can see what the Virginia folks are doing. Of course, San Antonio, New Orleans. There's no doubt in my mind that in the next five years there's going to be thousands of EMS agencies doing whole blood. But without this initial early data, it would never have happened in the way that it's happening now.

I don't, I don't think you could state that any better, truthfully. I think that the work, the early work that's being done here and the folks that are stepping up, right, like yourself and, and other, other physicians, other EMS directors that are actually putting the time in to prove data, I think what they're doing is they're driving this change that is going to be a national thing, right? I mean, because there are a lot of states and there are a lot of agencies that would love to do this, but they just don't have the time, the bandwidth, and maybe they can't get through the political hurdles, I don't know. But I think that the work that you're doing is going to produce that change, like you said, in a five year timeframe. I think it's probably three. You know, I think that there's, you have done so much great work on this and the results don't lie. I mean, they don't lie.

It's striking. It is striking. And, but what's, what's interesting, Mike, is that anything in health care, I mean, you're right, the whole blood thing may be faster, but it turns out that anything in health care takes a long time until it actually gets into formal practice, even with data, even with publications. But this is kind of sexy, right? This is like Charlie said earlier, you're bringing people back to life and there's no better feeling in the world than actually seeing that if you're in the field and you're seeing it happen right in front of your face. But it's been fantastic and we really are relying on the data to make it happen. And so it's been a great, great ride. And Charlie, I'm sure you can comment on it, but Charlie's made it happen.

No, really, I appreciate the credit on that, but I gotta tell you, there's a whole team of men and women in our workforce at Pont Palm Beach County Fire Rescue that believe in it. You know, they're not dispatched to all the calls. Some of the calls that we've administered whole blood onto is just our EMS supervisor monitoring the radio. They hear the call, it sounds like a potential candidate. And then next thing you know, you know, the report comes through that they administer blood, and it's just really because they've seen it, they believe in it. You know, we've done as good as we can publishing our data at the very beginning and then constantly updating them, you know, with. With the survivability of the patient. And, and ultimately it's. It is something that I truly do believe will catch on national, you know, from a national perspective. But there are some hurdles, you know, and there's a lot of things that people are going to have to push through. And ultimately it's. I can tell you it's all worth it.

I'll give you an example. Just real quick. This, this is something that I'm fighting for now, which is, Mike, this goes back to your point, which is a lot of agencies were starting blood, are saying, you know what, we're not going to add the kids in there. We're going to make it 18 and over only. And then you say to them, why are you doing that? And it's because all the surgeons wanted us to do that. And I say, well, what would have happened if you would have brought this hemorrhaging child unconscious to the emergency department, to the trauma bay? Oh, it would have given them blood.

Yep.

But what are they waiting for? They're waiting for someone to say, show me that it's safe. Show me the data. And so part of what we feel like it's our responsibility is to show that you can give children blood. It is safe. And so hopefully, people who are listening today who are utilizing whole blood, not only are you giving kids blood, but you're tracking that so that you can report back to the rest of the world that it indeed truly is safe to give children whole blood.

It is. And it's something that needs to be considered very strongly and needs to start to be widely accepted. I want to hop into something else that is right on par with cares. And we're talking about double sequential defibrillation, kind of a big thing right now and really having some really great results. Peter, talk to me a little bit.

About double Sequential, double sequential is something that we learned about years ago at the Eagles Conference. And Charlie, to his credit, we'll talk more about that and how that ended up happening at our agency. But what we've noticed for many years is that if you have a patient who's in vf, you have great CPR going on. End tidals are great. Everything seems to be going except that you just can't get them out of vf. Either it's refractory or recurrent, you bring them to the local hospital and 99 times out of 100, and actually in South Florida, it used to be 100 times out of 100, if that patient could not come out of VF with the standard treatment, then the ER doc would just call the code because the only other options were either taking them to the cath lab on a Lucas device and actually remove the clot. Right. Or start them on ecmo. And both of those things for many years were never done. Now we only have one hospital to do that. So we knew as pre hospital folks that we had lots of these patients. And so I'll let Charlie tell the story. But once we started doing it, we knew that we had to collect the data because there were a lot of people who thought this was crazy. Number one, the manufacturers were scaring us, saying that if you do that and you burn the machine, then the warranty is invalid, it's voided, and therefore that 30, $40,000 machine is now on you. Right? And now obviously, since Dr. Sheldon Chesky, and he's the man up in Toronto who actually did the study up in Toronto, and that was published in New England Journal of Medicine, now we know that it does work, but interestingly still not many people around the country have actually moved to it because the AHA and ILCOR have given it a weak recommendation. So this is all very interesting to me, but I do think that people need to switch over to double sequential. If not, your patients are going to die, but also collect your data and understand that if you're going to make that change, you want to evaluate whether it's making a difference. And Charlie can give us some of the. Can give you some of the data points from our agency, but we've seen great success from it.

