Handtevy Webinar - Pennsylvania EMSC (2017)

Okay, so how about we get started? First, I wanted to give a big thanks and shout out to Tom Winkler from the Pennsylvania EMSC for hosting this. It's greatly appreciated, Tom, thank you. If you're out there listening, appreciate it. So, just a little bit of background. My name is Dr. Peter Antebbi, actually trained as a pediatric ER doc in South Florida. I've worked in LA and Pittsburgh and made my way back here in 2005. And in 2010, I was fortunate enough to somehow become a medical director of Davy Fire Rescue, which was the first agency I was affiliated with. And it really changed the perspective I had on pediatric emergency care. I always knew there was something wrong with what we were doing. Even when I was in the pediatric ER for many years, I just felt like the resuscitations never went well.

I found myself making mistakes, tenfold mistakes, luckily, without any bad outcomes. And I always wonder to myself, hey, you know, why is it so bad? And when I became a medical director, my God, everything just hit me in the head. And now that I'm blessed to work with over 2000 paramedics in over three different counties and I really understand what happens in the field, my perspective is completely different. And what you're going to hear today is really something that we've really worked hard to really make a dramatic change, not just a change for the provider. So.

There are a lot of things that I believe that I think other people don't believe. But one of the most important things that I believe today is that it's not about the child, it's about us. It's about the provider. Because if I can enhance the provider's confidence, then that child will have a better outcome. And so this really focuses on you, on us, on me.

So let's start. And I almost never get to talk about the product, and I typically don't talk about the product. And so I always have a disclosure slide. You know, I'm an academic at heart. But just for those of you who don't know, there is a company behind this. And I'm just blessed to be able to be.

In a position where we can help so many children across the country through agencies, EMS agencies that are really high performing.

And so I actually wanted to start off. This talk with something that.

I was told about about six months ago is very interesting. And it really kind of pertains to this talk. It turns out that the McDonald's milkshake about, I think was a couple years ago now. They wanted to reformulate it because the sales were flat and so they. They hired a company to spend millions of dollars trying to make the milkshake better so sales would go up. And so what they did was they came back to McDonald's and said, you have to make it, you know, GMOs, you have to make it. You have to make better flavors and so forth. And so what happened was they spent millions of dollars, they changed the formulation, and they realized that the McDonald's milkshake, the sales didn't change at all. And so it was a problem that it seems like an easy problem. You can make sales go up, but it turns out it wasn't that easy. And so here's the real problem with the McDonald's milkshake. It turns out they hired another consultant. And the consultant said, I stayed outside a McDonald's restaurant for the last two weeks, and there's two people who buy milkshakes. He says, number one, it's a business person. Before 8:30 in the morning, they walk in business attire, typically a white male. They buy the milkshake and they leave. Then in the afternoon at around 4:30, it's a parent and their child who buy the milkshake. And so his recommendation was not to change the formulation of the milkshake, but for that customer who comes in before 8:30 in the morning, put the milkshake machine on the counter, let them swipe their credit card, let them serve the shake themselves, and then walk out. And that one change, that one change, increased sales by sevenfold of the milkshake. And so the analogy here, although it may be a little bit tangential, is that there are problems that sometimes people have easy answers to. And you listen to the answer and you say, hey, you know what? That makes sense. I'll buy that answer. But over time, nothing changes. And I want to show you graphically where I really feel like we are over the last 30 years in America. This data comes right from the American Heart association, from the front page of the guidelines, from part 12 of the guidelines. And you can see here that if you're an EMS provider, we're in the blue line there. That means that if you have a child with an out of hospital cardiac arrest since the 1980s, the chances of survival haven't changed at all. In hospital. You can see the red line has changed. Now, if we were in a live audience, I would say to everyone, hey, how did that happen? Right? How did we get to a point where we haven't made a change, not even a dent in survival in the last 30 years, and people have Their reasons, they'll give me a lot of good reasons that make sense. But at the end of the day, I'm realizing now that those are not true. And so I want to kind of take you on a little journey here and really give you an explanation that I believe is the reason why pediatrics really haven't made an impact in pediatrics in so many years. So I'm going to test your brain. So I'm going to give you a case and I'm going to let your brain just, your brain will automatically do the work once it sees these things.

