Dr. Marc Grossman- EZ IO for Epidural Hematoma (8/30/22)

We'll come back to the VIP here. Mark Grossman, for those of you who don't know, Mark was really probably the first person who introduced me into the world of EMS way back when, many years ago when he was the medical director at, for Miami Dade. And he was, you know, kind of an on the ground, boots on the ground kind of guy, as we all know. And unfortunately, we lost him to the Northeast, where he's now up in New Hampshire, doing incredible things in EMS as well. Obviously, when he was in Miami, he was part of the Eagles group. So Paul's going to be happy to see you here, Mark, today. But Mark called me up one day and he's like, you wouldn't believe what just happened to me. And as soon as I heard the story, I said, you know, is it possible that I can tell people about it? He says, wait till I publish the case report. So what you're going to hear today is it's incredible, but kudos to Mark for actually publishing it. Mark, do you have the PowerPoint or do you want me to pop it up?

Can you pop it up?

Yeah, yeah, yeah. So let me, let me do that. And we'll do some housekeeping stuff as well, just to make sure that. Let me see here. Set up, show individual window. Okay. Some housekeeping stuff just so we can get everyone credit for today is the following. There it is. So hopefully you can see my screen. Today is CME is 15289 and later it'll be 15290. As I've mentioned in the past, I'm going to start rebranding. You know, we had a meeting our Florida chapter of nmsp, and we're going to start to rebrand this specific webinar under the Florida NMSP brand and then work alongside Angus and FaemsMD so we can kind of parallel each other and complement each other. But as I mentioned, today's presenter, as you can see, is Mark Grossman. Mark, if you wouldn't mind telling us where you work out of a little bit of your history and then get started, we really appreciate you coming on today.

Sure. So I'm a rehabilitated Florida transplant. I grew up in New York, and after I was sort of involved with the recovery effort from September 11th with a group called Disaster Psychiatry Outreach. But I started out as an emt and I was always been involved. I've always been involved with EMS in my medical career. And when I was in Jersey City, I was working at Mount Sinai in Jersey City. I was the Jersey City EMS medical Director and then had an opportunity with Kathy Schrank. She recruited me in 2004 to come down to Miami. And I was in Miami from 2004 and sort of in a few different places in Florida, but I was in Florida till 2016 or 17.

And because of family reasons, actually my son was a figure skater. We moved back up to the northeast. He was recruited by us figure skating. And I got involved with New Hampshire. And so I'm the EMS medical director for various towns up here. So in Portsmouth, I'm the ER director of Portsmouth EMS medical director and also for a town called Derry, New Hampshire, which encompasses like a few other towns. So I've still been involved with ems, just not at the same level as Miami Dade. I mean, Miami Dade was a full time job that was. I don't think there are many jobs like that in, in the state of Florida, let alone in the field of EMS medical direction.

So anyway, that's a little background on me and I don't know. You want to talk about the case, Peter?

Yeah, yeah, go ahead.

So this case was.

Nearly a tragedy, but it was a two older teenagers that were driving on one of our main highways and I was at my community hospital, not at the trauma center. And so she actually, she was in the car. She was a passenger that wasn't restrained and, and they hit the guardrail and actually flipped the car over. And when EMS got there and the police. This isn't, this isn't the car because it was.

This is just me Googling something, right?

Those are in fact cars that have crashed. So Peter is right. So basically the car rolls over, police get there, EMS gets there, and they say she had this classic syndrome where she had loss of consciousness and then woke up. And the police get there when she wakes up and she's 17 and she lied and said that she was 19.

And just then the boyfriend's father arrives and they said, well, you know, this big bump on your forehead, you should probably go to the hospital. And EMS is so different from in New Hampshire, so different from Florida, that I literally had somebody having a stroke drive to the hospital, complete right sided paralysis. And he drives his car to the hospital. And I said, sir, why would you put people's lives at risk.

