Dr. Peter Antevy talks head-up CPR, whole blood use by EMS

Well, ladies and gentlemen, inside, EMS time, I am your host, Chris Savalero. And the man in the chair to my right, always in the chair to my right, is my good friend, the man of the hour. Too sweet to be sour. The ladies know he's the man with the power. Kelly Grayson. Kg. What's going on down there? And world famous Pitkin, Louisiana.

No, the same old, same old, man. We're stewing in our own juices. It's June, it feels like August. And just trying to stay out of the heat and deal with the day. It's no fun this time of year in South Louisiana. Man, you don't know what it's like when you experience humidity this bad.

Well, really, it's anywhere that's got sun. Especially when you're in the back of those ambulances and that air conditioner isn't kicking out, but you're in that little sweat box. And it's almost like every time I used to work when I was in Texas, I wanted to see the warden. I was hoping to get paroled out, you know, so. But, Kelly, I gotta tell you, man, I think, you know, we're gonna have a great conversation today as we talk about the gathering of the Eagles. With a change of venue this year, actually, down in Florida. And we have one of those eagles with us. He is the man, the myth, the legend, our good friend, Dr. Peter Antevy. Pete, I want to thank you for joining us on the show.

Chris, Kelly, it was great to be back with you guys, being on your.

Show, you know, I mean, you've been here so much. Pete, you're start getting your mail here at this show. So I want to thank you. So, you know, I guess we're really excited. I mean, I didn't have the opportunity to go down to Florida and go to the gathering of the Eagles, but, you know, Pinnacle is coming up. EMS world is coming up. It looks like we're back to the conference season, right? Which is really kind of exciting because I gotta tell you, I really missed going to the classes and seeing my peers and just having some adult beverages and kicking back and seeing what was going on in the career field. And maybe you just give us a little bit synopsis. I mean, what were they, like, 30 people there? I mean, how did it look for attendance and what was going on down there in Florida this year?

Let me tell you, hopefully next year you guys will come, because let me tell you, Chris, Kelly, we were back. We had a full week of conferences Monday through Friday. Beautiful venue, the Hard rock Hotel. In Fort Lauderdale, brand new conference center. We had over 500 people. We probably had over 120 vendors. We were maskless and we were at the bar, we were drinking. We had a great time. We are back, baby.

That's great.

It's slow catching up. And many of the conferences that canceled or went virtual in 2020 are still trying to catch up. The ones that canceled in 2020, many of them are just continuing over, carrying over their conference schedule and speaker lineup from the year before. So one of the things I've seen is seen fewer of the conference call for going out than I usually do at this time any other year. But hopefully with trendsetters and groundbreakers like Eagles and IAC conference and several others that are getting it rolling in person again, putting those safeguards in place that we can do so safely, we'll start to see more conferences adopting that. We'll get back to some semblance of normal. I'm glad to hear that Eagles was maskless and safe this year.

Yeah, well, Kelly, we had a testing protocol that was really rock solid. We had not just the antigen testing, which everybody has heard of, but we had a new type of test that I could test 450 people all at once within 30 minutes. We used pooled testing with a test called RT Lamp provided to us by a company called Floodlamp Bio. And honestly, it's for mass scale testing with the level of PCR quality. So sensitivity, specificity of 99%. And lo and behold, everybody that we tested was negative. And I think we've probably hit on something that other conferences could potentially use as they seek to open back up.

Yeah, it's really interesting.

Sensitivity and specificity, that high, that's kind of hard to beat. Hard to refute.

Yes.

Yeah. And that's one of the things that I was going to say as you brought up, is this going to be the standard now for a little bit when we start to get back into the conferences, especially if you could test, you know, 450 people in a 30 minute timeframe. But let's, let's get into the, let's get into the nitty gritty of the conference, Pete. And you know, one of the things that I first want to, you know, give you is maybe you could tell the people who don't know about the egos what it's about. And then my follow on question to you would be, what's the one thing that really kind of stood out to you as to the growth or the future or what EMS may look like in the Coming years?