So there's your next patient, you're en route, you have 5 minute ETA. So think to yourself what your brain is telling you right now. More than likely scene safety, bsi. You're going to get into the apartment, you're going to see the guy stuck between the toilet bowl and the wall, you're going to pull them out into the living room, you're going to change, you're going to move all the furniture, you're going to do high performance, pit crew, cpr and it's going to go smoothly. And you're actually visualizing that en route to the call. And your confidence is building. You've done it a hundred times before. How about this case? Same thing, right? 65 year old is in a restaurant, he had a peanut by accident and he's in anaphylaxis. I'll guarantee you, guarantee you, you'll walk in there and you'll say epi, 0.3 to 0.5 Benadryl, Cymedril, Albuterol. Let's start a line, let's package that guy up. And as you're leaving the restaurant, you're looking around, looking at people in the eyes and saying, yes, that was me, we just did that. Thank you very much, I'll be back. Right? It's that, it's that feeling that you have before you get to the scene. It's a feeling you have on scene and then it's this feeling that you have when you drop off the patient and you give a high five to your partner and says, that was awesome. Right? Now let's take you to another case. But the cases, by the way, are not different. The only thing that's different is the age. And see where your brain takes you. Now, five year old in cardiac arrest, five year old in anaphylaxis. Chances are that you're seeing that and your brain just went to a whole other area, right? Your brain said, oh man, five year old, oh, I hope that when they update me on the mdt, that it'll be that the five year old's really breathing, right? That's the answer I hear most when I say, what does your brain tell you when you see 5 year old in cardiac arrest? That I hope it's not. And we all know that hope is not a strategy, right? And so it turns out that the adult versus the pediatric call is different from the moment you hear the age 65 or 5. That's when you take a turn either right or left. And that's a very important point that we're going to get back to at the very end of this.

And you know, I told you guys earlier that I started as a medical director in 2010. Well, here is a case of 2015. What happened? So in 2015.

I started at Palm Beach County Fire Rescue. And you can see here that we changed three things in Palm beach in 2015 when we took over. Myself and Dr. Ken Shepke, top left, we stand scene for 20 minutes. The top middle, high performance EPR. The top right. We actually don't provide positive pressure ventilation for the witnessed cardiac arrest for the first six minutes. After six minutes, then we'll upgrade to an eye gel or we'll intubate and that's when positive pressure will start. Why I'm telling you this story is look what happened to our data and to our numbers within one year of making these changes for adults. Okay, this is for the adult sector. And this data was presented by Dr. Pepe at a recent conference and is actually published in circulation. The abstract is, and you can see here that in 14, when we weren't there, you could see the numbers in black, the transition period was in blue. And you can see how we've just increased our numbers on adult cardiac arrest. We actually peaked at 53% in September of 2016. Now that is pretty remarkable. And I said, well, why aren't we doing the same thing for pediatrics? And so I'm going to kind of move over to a different topic now, which is where I learned a lot about what happens in the field for providers. And this is Lieutenant Jonathan Robbins, who's become a very good friend. He's actually one of my lieutenants at another agency that I provide medical direction for. And what I learned from Jonathan Robbins is the following, that the pediatric arrest has a very, very big impact on the person. Even if you. In other words, if you don't feel like you performed 100% on that case, it's gonna affect you for the rest of your Life. And let me, let me give you the story. So Robbins, when he was a rookie, so about nine years ago now, he actually came up on scene of a two year old drowning. He opened the back door and a police officer was holding this two year old dead kid dripping wet. Robbins puts him in the back of the vehicle and his lieutenant at the time said, hey Robbins, you drive. And so Robbins went out, he got to the front of the, of the vehicle, lights and sirens. But he didn't know how to get out of the neighborhood. It was a gated community and he, he went to two dead ends and he passed the house twice before he actually got out of the neighborhood. When he got to the hospital, he watched the physician code the kid for about 10 or 15 minutes. They called the code and Robbins walked out of there with his head down. And who do you think he blamed for that kid's bad outcome?

I'm sure all of you are knowing this, right? He blamed himself. And who do you think he told? Well, he told nobody. He didn't tell his mother, his sister, he didn't tell his girlfriend. And surely he did not go back and tell anyone back at the station. What I learned from Jonathan is the following cycle, arrest, life cycle, I call it that. Basically right here at the 12 o' clock position, right when the call goes off, two year old drowning, that quadrant here, that's where you're having to step up to the plate in your mind and know what to do for that kid. But it turns out in pediatrics you can't. So let's put an X through that quadrant. On scene, it's load and go, it's rush, rush, rush. Right? We don't treat them like we do adults. That's an X there as well. For this quadrant. Then we have the debrief, as most of you know, for cism, for mainly pediatric calls. And then finally what we're trying to do here is get to closure.