Driving to the hospital when you knew you were having a stroke? He walked in and he said, I think I'm having a stroke. And he says to me, well, I didn't want to pay the copay. The ambulances, $250. Like people here are well insured, but they're very cheap, right? So I said, well, I don't understand, how did you do it? Like you have complete right side of parallels. He's like, I just kept making left handed turns and I looked at him and I said, of course, of course you have an answer, right? So the motto of the state is live free or die. And you know, they, we, we go through this every day as opposed to Miami where people call 911 because they lost their prescription. So very, very different systems up here. Anyway, so she doesn't come by ambulance. I thought, I guess she figured she was gonna get in trouble. So she walks in with the boyfriend and the father. And two o' clock in the morning, middle of February, it's snowing out. And very dramatically collapses onto the floor in triage and starts vomiting. And now she's unresponsive. So we get her on a stretcher, we bring her back, I call for a trauma alert, which, you know, in a community hospital doesn't really do anything because we're already there. It's just the emergency department that's really showing up to that. But help facilitate getting the CAT scan prioritized. So I get the CAT scan and I just, you know, I put in for a trauma series and I was in the middle of doing something else, so I get her to CAT scan, I get her ready to probably be intubated because she doesn't look good. And the tech calls me and she's like, I'm not sure you want me to do the rest of the CAT scan. You know, the best of the pan scan. Because the CAT scan. Is that the video? Peter.

Can you play the.

Yeah, yeah, that's the video. Yeah, they play it real quick.

Yeah, okay. So the CT tech is, you know, calling me out of the room saying, can you come look at this? Because I don't think she needs the rest of the scan.

So everybody sees that it's obviously large scalp hematoma, but there's an epidural hematoma as well. And something needs to be done immediately. I mean, this is something that doesn't come up very often. I've been practicing emergency medicine for a while. I graduated from residency in 2000 and I did this once with the neurosurgeon when I was a resident and I hadn't done it since. And I've worked in trauma centers, but I don't know, it just hasn't come up. And.

So I tell the secretary, can you call for a helicopter? And the helicopters weren't flying because it was snowing. Out. I mean this is something that doesn't come up often in Florida, I guess if there's a hurricane. But the helicopter pilots are pretty aggressive in Miami at least. So.

The next call I make is there's like a back channel line for the Boston Children's ER because I figured, well, she has to go to Children's. And that's really our only children's resource hospital. I mean there's Mass General, but Children's is Children's. So I call up the ER Children's. It's an ER doc, I don't know. And I explain what's going on. She's like, hang on, let me loop in the neurosurgeon again. It's like 2, 2:30 in the morning. I don't know any of these people.

I call the neurosurgeon and I just, I'm describing what's going on with the patient and I said, I think I know, I knew I know what to do. I think I know what I need to do. I just haven't done it. Like I don't know how to do it right now. I feel like watching YouTube videos. So he says, well why don't you start with mannitol and hypertonic saline, just get her evacuated. And I said, well, it's no helicopter. By the time I get an ambulance, you know, we're having the same problems up here that I would imagine you're having where inter facility transports are taking a lot a long time because they're. Everybody's so short staffed and this is still the beginning of true last that and that is an ambulance for reference. Thank you, Peter. So I, I called a neurosurgeon and you know, he's telling me just treat it medically and get her out. And I said it's not going to work. She's already unresponsive, she already has a blown pupil, she's already vomiting, she's already bradycardic, she's already hypertensive. Like all. She's got all the things right, all the things that you worry about like she is actively dying.

So I FaceTime with him, I said, can I just show you what the CAT scan looks like? So I FaceTime with him and this is kind of a novel thing. I mean, you know, hopefully nobody here is going to rap me out to hip to the HIPAA people. But.

So I'm FaceTiming with him the CAT scan and his quote to me was, oh shit.

And he said, what are you going to do? And I said, I have, he's like, do you have a trepidating drill or whatever it's called for the skull? And I said, no, and I wouldn't want to use it if I had it said. The only thing that I have readily available that I know what I'm doing with at least is an easy I. Oh. And he says, what's an easy IO? So I show him, and he says, okay, that looks okay, but do you have anything that's a larger bore, like a larger gauge, because it's, you know, to evacuate the blood? And I said, no, it doesn't work that way. It's length based. I have pink, blue, and yellow. And I opened them and I showed him, and he's like, well, the blue looks right.