Charlie.

Yes, sir?

Wake up.

I'm here, my friend. I'm here. I'm actually just reflecting back on the journey it's been with this process, because when you look back to 2016, like Dr. Entebbe said, you know, we heard of double sequential defibrillation at that time when you heard it for the first time, you're like, oh my gosh, what are we trying to do? Are we trying to shock the patient 10ft off the ground? Like, it doesn't make sense to me. You know, you're given 360 joules here, 360 joules there, and 720 joules all at the same time. Just seems like overbearing and a lot. And you worry about these things, right? You worry about, you know, is it going to harm the patient, right? Is it going to. Is it going to backfeed the monitor? Is it going to backfeed your CPR device? And you know, when you talk to the manufacturer of the equipment, they tell you that this is not authorized. So really, when you make a decision to go down a road of doing something that the manufacturer of the, you know, the equipment says no. And then you look at the American Heart association and the associated accrediting bodies, they say no, you really got to make sure there's some sound science that's out there. And then ultimately you have to make sure that.

The responders, the first responders are believers. And the first case that we had was, it was just phenomenal, right? It was a case. A guy was visiting from Ohio, gets shocked, you know, five standard times. Then we do double sequential defibrillation, and the guy wakes up three days later, and ultimately his wife comes down from Ohio. She hasn't spoke to her husband in three days. And, you know, this guy was 100% in refractory V fib. He ended up having an LAD. They stented him, and he ended up going back home to Ohio. But, you know, you look at somebody like a Dr. Sheldon Cheskys that comes out of Canada, doesn't really worry about what anyone else has to say and doesn't. I mean, now you got to imagine what I find most fascinating about him is he's a true scientist, right? The guy doesn't say, this is definitely going to work and we're going to study it to prove it works. He says, I'm not sure if it works. We're going to study it and then we'll tell you if it works. That's the difference. Sometimes people study things to prove things, and they're very biased in their approach. This guy was. He's a beautiful guy to begin with, but he took a beautiful approach. He says, I don't know if this works or not. Let's study it and find out. And what he found out is, yeah, it double and triple Survival rate. I mean, it just makes sense when a patient's, you know, in a dysrhythmia that they're not coming out of this rhythmia and they have no pole. I mean, they have no pulse. They're not perfusing their vital organs based upon, you know, the heart working. Right. Everything is being done by manual CPR or, you know, the Lucas or the Zoll device, et cetera. And even at best, you might be perfusing your organs by 20%. Nothing beats the heart pumping by itself. So he comes in, studies it, and finds out that what we thought is true. And now we're very fortunate to have a relationship with him. He's looking at our data and says, wow, I'm very curious to know that if we mirrored what we did in the New England Journal of Medicine, does it render the same outcome? And if it doesn't render the same outcome for us, maybe he's going to be able to give us some tips to make it better. But that's the purpose of the whole talk today, right, Is looking at what you have, knowing what's out there, analyzing it, and then ultimately researching it. And we all have that obligation, no matter what. Whether you like it or not, if you're listening to this podcast, you care about ems. That's just the bottom line you have. You're obligated to research it to make sure that you're. Whatever you're doing is right for your team and most importantly, for the community they serve.

Well said. Now, let me throw this at you, and certainly foreign to Florida, who has. Who have paramedics, you know, coming out of all corners. But let's say you come from a different state. It's a BLS only agency. All right, can we do double sequential with two AEDs?