So really what I'm really trying to get to here is that in order for you to feel good about these pediatric or adult calls, you have to get to this quadrant, which is closure. Now how do you get the closure in your own mind after an adult arrest? I'll tell you how. En route to the scene, you feel really good about it. On scene, you feel really good about it. You don't need to debrief and you leave the hospital saying to yourself, I did everything I could for that patient. In pediatrics, this quadrant doesn't go so well, right? Because the only way of knowing the dose of the child before you get there today is by actually using a length based tape on scene, you don't feel so comfortable. And you're telling your own self in the debrief that you're not feeling well. And then if you never get closure on that patient, it turns out you'll never get closure at all. And so that's a very, very important point. And there's many studies, I'm just putting up one of them. But, you know, every month it seems in prehospital emergency care we're seeing these types of reports where the amount of people who feel comfortable just doing the medication dosing is low across the board. This was just published, so let's now move into how do we overcome that? Right. Why is it that your brain, when it heard 5 year old versus 65 year old, went in a different direction? Well, it turns out there's a very good reason for that. And it's based in Resuscitation Psychology by Daniel Kahneman. This is a phenomenal book. You should read it if you haven't. So the next five slides or so kind of talk about Kahneman's understanding of how our brains function. And this is so critical. It's so critical that.

This item will really explain everything about pediatrics. And I think really, it really unleashes a lot of information for us to utilize to make ourselves better. Kahneman's very, very basic principle, which took him many years to figure out, is that there's two parts of your brain. On the left side you see system one, it's the fast part of your brain. This is the part of your brain you have no control over. It's a part of your brain that answers questions and it thinks it's right even though it's wrong. And in other words, even if you tell it it's wrong, it won't believe you that it's wrong. So it's very arrogant, but very fast. System two, on the other hand, is very slow, very lazy, and you have to kind of wake it up. I'm going to prove to you here in a minute that system one is where all of us live. All of us in ems, in the er. We're quick, we're rapid, and we know that we're very good. But mistakes are made without us even knowing it. In pediatrics, on the other hand, it's a lot of system two, you have to stop and think about things. And oftentimes this is not so effective when you have someone dying in front of you. So let me let's explore this concept a little further.

So if you've never seen this question before, take a second and try to answer it. And your System One is already giving you an answer. Most of you are probably saying two or one of each kind, right? But in reality, and for those of you who know it, the answer is zero, because it wasn't Moses. And you see here, that's the fascinating part about System One. It gave you an answer. The answer wasn't correct. But unless I pointed it out to you, you wouldn't have known that. And so System One is very intriguing to me because in ems, you'll walk in, you'll make a decision. Most of the time you're right until you're not. So it can make mistakes. Here's some more examples of system one. So what you see on the screen now is 12, 13, 14. What you see on the screen now is ABC.

But what you now recognize is that that middle image was the same exact image. But your System one was able to situate, situationally tell you this was a number, situationally tell you this was a letter. And so you see how fast your System One functions. For its benefit.

Here's where System One can get into mistakes. And I can tell you that in my agencies over the years, we've made similar mistakes. Not this one particularly, but where you're thinking you're giving Zofran, but you give Vasopressin instead, you're thinking you're giving Reglan, you're giving oxytocin. I mean, that's a hospital issue, obviously. Here's a case study that was published of a child who was supposed to get antibiotics, Ancef. Instead it got Vecuronium, because the System One saw a clear vial with a red top. And that's what it did. This is all fascinating, right? So I'm going to test you guys here. Again, this is a one way conversation, but I want each of you to do this individually. And then I would love for you guys to type in the answer in the chat bar. This is how we'll make this interactive. I'm going to put up nine numbers. You're going to have to count up those numbers and tell me what the answer is. As soon as the last number shows up on the screen, the numbers will go away. And I'm going to ask you to type in the number. The beauty of this exercise is you're going to think this is the easiest thing you've ever seen. And then about 80% of you will probably get this one wrong. Only because I've done this many times in public. And this is your system one. So arrogant, so cocky that it's going to get this one right, and you're going to realize how difficult this is. So here we go. I'm going to give you nine numbers, one and a half seconds between each number. Don't write anything down. And at the very end, I want you to type into the chat bar or the question bar, the answer. Here we go.