Okay, that's a very strong endorsement. So with that, I show him the patient, I show him the scan. He starts doing calculations in his head that emergency docs don't do, including using PI. He's like, okay. So if I divide this any, what he's doing was figuring out the volume and how much I'm actually going to be able to get out. So he figures that out for me. And I already had her intubated. She's head of the bed's elevated. I'm hyperventilating her. And I explained this to the doc. He's explaining to me what to do. And I go to the mother now, and I said, look it, if I don't do anything, it's probably a very high likelihood she's going to die. She's not even accepted anywhere. And I still have to get an ambulance. And the closest trauma center is.

30 minutes away. Once the ambulance gets here, the pediatric hospital is an hour away, 45 minutes away. I said, so if I don't do anything, good chance she'll die. If I do do something, good chance that she'll die, but it's also an equal chance that she'll live. I'm just making it up. I mean, I don't know how people do this, but it's like, let's say it's 50. 50.

This isn't something that I normally do, but I'm on with expert who does this often, and he's going to help me. And she said, obviously, please do it. And she gives me a hug, like, okay, we're in the room, like, next to the girl. So I kick her out because I don't want to hear. I don't want her to see me crying. And I'm FaceTiming with the guy, the neurosurgeon. He tells me where to go. And it was, you see that it's frontal, so it's not over the middle meningeal artery where you normally imagine this. So it's a slightly different location. We sort of do like a, you know, a FaceTime stereotactic. And he's like, okay, I take my pen and I mark where I'm gonna drill. And then I put the phone down on the table and I start drilling. And I'm. The nurse is standing there staring at me like, what the hell is going on here? Like she's not helping at all. And. And I drill and I take the needle and I start drilling until I lose resistance, which is a very, you know, scary moment because I don't know if I'm losing resistance in blood or brain or whatever. And then nothing's coming out. So I, you know, I take out the little trocar and I put on a syringe and I guess I just sort of had to break the seal of the, the first clot. And I start pulling out with a 10cc syringe. I start pulling out blood. And I think I initially pulled out five.

Syringes full of blood. And.

Then I put the syringe back and it's sort of coming out slowly. So I just leave the syringe. And the guy is on FaceTime on my phone on the table saying, what's going on? What's going on? So I pick up the phone and I show him. And she begins to wake up. So her pupil goes down. She's moving now she has to be sedated. And we get a second CAT scan. And what Peter has up right now is one picture of the Ezio in her skull on the post evacuation CAT scan. And then you see there's blood all over the place. I mean, it wasn't just his epidural, but you know, there's components of subarachnoid and stuff like that. And there's skull fracture. Peter, do you have the next slide? The next picture? Yep. Nope. Nope. Maybe you don't have the one with the easy IO? Nope. The other one. Is that all you got?

Show the one from the slot from the article.

If you don't have it.

Yeah, Mark, hold on. I have it a second. Can you see that?

Hi, Kathy. No. Yes.

It'S showing the right one.

Hi.

Yeah, so that's the picture. So it was in the right spot. I'm evacuating blood. And what's scary is that even though I pulled like 50ccs, seems like a lot of blood to be in the skull. And what's interesting is even as I'm pulling out blood, it's reaccumulating.

So you see that there's still a fair volume of blood. I mean, you can see that little demarcation line.

So anyway, AMR gets there and they're like futzing around and I'm like, look guys, you know, this isn't the time to make sure you got everything right. She has to get to the trauma center, Just take her, you know, so they put her in the truck, mom gives me another hug, I put her in the ambulance and they go. And then I somehow, you know, it's an hour, hour and a half later. And you know, of course I have patients waiting to be seen and you know, I have to sort of like figure out for my own mental health, how do I deal with this? I have no idea if this little 17 year old girl is going to live or die, right? I mean, she's already essentially dead.