Yeah, that's a great question, Chris. So the Eagles, for those of you who don't know, started by Dr. Paul Pepe and Raymond Fowler back in Pittsburgh. They were just a group of doctors in EMS who wanted to get together and talk about ems. And it started off as just a group of people, then they said, hey, let's make a conference out of it because the local people wanted to hear what they were thinking. So Eagles is split up into two days of just all the Eagles in the room talking about what's new and exciting, followed by two days of conference where basically everything we just talked about, which is typically more futuristic. It's atypical because the typical conference you go to, we talk about the basics or maybe things we've been doing over the past couple of years. The Eagles is usually what you'll see in EMS in the next, let's say two to five years. And so the people who are in the room are people who are typically early adopters, innovators, chiefs and medical directors who want to know what's coming up. And oftentimes the data that we're providing and that we're showing is very raw, meaning that hasn't been published yet or just been published. And so there are a lot of different takeaways from the conference. But I would say that I think number one for me only because we were part of the initial trial, is the heads up cpr. And for those of you who haven't heard of that, it's essentially the discovery by Keith Lurie, really well known cardiologist in Minneapolis, that when you are performing high performance CPR and you're in the supine position, you prime the pump and then over a two minute period you start to raise the head and that allows the venous blood to empty the brain so that you can refill the brain with blood that you're actually doing chest compressions with. And the data showed that, you know, double and tripling of neuro and tax survival across all rhythms. We saw that in Palm beach county. We were one of the nine sites. And the one big takeaway that they discovered recently was that if you got the device on within.

Nine minutes, you can have that doubling and tripling of neuro intact survival. That begs the next question is should our police department and our BLS or fire department, who typically get there first, have these devices? It turns out that there are agencies today who have deployed it that way. My agencies are going to it now. I think that the future of resuscitation still, I think in its infancy in many ways. And heads up CPR is just one of those big topics that really kicked off the conference this year.

That was something that was really intriguing to me, the heads up cpr. I first read about that, I think in the Jim's article a few years ago about the tremendously high success rate for Rialto Fire Department's resuscitation bundle. And one of the elements was, of course, heads up cpr. And reading further on it, correct me if I'm wrong, I think this initial conversation got started with, with someone, a Korean physician or researcher posing a question to Dr. Lurie's like, why? We've got some patients that, that, you know, when we have to tote them downstairs doing cpr, they seem to be doing better. And you know, at the time, reading about Rialto's really impressive success rates and thinking, well, you know, this is, this is a fine theory, but it's immature and we're going to, we're going to have to wait until we see some, some other people adopted and get a bigger data set. Well, it looks like we're getting that now and it's, it's something really impressive.

Yeah, Kelly, you're absolutely right. The story you're alluding to is in South Korea, a lot of high rise buildings and you have the elevators which are super small. Oftentimes when you're inside one of these elevators and you're trying to move the patient, oftentimes you're moving them. And what they had was they had the head down and they had the legs up and there's someone doing CPR that way. And Keith Laurie was in there and he was thinking, can this be good? It turns out that when your head is down in cpr, you end up doing worse for the brain. And so that's. That led him along that path of working on this in pigs and then in cadavers and then now in real world situations in frontline EMS system. So, yeah, great stuff. And yeah, you've been following and I know that. Yep.

Just one tangent on that. You know, this also brings to mind just the inquisitive mind of some of our leaders and our medical directors, the progressive medical directors in ems, people constantly questioning and asking why and kudos to the South Korean doctor who noticed a difference and saying, could this possibly be. I don't know of many medical directors or researchers for that matter, who look at things, dive that deep into the circumstances of the resuscitations their people are working and ask why. And it's really Impressive that, you know, an innocuous conversation like that can yield such impressive results.

Yeah, well, you know, I love that comment because there are so many things around us today that we do inherently because someone told us to do it. And I think we have to continue to do that, continue to ask why. Even something like, you know, why are we giving epinephrine and shock orthms? And there are so many things that this Eagles conference, and just one other one is this thing about the supraglottic airway. There is some data to show that if you don't put it in correctly, it continues to pop out. RJ Fresco looked at that and he said, hey, is the supraglottic airway actually working, namely the Igel? It turns out if you ask why, it'll help you even refine what you're doing. So, yeah, I agree with you, Kelly. We have to continue to ask why. And I think EMS is really maturing to the point where we have some great people asking some great questions.

Yeah. But we still have to be able to get. Ensure that we're getting the data that's going to back that up as well. I mean, when we talk about, you know, the heads up cpr and even though we are seeing numbers of patients being more neurologically intact, we still got to get to return to spontaneous circulation. So it makes no difference, you know, what's happening with the circulation. And I think there's still a lot that we don't know about, you know, cpr. So I think all this goes into it, even now, if we're starting to talk about adjunct airways and what they're doing or what they're not doing, I think that's really interesting. But let's go ahead and switch gears a little bit, Pete, because I know that there was a discussion and really kind of talking about it in the career field for five or six years now is whole blood. So how did that play out while you were down there? And is there a future for that in our field?