Okay, at the end of the day, here's all the numbers. Most of you answered 51, sorry, 6,000. And here's what happened to your brain, right? You have a thousand, a thousand, a thousand. And you have 5,000. And you have 30, 20, 40 and 10, which is 100. And then most of you took that hundred, made it a thousand, and gave us 6,000. So, Susan Yeager, Russ, Matt Rogers, Valerie Glenn. Okay, now you guys are all getting it right, but the whole point is here, without belaboring it, and sorry for the technical difficulty there, but the whole point is you would have left that scene giving the quote unquote, 6,000 dose. And you would have said to yourself, wow, that kid's pain just stopped after I gave that dose of fentanyl. But what you wouldn't have realized is that the math that you just did was completely wrong. So the danger of system one is its arrogance. The danger of system one is that you think you got it right. You give the dose, and you're not gonna go and tell anyone that you gave the dose correctly. So this is the danger in system one. And so I got this wrong twice the first two times I saw it. And I finally got it right on the third time because I thought this was the easiest thing in the world. Little did I know that my system one was getting it wrong. So for those of you now who got that question right, here comes system two. This is a different part of your brain, Kahneman will describe. Your eyes will dilate, they'll go up and to the right, and your heart rate will go up. Here we go.

So as you're seeing that on the screen, your brain just. Your System one just says, I'm done, right? I'm checked out. And now you have to ask your system 2 to wake up and do this. Very few people.

Are actually going to try to do this, especially when you're during a resuscitation. And it turns out what Kahneman says is that if your system 2 gets activated in a stressful situation, you get the fight or flight response. And so the little Hidden secret. The little hidden secret that we now know is that if your system two gets activated, that's the danger zone right here. It's the same thing if you're a neurologist and they say do an NIH stroke scale. There's no one who could do the nih. No neurologist I know. They got to close the curtains, they got to do the three page exam and they have to come up with a number. System 2 is a different animal. If you're someone I know, there's a lot of hospital people on the call today. If you're at the head of the bed for this kid and you have to put in two large bore IVs, you have to give antibiotics, but then you say to the nurse, I'd like a central line, a norepi drip, let's get ready to intubate. I'd like a foley and an NG tube. I will tell you that not 99 but 100 times out of 100 people are gonna ask you the following questions. What size central line? How would you like to norepine drip? How do I mix it? What rate do I start that at? ET tube, you want it cuffed or uncuffed? Blade, you want straight or curved? What sizes do you want of the Foley and the ng? And so I had this case many years ago where I made a mistake. And my mistake was I didn't ask for norepi drip fast enough because I knew that I didn't know the answer to the questions the nurse was going to ask me. I waited an extra hour before that got done and the girl ended up dying two days later. I took the blame for that. Me. Right. And so that that should never happen. I knew I needed norepi, I just didn't call for it fast enough. Why? It wasn't that I didn't know, it's just that the system two was there. I had a fight or flight mechanism and I ended up delaying the ask. And that was the problem. So this is the secret, folks. System two is the problem. It's not the fact that you haven't been to a pals class. You know, the information getting to it is different. So I'm going to prove that in a different way.

Here's a 60 year old male who's hypoglycemic. He's unconscious, he has a pulse, but he's breathing. His blood sugar is 18. Now I know many of you have switched over to D10, but let's just imagine using D50. What's the dose now he's in asystole. He needs epi 1 in 10,000. What's the dose? And here's a mild allergic reaction. He needs Benadryl. What's the dose? And so most of you are saying it's an amp of that. It's an amp of that. And for the Benadryl, it's an ML, right? It's 50 milligrams. And so we could do this with our eyes closed, right? This is very, very simple to do. I'm sure most of you didn't even blink when you saw that your heart rate didn't move at all. Watch what happens now when I give you the same exact three problems. But now it's a five year old.

So what just happened to you instantaneously is the following. Your brain just made a left instead of a right. And now your brain is telling you something like, okay, I need the weight. So I'm gonna go along that game here and I'll say, okay, let's say he's 21 kilos. Now what? Well, now your protocol says 21 times 0.5 grams per kilo. That's what my protocol says. That's 10.5 grams. Now it says D25. And I don't carry D25, I carry D50. So I gotta cut it in half. I gotta make D25. And once I make D25, now I have to figure out what the volume is. It's 10.5 grams. Impossible. You won't do it. Your system two will get activated. You'd rather just package this kit up and drive the five minutes to the hospital if you have that luxury. Same thing for EPI and same thing for Benadryl. So it's not that you don't know what to do. The problem here is that it's system two creeped in right here.