Yeah. So I believe Dr. Cheskes has studied this. I know some of you know, in the dose VF trial, I believe they had some AEDs and some LifePak. So basically, the beautiful part about his study is it wasn't just one monitor over the other monitor. There was several monitors involved to include aed. So, you know, I'm definitely not the expert, and I don't want to endorse something that I'm not 100% sure, but I do believe there is a potential for that. Right. I think the. I believe in the study, and don't hold me to it, but I believe there was. Peter, maybe you know better than I, but I believe that they did do a monitor and AED, but I'm not 100% sure?

Yes. Yeah, yeah they did. And I have the whole file of videos because I asked him for it, I begged him for it and he finally, he was nice enough to give it to me and he allowed me to post it online. Effectively most people know that depending on the AED that you're using, you have to figure out what the timing is until from the time you push the button and the time that the machine actually shocks. So he has a whole tutorial that shows it to you. Obviously it's a little bit more kind of complicated because you have to figure out exactly that timing. Two ads, one ad, one monitor. But it's definitely doable. And to go back. I think that's why Elcor and the AHA made this weak recommendation. What they were worried about is that making it a strong recommendation would mean that agencies would have to go buy a second a very expensive piece of equipment and they wanted to avoid doing that. But there's no one who can argue with the fact that if you got double sequential, it doubled your potential rate of neuro intact survival. Doubled it. And there is nothing else in the world that you could say where we know all those patients would have just been dead, dead when they got to the hospital. So if you can give someone a chance at survival at that high of a rate, then you owe it to yourself and your community to do it.

Certainly something to follow up on within your agency. If you're not considering double sequential or you haven't heard of it or you don't know much about it, definitely look into this because these are the game changers, right? We are looking for things that are going to increase survivability and these are the things that we're talking about. But again they're driven by data, right? And the data is out there. Read it, look at it, see what it, feel it, understand it, pivot. Now we're going to pivot over to ketamine and seizures. Let's talk about it. Peter.

Listen, ketamine has taken a beating in the media. We talked about.

Remember we actually spoke about on one of our podcasts that we actually published. Myself, Dr. Schepke and many other folks from ESL, we published over 11,000 cases of pre hospital ketamine and showed it was safe and that that that data was used in many news articles after that. So here you go. EMS proved that when used correctly, that's the key. Ketamine is safe moving into this next area of seizures. Many of us know that EMS typically only carries one type of antiepileptic and that's a benzodiazepine, right. When you're in the hospital, you have Keppra, you have, you know, all these other medications you can, you have your hands on. But, but in EMS we don't. So Dr. Schepke loves the use of ketamine. He came and said, hey, why aren't we using ketamine for refractory seizures? So we did a massive literature review. And I have the folder for everybody wants to. I probably have dozens of articles in there now, but every single article, Mike, was about ketamine used in the hospital days and days later. Meaning these are patients who were sitting up in the icu. They had the EEG on them. No one can stop the seizure. And then someone said, hey, let's use ketamine. And in many of those cases, ketamine did the trick. So we said, wait a minute, we already used ketamine, let's just add it into our protocol as a second line agent for refractory status. And we incorporated that into our protocol and years ago we actually presented the abstract and we did that at the NAMSP meeting. So again, we put our data onto a poster and we presented that data. And finally, thanks to, again the folks in Mount Sinai, thanks to the amazing work of Dr. Pepe, we actually now have published our data. Actually, it's still waiting to be kind of fully formally accepted, but the manuscript has been submitted and we can go through the data. I have it here in front of me in a minute, but I want to let Charlie come in. And this is going to be a game changing paper because many people in EMS know that if the benzos don't work and you have, let's say, a 20, 30 minute ride into the hospital and the patient's seizing the entire time, those patients can die. Those patients could have bad outcomes. And here's something that we did, that we evaluated, that we studied, that we're publishing, that will actually show people this is the right way to go.

Charlie, talk to me about the results.