But I go about my day and I don't know anything because it's not at my hospital. I've accessed that hospital and she's just sort of off. And.

Somehow the PA from the neurosurgery team at the other trauma center, he texts me. I go home after my shift and I'm like an emotional wreck. Like I'm, I'm crying, I'm shaking. It was very, very anxiety provoking, very scary, very intimidating. And you know, at the time it was like, yeah, very easy to make the decision, like, I know what I have to do. And you just motor through it and it's adrenaline and you do it. And then as you begin to think about it and ruminate and you're not sure what's going on, you're like, should I not have, you know, did I make a mistake? Should I just try to get her out quickly and like, if she dies, you know, am I responsible for it or whatever. It was just very emotional. And then the guy texts me, like at 9 o' clock in the morning, I'm not sleeping, it's an overnight shift. And he, he sends me the after. He starts sending me after pictures. He's like, oh, she's fine, she's in the or, you know, for like an hour. We drained out all the blood, we fixed the, we fix the fracture and she's awake, she's extubated. I'm like, huh, that's amazing. What? Are you sure?

And so Peter was showing the after picture. She came back like a month later and visited with us. And that's her. That's her scar. She's, you know, like, that's actually like a. A legitimate hairstyle in some places.

So.

And she is fine. I mean, she has migraine headaches and she has some. That's the. That day. That's that morning.

That's the picture he sent me, like, nine o' clock in the morning. And then later in the afternoon, the mom's texting me, showing me her walking around with, like, physical therapy. Like, okay, I guess. I guess I'll go back to work tonight and hope this doesn't happen again.

So. And this is her when she came back. Oh. So what's cool was the picture that's on the right. We're FaceTiming with the two doctors, the neurosurgeon and the ER doctor from Boston Children's Hospital. And obviously that's me with her and her two parents and then the three nurses I was working with that night. So it's very nice reunion. I still talk to her and her family. Obviously, they're, they're grateful. And I her. The mother's brother is actually like a ER doc in Ontario or something like that. And he explained to her, he's like, what happened with my niece is nothing short of a miracle. Like, so I think they have a real appreciation for what transpired that night and how important it is that she's okay.

And then when we looked it up in terms of Easy IO itself, obviously it's not approved by Telflex or Easy IO or anything like that. It hasn't been FDA approved as a procedure.

And.

There was, I think, one or two other cases that were unsuccessful where the person died.

So it's nice. What's really nice about this, and one of the reasons I want to publish it, is.

Not every ER has somebody trained in how to do a burhole or trepanation or whatever you want to call it. Most every ER has people that are experienced with Easy IO And I was curious how many people would be willing to reach for this or think about reaching for it and then actually use it in anger if you needed to, who would be prepared to do it? And I think it should be part of a training like this is a MacGyvering method. It's a temporizing method, but it's something that, again, somebody who's an extremist. Is this something that we can use to temporize things until we could get them off to more definitive care? Because a lot more of us work in hospitals like I was at for this than work in level one trauma centers, level two trauma centers, academic centers, we all work all over the place. And you know, people in Florida, it gets real rural real quick.

So New Hampshire is the same thing. I mean, you have southern New Hampshire and then you have northern New Hampshire where you could go for hours and not be close to a hospital. And then you get to one and it's one of these 25 bed critical access hospitals. So it's not even that helpful.

So I don't know, I don't know who else would reach for this or would have thought of it. But.

I just like talking about it and seeing who else would consider this and who would consider it even more now. And I do think that Easy IO should have this as some sort of training and say it's an off label indication. But listen, you guys have it, you know how to use it, you're comfortable with it. I use Easy IO all the time.

For obviously the indicated reasons.

But so Mark, you know, first of all, I think I could speak for all of us that.

This is a life that you saved. And I'm not so sure how many people would have had the, the thought process, the wherewithal to actually think through that and do that. And obviously it's never been reported before, at least only maybe a few times. But my question for you is, have you approached anyone, let's say ATLS.