Because it creeped in. Now you have to make that decision of am I going to do this in front of mom and dad, or am I going to go in the back of the ambulance and just rush? And that's what we end up doing.

So just to recap that part, System one is fast, but it makes mistakes. System two is a great information resource, but if it activates during a resuscitation or even any critical kid, then your fight or flight mechanism goes, and then you end up leaving the scene and not performing like you would for the adult. That's the critical difference there.

And we're not just talking about resuscitation, okay? I'm talking about anaphylaxis. I'm talking about fentanyl, which most of us use now, Midazolam, which I think most of the country is now using for seizure. And I can tell you that that one on the left, I made a tenfold error in 2005 when I gave a 5 year old girl 2.1mls 2.1mg.

Because.

I made a tenfold error because I was looking at a length based tape and I saw the number and I gave it and turns out that was a resuscitation dose, not the anaphylaxis dose. Thank God the girl did okay. I didn't realize I made that mistake until I became a medical director in 2010 and my medics were making the same mistakes for EPI, they were giving three fold overdoses for fentanyl and they were giving threefold overdoses for midazolam because the dose for fentanyl and midazolam on the length based tape were at the time for RSI for intubation.

Once I became a medical director, I started to realize, hey, this is not just me making mistakes, it's a lot of people. What I decided to do was look at the length based tape and compare it to my protocols. And I found a very large discordance. All the ones in red either didn't match or. Or the dose listed was not the dose in my protocol. And this is the same as the Mosis illusion we talked about earlier.

And then I actually presented this abstract at the NAMSP where I looked at 38 agencies across the country and I found the same exact number. Actually one was about 63% up in Minnesota. Discordance between the tape and the protocol and the protocols are very complicated, right? We now have txa, we have lots of different drugs, we have multiple drips, especially the helicopter agencies as well.

There is a peer reviewed study. We were not involved with it. This is the folks out of Denver Health and this is available to you guys. You can go on the website, you can find it.

Where they compared paramedics with a length based system with the Braslo system compared to our system. And they found a threefold reduction in error only with two drugs.

Which was epi, 1 in 10,000 and dextrose, kind of relatively simple medications. And people are still making mistakes, but at a threefold clip higher.

Now I want to talk about education because a lot of people, and this is kind of, it bothers me a little bit because as a medical director when one of my medics makes an error and I go Back in. If my answer is more education. Well, if the education was valuable, I would say, okay, here's a study that was done out of Houston and really it points to me, it answers the question, does education in pediatrics matter? So here's what happened. It's a fascinating study. I have to congratulate the authors on this one. They actually took a large majority, or actually they have so many medics. They took a lot of medics, their department and gave them a special training program called PD Steps. It was eight hours. It was pediatric specific. It was only to EMS providers. What they did afterwards is that they followed only that subset of medics for two years. And without letting them know that, but they wanted to see how did these medics perform after getting specific education. Let's take a look at the data. In Houston Great Fire department, they had 250 children who were in the cohort who were actively seizing en route to the hospital. And you can see that there was either the group that had no additional training. So these were medics who didn't have that training. And they compared them to the PD Steps trained group. Let's take a look at who did better.

So let's take a look at the top line first. Did those children actively seizing receive a dose of midazolam? And you can see that the non trained medics, 56%. The PD steps trained medics, 63%. So what that says is that on a percentage basis, 37 out of 100 children of those who are trained are still not getting seizure medication in the back of an ambulance and they're actively seizing. But what hit me the hardest is if they did get the drug, did they give the correct dose of the drug? And look at that, only 51% in each group. So to me, this is crystal clear now because there's two issues that happened here. Two different types of errors. The first type of error is the error of omission. You have a child seizing and you don't give a benzo. That's number one. The second error is you have a child seizing. You know you want to give a benzo and now you gave the wrong dose of the benzo. And so those are two dramatically different problems. The first one is a confidence. And system two.

System two went off and you just said, I'm leaving. And then the other one is really like a System 1 math mistake where you thought you knew how to calculate the dose. You calculated the milligrams to milliliters, and next thing you know, you had an error. 51% of the time. So think about it. Do medics not know how to treat seizures? Of course they know how to treat seizures. The problem is not in their knowledge. It's the problem in how we, how we get them, how we give them that information. And if we don't allow them to know the dose before they get there, if we make them do math on scene and pull out a length based tape in front of mom and dad while they're there, that's not healthy and it's unsafe, really. And so when you look at these numbers here, it proves one thing, that we shouldn't keep teaching people how to do math and how to do calculations, because that's not the problem. The problem is removing system two. And so I want to give you.