So the results are, you know, again, I think we're obligated to keep some of the results a little under wrap because of the manuscript and where we're at in it. But I will tell you, it's profound. You know, we started roughly just to kind of give you a general consensus of what it is. We looked at like close to 2,500 cases, you know, and then after the 2,500 cases, you obviously look, the protocol states that they're going to get one dose of benzodiazepine, and. And then they get a second dose of benzodiazepine. And then ultimately, if the patient's still seizing at that time, they're, you know, it's applicable for them to get a dose of ketamine. So, you know, by the time you looked at, you know, the 2500 cases, you know, roughly 1500 of them, you know, obviously get cured with one dose of benzo. You know, the large portion of the rest of them got another dose of benzo, and it broke the seizure at that point. But there was a group that stood out, right, that did not break the seizure with, you know, with your two traditional doses. I'm going to talk briefly about the. Studying this and looking at each case, though, there was a group with. That merely had 15 protocol violations in it. Right. So it's interesting when you look at the group that got one benzodiazepine and then essentially got the ketamine, which is a protocol violation because you're supposed to get two. When you look at that group, 14 out of the 15 stop season after getting the ketamine, it's one of those things. It's not what you were looking for, but in the discussion portion of the paper, it's really interesting because then you start to look at this and you're saying, wow, do we have the protocol right by waiting to give the second benzodiazepine? So that's just one of those things, things that make you go, hmm, reward the violators.

Reward the violators.

Correct. Yeah. So it was interesting when you broke that down on the char. It was just that. That was. That was pretty interesting to me. And then, you know, largely we ended up with roughly about 60 patients. And it looks like we're in the 90th percentile on seizures that were stopped now. You know, some of the things that I wish we would have been able to determine a little bit more is we didn't look at the backside of every single hospital chart, but it would have. I would have been curious to see what happened to the patient later on. You know, as far as, like, retrospectively looking forward, you know, we look back at all the cases. It would have been really cool to maybe set something up with the hospitals and do it prospectively. But, you know, either way, we learned a ton of information just by actually digging down into our charts and seeing if it makes a difference. And the answer is, yes. I can tell you My daughter is 15 years old right now, and when she was 6 years old, she was diagnosed with Something called benign rhalondic epilepsy. And very quickly I realized that I know nothing about seizures. What you think you learned in paramedic school, and then when you start talking to some neurologists, there's really so much to that disease itself. You know, it really is a life sentence for people that suffer from seizures. And I feel for each and every one of them. But I will tell you that, you know, we did have to give her some benzodiazepines a couple times, and fortunately enough it broke the seizure. But I couldn't imagine, you know, being on a call or being on a case where you can't break it and knowing that, you know, there is a potential drug out there that works on a different receptor side of the brain that ultimately stops the seizure. And a couple of them, it was so crazy. We had this one case where we were given the drug to, I believe it was, you know, a younger, under the age of 18 child. And essentially the EMS supervisor is given the drug, they're running the drug in, the seizure stops. The EMS supervisor is unsure should they continue the drug or not, stops giving the drug because it was an infusion of ketamine. And. And as soon as they stopped the infusion, the seizure started again and ultimately they opened the drug back up, kept the infusion going and it stopped the seizure. So that really led us, you know, from an evidence based perspective, although could potentially be anecdotal because it's such, you know, we're talking about one case. But what we did at that point was we said, you know what? We're going to focus in on making sure that each and every case gets the entire dose of ketamine. While we obviously do, you know, some, you know, divine intervention and continuously monitor SBO2 etc, you know, so it's just you, you kind of, you kind of got to always be looking at each one of these cases and ask the difficult questions. To really adjust your protocol.

You have to, you have to pay attention to detail. You have to look at all of these little nuances. Peter, talk to me about how your work and studies and implementation has been picked up by other agencies.