Or you know, kind of someone in that realm to perhaps look at this as an alternative option? I mean, is that the right thing to do? I'm not sure, Paul. Maybe you have some comments on, on that. Because I think this is, you know, something that everyone should know about, which is one of the big reasons I want you to come on and tell the story. So Paul, what are your thoughts? You've been in that. Go ahead, Mark.

Well, well, no, I approached, I approached Teleflex and they haven't really responded to it. I was surprised. I would have thought they would have jumped all over it, but I may have been talking to the wrong people.

Probably.

Yeah.

Hey, Mark. So first of all, this is like a. We don't have enough time for me to gush out about how cool this was that you did this. We're here to support you. If anything ever came out of it, obviously it's not going to be a negative thing because of the outcome. Right. And I think it was really clever and it was great. And I think it should be possibly an indication if it comes down to it. And the reason why is that there are some people that work in Austere conditions as well. And if it gets down to it and you see somebody who's coning out like that because she had all the clients. Classic Cushing cushion signs. Right. And it would be worth something. Worth a try. Just like we do a finger thoracostomy in a desperate situation. So I think there are some potential. So a couple things. I'll have to do this offline with you, so make sure you communicate with me. But there are people in the neurosurgical community and people in the austere community, such as the military, that I will plug you in with because this is very, very cool. I have one question. So you were taking blood out. Got 50 cc's out. Is clear that there was ongoing bleeding. So there's a couple things I would even think about or anticipate if you were getting it out. But I'd have to do it. You'd have to do it real early as something like considering in the future 2 grams of TXA. Just a thought to throw that in that situation, because these guys can continue to bleed. The question is, did they find a source for it? You.

It was.

Was it the meningeal artery or just. It was it hit in a place where it ripped a lot of different things and it went all over the place.

I think it was just a. I'll have to circle back with the neurosurgeon, but my understanding was that it was just like a bad dural tear. Yes.

Okay. Got it.

Okay.

That's what it sounds like to me, and that's what I was getting at. And that makes a different challenge, too. But also the reason why is because if you're over the temporal area, then, you know, the bony. It's very thinner bone and it's a little, you know. Or he's just crack. But then. So I don't know. There's a lot more to get into this whole discussion. But. But this is fantastic. It's fantastic. See. By the way, where do you live? Whereabouts are you living?

I'm living in Exeter, New Hampshire.

Yeah, I know Exeter well. And then. And you're working out of. For the most part in. Then in Portsmouth, so that's fantastic. I'll have to.

Yeah.

Have lunch at the library sometime. Okay, Sounds good.

Anytime.

All right. I got to go to my other meeting, but this is. This is just a great presentation. I actually want you to present it to the Eagles sometime, Mark. And you can even stay on. Do it now. I just have to have it a tighter presentation. But Peter can help you get on later on, I think into that. Or we'll switch over to that.

Okay.

So.

All right, thank you.

I'll give the link.

Thanks, Paul.

Yeah, one more time.

But Peter told you before, the CME for today is 15289 for this session. And then also, is there anybody else that wanted to type in? Kim, as usual, I think you always have something great to say too, Kim, so go ahead.

Okay.

Hey.

Yeah, this Kim Landry. I'm wondering if you couldn't expand this to perhaps incorporate ultrasound and use this for, say, for example, cardiac tamponade. Maybe using an IO for evacuation of a cardiac tamponade if you had it under ultrasound guidance.

Your thoughts on that?

I mean, it sounds interesting.

I'd be afraid to if the heart's beating just because of how rigid it is. But I do the same thing with a spinal needle now, so I guess it's not that. That much of a far of an extension.

Yeah, but that's a great idea for the brain if you have that available. I. I think. Hey, one thing I just wanted to see because of your presentation. Did you. I don't know if you saw what my name was for today. Peter, did you see that?

Yeah.

See? More blood. Sounds good. I finally got it this week. I finally got it this week.

Yeah.

What I do want to mention real quick is that, you know, Dave Miramantes had published a paper on the use of the femoral IO in adults for distal femur.

Yeah.