Oh, my God, this is my favorite topic because I really applaud the people who started it. You know, you look at John Holcomb out of Texas and bringing in all the military data on whole blood. And when you look at the landscape now, guys, it's very interesting that all the hospitals use component. Well, I should say 99% of the hospitals use component therapy. What does that mean? It means that when you go donate blood at the big red bus at the blood bank, they end up separating that blood out into its components. And then at the hospital level, they end up giving you back those three components. Well, we can't do that in ems. It doesn't make sense. So the folks in San Antonio started using whole blood in the field. They figured out a way to actually not waste the blood. They figured out a way to give the blood quickly. And the setup actually doesn't cost that much money. And they've proven over hundreds of patients that it works. And they're saving so many lives of traumatic arrest, people with GI bleeds, people who need massive transfusions in the field. But the big. The big secret and something that we're trying. That we're trying to unlock now in Florida is if you don't have a hospital to accept the whole blood so that you don't waste the unit, then that whole blood goes to waste. So the setup for whole blood is under 10,000 bucks. Right where you have. You buy the freezer, you buy the cooler, you get the quinn flow, you get the warmer, which is the quinn flow, you get the life flow, the device to give the blood quickly. And so if you're telling me that with under ten grand, I could have on my ground units, whole blood, and all you guys know, right. You know how many patients we go to who were shot, who were stabbed, who were. Whatever it was, and we just look at them and we try to do cpr, which we know is futile, because these people are going to die. And how could it be that with just a little bit of capital, you're now going to go and you're going to save people's lives. So I personally feel that this is kind of. It should be like on the captain's unit, an officer, not on every unit, has to be staged around the city appropriately. And there's no reason that EMS should not be carrying blood, especially if you're in a city. I mean, Chris, I've got to tell you, where you work, it's. I mean, those people will be saved by one thing, and that is whole blood. So this is the year of whole blood. In my opinion, we just have to have people figure out a way to get it done. So that's the hard part about it.

My question, Pete, is how are those agencies addressing the expiration issue and rotating it.

And that sort of thing? What approaches do they have to make sure that they're not wasting stocks? You mentioned that.

Do you have a hospital that will accept it and rotate it out? How are they doing it?

Yeah, these.

Units of blood, they have a little tag on them. And if they're cooled at the right temperature, the tag stays green and you know that the blood is good. But the blood has a shelf life of around 30 days. So what they do is at around 21 days, they go to the hospital, they say, here you go. And these trauma centers are using blood all the time so that unit does not go to waste. And then the hospital says, we're going to swap out that two units you just gave. Here's a brand new two units. We'll see you back if you have to swap it out in 28 days again.

But if you don't have a hospital that's willing to take the whole blood and use it, meaning that the hospital has to change from component therapy to whole blood, this whole system fails. We are now in Broward County. The hospitals still don't accept whole blood. Broward Sheriff's Office, who's the one using blood in our area, is basically either using it or wasting it. But we've saved eight lives. Eight lives just in the last couple of months with whole blood in the field. These are eight people who would have died. Two hospitals in Miami have now converted. This is one of those slow progressions. It goes back to, let's ask why we do things. And I'm hoping that by the end of the year, and certainly by 2022, that the hospitals in my county will switch to accepting and using whole blood. And therefore we can have whole blood on the ground all through Broward county rather than only in one distinct location. And in the helicopters, which is where we are right now.

I think that's going to be interesting. And really to make the determination of how effective that's going to be in the field, I think that the research is going to have to show and certainly a lot of things to think about, a lot of things to worry about when we're carrying and administering blood. But, you know, I heard an FBI agent, a friend of mine, say one time, and I thought that he was crazy.

That in this day and age, there is more slavery going on than any other time in the history of the United States. And I know that there was discussions about human trafficking down there at Eagles as well. And when we talk about EMS providers being in the front lines of maybe being able to see this before it materializes outside, I mean, what's going on with that?

Pete?

Yeah, this is something that Dr. Augustine spoke about. This actually, it's a very active issue. It's something that's come up on our Eagles listserv. So we have an email listserv that we kind of throw questions at each other. And I think training on human trafficking recognition is something that EMS is poised to do and really needs to do. And really, that's, you know.