Right. So Charlie mentioned earlier how we speak to Dr. Cheskys and we've met you and we've had so many great conversations. You know, EMS is such a wonderful community that when you go to these conferences and you walk around, you talk to people you meet at the bar, you have a drink, all of a sudden you start to share and cross pollinate. And that's exactly what happened with this ketamine information? We had the data years ago. We actually went to naemsp, which is a National association of EMS Physicians conference, in January, and we presented it a small little poster. We didn't have that many patients at the time, but the word got around pretty quickly that ketamine was being used for refractory seizures. Over the next few months, people were calling me and they were asking me some clarifying questions. What's your dose? Can you send me your protocol, et cetera. And next thing you know, there are people all around the country who have implemented ketamine into their protocol. And so there's two. Two examples. One is Jeff Ziegler. He's out at washu in the St. Louis area. And he said basically, after seeing our data, he basically has a kid who's got Angelman syndrome, which is a complicated disease, and he basically has modified his protocol. And they have it in the CAD that when they go out to that kid, to that kid's house without address, it's ketamine first, because he found it's the only thing that works. The folks in Oklahoma, Jeff Goodloe, I remember he texted me, he's like, what are you guys using for ketamine for seizures? And they added into their protocol. And if I had to guess, there's been probably dozens and dozens of agencies who have done it. The folks in Texas have done it. Casey Patrick, and he's actually published his initial series. So it's the kind of thing where if you're into ems, if you're into the medical side, if you know your data, you go to these conferences, whether it be EMS World and emsp, and you can come back and you can say, we're going to do this because it's rooted in real, actual outcomes. That's the beauty of this.

Isn't it great that we're at that spot now? Whereas we used to just do all of these things on our own. We. We function in our own vacuum, right? In silos, like, oh, we're doing this right? And it's top secret, secret sauce. But we have such a great community now, whether it be at these incredible conferences or these incredible podcasts. You know, we're. We're learning from each other and we're sharing this stuff. But at the end of the day, it is all based in data, right? So that is the common theme. If we are going to change, if we're going to share, if we're going to implement based on something that someone else is doing, it's rooted in data. And I think that that really is the takeaway here. And we could probably go on for three more hours. We're already at the 45 minute mark. But I want. Before I break and I let you guys go back to royalty, what I want to do is I want to say, you know, number one, thank you again. Is there anything else that we should be talking about real quick as far as data that has changed. Right. Or something that we are changing based what we've learned?

I have one, and obviously I've been working closely with Charlie on it, but it's the distal femur IO and we've been doing it for many years. And it turns out that there was not a paper in pediatrics where they actually showed anything related to the distal femur IO success. There had been papers on the lack of success of the proximal tibia. There have been papers on the adult distal femur IO in San Antonio.

We decided recently that we're going to look at all of our data. We have about 175 cases, got a couple medical students. We just got all the charts. We created a spreadsheet. They extracted the data. We partnered with our Montana friends. Guess what? We just submitted an abstract into asep, which is the American College of Emergency Physicians. And we have greater than 90% success rate for the distal femur IO this, I think, will allow the country to finally get over the hump and say we're going to do it, because here's the future, Mike. The distal femur IO will be the go to for pediatrics and adults. Cardiac arrest period. Hard stop. Because of where it's located. The bone is sticker. It doesn't come out. The flow rates are just as good as the proximal humerus, and it's out of the way. And the folks in San Antonio said no one does anything now except distal femur in adults. We only do distal femur for pediatrics. And easy IO is coming out with a 65 millimeter green needle very shortly at the end of the year. So this is the beauty of how this community has come together. And then the hospital is not going to make the change until I think we have grandchildren. So they're a little bit behind, but that's okay.

Well, I am actually marking it right now that on this date, right, we're May 13th. Peter Anteby said, hard stop. This is the access point. It's done. And it was. And it was broken on this podcast.

I will die on that hill, Mike. I'll die on that hill. Okay.

That's fine. We'll make sure that we're there with you, pal.

Mike, if you want to compare it against something, just while we're looking at our data here, you know, just if we looked at how successful were our crews and, and establishing an IV compared to the distal femur IO, which is roughly 90 successful, we were right around 19 for the IV. So, you know, I think the proof is in the pudding with this one.

It really is. And I, I think that that is pretty undeniable. What else do we have?

Or is that enough for one day?

I think, I think we gave a lot, Mike. I don't know.

We gave him a lot to think about.

The other one that we're looking at now, I mean, I guess we could talk about it if you want to, but.

Go ahead, I'm going to talk about it.