And that's not an FDA indication. It turns out in order for Teleflex to get these things, FDA indicated they have to reopen the application. Is my understanding it's the same reason that they still have the Ezio label, 3 to 39 kilos, which makes no sense whatsoever. Right. So they will inherently not expand on their offering because it makes them have to go back to the fda. So it's unlikely that that would happen.

It's a can of worms.

It's a can of worms.

Yes.

Say, Peter.

Yeah, Wayne, go ahead.

Hey. Hi, Mark. Mark. You know, you get a Buckeye or whatever on your helmet. That's amazing story.

Thank you.

When I came out of the Air force down here and I'd seen a lot of trauma, I had a very, very similar case. And I didn't have a clue. And I didn't. And iOS had not been invented yet, and she died right in front of me. A neurosurgeon did come in, but it was a very terrible case. And that's. I think that's what also happened to Liam Neeson's. Wife, if you remember that. But what I wanted to ask you, you said early on that you had some, you had an episode in your training or somewhere that you quote, tried this with a neurosurgeon, but you didn't try it with an IO With a neurosurgeon.

No, no, no. Yeah, it was a regular burr hole drill.

Okay, okay, so you had, you had seen a burhole done by the neurosurgeon. But so, okay, I tell you 25.

Some odd years ago, I tell you.

You open up the doors. This is great. Thank you, Mark.

Thank you. Thanks, Wayne.

The other thing I was going to say was that we, we definitely have to progress and I think we can get past some of the FDA stuff by getting to the right people, especially the T triple C people and so on. I think there's a lot of.

Great.

So let's. I'll get you plugged in with them because we're working on some other stuff. So I gotta go. Thank you all.

As well. All right, see you later.

Thanks, Paul. Mark, I'll send you an email so you can come on to Paul's show and you can present it there. But any other comments before we, before we move off?

I see Yoram from Hatzala. Yoram, you want to make a quick intro and say hello to everybody before.

We move to Paul's. Hi everybody.

I had a especially show my face to my old friend Mark. Mark has a great presentation, really enjoyed that.

Thanks, Joram.

But you're giving a hug in person for that one.

I appreciate it. One day next year in Jerusalem.

Well, we all, we all learned something, you know, pretty special and I think we'd all feel pretty confident doing it because we all have so much experience with the Easy IO. So just another thing to have in the toolbox, you know what I'm saying?

I agree. And, and I think it's a great idea to have it rolled out to atls so that, you know, people at least have it in their mind that this is a possibility that it's been done before and if push comes to shove, just do it, you know, 100%.

100%. All right, awesome.

Maybe, Peter, in terms of expanding, maybe Easy IO ought to think of a re engineered device for these purposes.

Yeah.

As far as stabilizing the needle, Wayne, is that what you're talking about?

Or maybe a slightly larger diameter, perhaps a little longer if you're going to.

Start a larger bore drill.

Yeah, right.

You know, anyway, interesting, good stuff. All right, well, you know who Also, you should tell about this. Mark, I can put you in touch with Scotty Bolliter who does all the all of the cadaver labs out of Texas in near San Antonio area.

I'm going to connect you with him so you guys can discuss. He'll send you an email like 3. He's so intense about what he does and he loves and he was one who got easy IO to the market with all the studies. So I'll connect you. Mark, I sent you an email so you can log on to the other side. Angus is going to switch us over. This will be posted on our YouTube channel, by the way. So you know, we now put all of these webinars on the Florida NMSP YouTube channel. Please subscribe, find us on Twitter. We're trying to become social. If you haven't joined, you can always email me and learn how to join nmsp, not just your medical director. This is for EMS leadership as well. And the conference is in Tampa. Mark, you're going to be there. NMSP in Tampa. January.

Maybe. If it's in Tampa, maybe I'll go.

Yeah, bring your pirate outfit. Gasparella is apparently 300,000. 300,000 pirate people are going to be joining, so I'm sure Angus is going to have his outfit ready.

All right, we'll see you guys at the other side. Thanks, everyone.