That was really the thrust of it. There are people around the country. I'm sure you've all been at conferences where people have spoken about human trafficking. But unless we practice and understand and know what to look for, look for the signs, then you really easily miss these things. Right. We in the emergency department have to practice looking for signs.

Because these people who are being trafficked are scared to death that they're going to be killed and murdered if they give themselves up. So we've.

Been trained now to look for things and see if these people are trying to give us little signs that they need help. But so many people are being trafficked in America year after year, that I think we have to start paying attention now in ems.

Yeah.

In my reading and education on the subject from various conference presentations, this is not something that's limited to.

Migrant workers and people smuggle across the border. This, or prostitution and illicit sex. This is nannies and affluent homes and au pairs and stuff, who are really kind of at the mercy of their employers for everything. And their agency is taken away because of the position they're in. And we're in a unique position, like we are in many situations, to see this in its habitat, outside of a traditional healthcare environment, where these people are much more likely to.

Accept our care without this aegis of the hospital being all that intimidating where they don't want to go. I just agree. I had no idea how prevalent it is. I always thought that I was kind of Chris's slave, but apparently it's going on more than the inside EMS podcast.

Actually, Pete, you're gonna have to come and help me to rescue Nancy from down Louisiana, because I think that, you know, she needs to get back to the Northeast.

But she's just. She's just a. She's just a captive of circumstance.

Oh, is that what it is?

She's free to go. She's free to go. She's not traffic. She just.

She.

I'm just such a captivating personality that she doesn't.

I can hear in the background. I look good. At least she's talking.

She's giving her distress signal right now. So it's certainly giving the high side.

Of the camera, and certainly we're kind of just joking around. But we know that this is a very important topic and one that we've got to be able to keep our eyes open. Because if we can make a difference for one person, that's going to be a difference for one person. But as we get up there in time, Pete, I wish we can spend more time with you. We always have great fun when you're here. We always have great, a great educational opportunity. So if you think about this and kind of sum up the Eagles conference for ems, I mean, all the top medical directors were down there and you're talking about the future of ems. What do you think we can expect in the next two years or so?

Wow. I think that's a great question. I think that there's a lot coming down the pike with cardiac arrest management.

I think that the next two years comes really refining what we do. Just another quick example is should we be giving a milligram of EPI for cardiac arrest or perhaps should we be doing an intra arrest epinephrine drip? That's just kind of some of the things we're talking about. Other things, when you look at heads up cpr, people are waking up during cpr. What do you do with those people? Well, maybe give them a little bit of ketamine. And so we're continually trying to refine what we're doing. We talked about, obviously ketamine was a huge topic of discussion looking at all the tools that all of us need to be successful where some states are trying to take those tools away. We need to continue with research.

That'S highly qualified, research that's really clinical in nature so that we can continue to do our jobs at the highest level and continue to refine what we do. Ems, I think, is a specialty of medicine that I think has tremendous possibilities and we are just in a great place. So I hope that people come visit us in South Florida next year at the Eagles. It's also going to be in June and we're going to continue to do the research that we're doing and present that data at that conference each year.

Well, we're going to be there and Kelly and I are staying at your house. So just make sure you get those guest rooms ready.

I got to say, Dr. Peter Antonio.

I'm a sad spoon Sevillero. We fight over this every time.

That's never true.

Dr. Peter Antavi, I want to thank you for joining us on Inside ems. We had a great time with you and promise you're going to come back again.

Love you guys. Of course I'll be back.

And if you're enjoying the show, please take a moment to rate and review us on Apple Podcasts. Contact the Inside EMS team at the showms1.com to share ideas, suggestions and feedback or if just if you'd like to join us as a guest. But Kelly, time to put a wraps on another show.

Yeah, yeah it is. You know, a wise man once said that if you, if you read relevant research related to your field, even 10 minutes a week, you'll be ahead of the vast majority of your peers. And if you follow things like the gathering of the eagles, you'll be a well versed advocate for your profession knowing where it's headed two or three years ahead of time. But that's what we think. We would like to hear what you think. So hit us up at the show@ems1.com and for myself and co host Chris Ceballaro and the best smelling Medical Director in EMS, Dr. Peter Anevi, thanks for tuning in to Inside EMS. We're going to catch you guys next week.

Sam.