Yeah. So we're about to fire up another study. We did something that was against the grain again. There was a Netherlands study years ago about antibiotics in sepsis in the pre hospital setting. And they said you should not give antibiotics in the field because it doesn't work. And that study was looked at by all the folks in EMS and said, aha, you see? But what they didn't, you know, that paper didn't really have patients who were in septic shock. Only about 4% of the patients in that study were in shock. So we said we owe it to ourselves, we owe it to the EMS community. We have about 150 or so patients that we're looking at now. All that went to a single hospital system, all that got antibiotics in the field. And we're now going to be looking at those patients outcomes. So it's, again, it's something that not many people do today. They get a lot of resistance from the hospital, but nobody knows what the right answer is. And so we just spun up this study. We have a couple of students who are going to start abstracting the data. We have a good hospital partner and again, so probably within the next six to eight months we will have more information on should EMS carry antibiotics for sepsis in the pre hospital setting.

Awesome. It's awesome, guys, honestly, you know, and I, and I, we joke a lot, but you know, moving this forward, moving the needle forward, these are the things, right? These are the things that are going to bring EMS to that notoriety, right? To that validation where, okay, we are a medical provider, we're not ambulance drivers. Right. We are providing necessary intervention and, and in the process making a huge difference. Not just a difference, right, A huge difference. In outcome.

Again, guys, it's always awesome having you guys on because it's. It's easy and, you know, we have a lot of fun doing it, but it's so much important information. And I think that the research, EMS research tends to have a stigma to it.

Right?

Boring. You know, it's not cool. I don't even know how to read it. You know, what does this graph mean? All that type of stuff, right? I'm right there. But, like, when you break it down, right, and you dissect.

Is so important to have this type of information to drive change. And I want to thank both of you guys because you're always at the forefront, forefront in doing it. And I just want to implore you to continue doing it and sharing that, because it does make a difference with everybody throughout the country. So thank you for coming on with me again today to explain these types of things.

Mike, I have to say thank you. And listen, you make the time on Fridays where We talk about EMS research every Friday at 11am and everyone else is invited, and we bring actually the authors from these papers, and they actually tell us about the research that they've done. So there's so many people out there who are passionate, who are providing the information. We just have to ingest the information and consider whether to change it in our protocol. So thank you for helping us spread the word. You are the man. Even after you fought a fire, you came into this podcast, man, you're amazing.

Listen to me. Let's just get one thing clear. I did not fight any fire. I am not. That is not my role, pal. I am there to support them medically. That's the best I can do. Honestly, the best I can do.

On a serious note as well, I like to, you know, obviously echo Dr. Antevi's comments, but, you know, I also want to thank you on behalf of the men and women that serve for Palm Beach County Fire and Rescue. You know, you do an excellent job making sure that your listeners and people in the EMS community have access to all of the things that are important. And, you know, I've had the blessing to be on here with Dr. Antevi several times with you. Obviously, EMS world's been gracious enough to allow us to present there every year. And really, what we're doing is highlighting our men and women that are out in the field doing the difficult job day in and day out. So thank you for allowing me the opportunity to speak about them, speak about what we're doing as an organization, and hopefully continuously work with you and your team in the future to try and make things better for Everybody in the EMS community.

100%. Guys, it's always my pleasure. I truly do appreciate all that you do, and I appreciate everything that the EMS community is doing because I do think that, listen, we are always up against it, but we are doing some really great things that are going to push us over the hump. And it's things like this. It's the research, it's the data, and truthfully, it's the ability to take risks and to say, hey, listen, we're going to look to do this. We're going to, we're going to rattle some, some, some walls here, right? We're gonna, we're gonna push some cages out and we're gonna look to make a difference. We're not just gonna be stagnant, and that's what's important in this industry, and that's what's gonna take us over the hump. So, again, Peter, Dr. Peter Anteby. Charlie Coyle, Palm Beach County Fire Rescue. Always a pleasure having you on. And I want to thank the listener. This was a long one, but listen, a lot of important information in here for you to dissect, take back and say, hey, listen, are we doing everything that we can be? Because there are so many things that can be changed. There are so many things that can be looked into and push the envelope so that we make sure that we're delivering the best possible care to our patients. So I want to thank you guys, I want to thank the listeners and I want to thank EMS World. And stay tuned for more amazing podcasts up and coming. And again, we're going to see you in Vegas this year at EMS World Expo. So thanks for listening. I'm Mike McCabe, and we'll talk real soon.

This has been an episode of EMS World Podcast. You can find this audio and more like it on the podcast page of emsworld.com youm can also follow EMS World on Twitter, Facebook and Instagram.