This perspective of pediatric data, which is there's a lot of studies out there that are looking at data. But what is the data going in versus the data going out? That's the question. So my question now is when you're actually documenting that dose of fentanyl, Think about it. I could tell you that with all the medics I work with, if we're going to give a dose of fentanyl on scene, when we're going to document that dose is sometime much later, right after we drop the kid off at the hospital. So is the data that we're even documenting correct? When are we documenting it? How is that data being obtained? Right. And again, if you're inputting data in later, are you obtaining that data from the protocol at the time versus the drug that the dose that you gave on scene and where is it obtained? And then going back to the accuracy. And so when I look at data nowadays, I'm really focusing in on, you know, are we looking at the right data and are we actually looking at outcomes? And that's really what I want to talk about in this next segment here.

Because I think that.

We'Ve been living in the past for a long time. I'm going to show you now what we're doing to really try and, you know, enhance outcomes in the field. And then we have a big future that I want to talk about as well here in a minute.

And I want to talk about data and integration with our first integration partner, which is eso. We're now working with image trend, we're working with EMS charts, but I'm focusing on ESO only because we've integrated with them first. And I want to show you something that we've done which I think has, has tremendous value. So I'm going to go out to the Internet here.

Let's make this large. Okay, so what I'm showing you here is something that we've really worked hard on. We do have the Hantevi system. Let me just stop for a second. The Entebbe system is really something that's unique in that it's customized to your agency. What do I mean by that? It means that when you look at your protocol and the significant variability and the significant complexity in your protocol, you need to have information that reflects exactly that information. Number one, that information should be available to you just like in adults before you get to the scene. And then you should be able to document that information at the same moment that you're giving the information. So what we've done here is this is an example and it says here EMS integration. But we have agencies in all 50 states. So there's one that says San Antonio Fire. There's, you know, Miami Dade, there's Denver Health, there's Honolulu, Hawaii, there's. I mean we have agencies all across the country. And this information would be only the information coming out of your protocol. So let's go ahead and say we're going to start a new patient. And so you see here that I'm doing this now on my toughbook, right, as the example. And let's say I'm going to a two year old drowning. So I click on two year old. And then you can see here that all this information has been customized on the back end. And we have an entire clinical team here at the office. We have pharmacists on staff who help you get to the point where all this information is customized. So as an example, let's say that we're going to a two year old in cardiac arrest. I know the dose before I get there. I'm going to click on it. And you can see here that we even allow the individual agency to put notes in here. And now when the medic is actually giving the drug, I'm saying given and it turns green. And so what's never been done before is the speed of which I can go and I can say I'm giving etomidate, let's go ahead and give magnesium.

And again, as fast as you could say it, I can click on it. I'll get some calcium chloride, 2.4 mls. Uh, let's go ahead and give our first dose of adenosine. And again, this is a note from the medical director or the EMS chief and so forth. What about drips? I'll go to the drip section, lots of agencies use drips. So let's go to Norepi. It tells me take 4mL, which is 4mg added to D5W250 and that's gonna end up giving me my final concentration of 16 micro ML. And then I'm gonna run it at 2.3mls an hour. If you don't have an infusion pump, it would give you the drops per hour, the drops per minute going down to equipment. So if you want to intubate, you can get a 4.5 cuffed ET tube. Let's say that was not successful. Again, this is happening in real time. I want to go to an Igel size two and I'm going to say that was successful. What if I want to defibrillate?

It says here 30, 30 joules. That has been pre calculated for me by our software already. And let's say that was not successful. So my partner will say now hey, let's go to 50 Joules. And this information by the way is all customized to the LifePak or the Zoll, whatever monitor you're using. And you can just flip back and forth very simply and you can keep going. And so this is something that we've worked on for about the last, let's say year and a half. But now the real win, the real win is that if I'm a medic and I want this information to be sent over into my chart, that's where the win is. And I can tell you that a few weeks ago I was on a call, we had a 65 year old in cardiac arrest on a tennis court. My crews did an amazing job. I was there, I was handing them the epi where every, everyone did a great job. We got rosc. But when I saw my medic, my lieutenant document at the end of the call, he was just making up times and he was honest with me. He says document, I know when I got there, I know when I left and I just fill in everything in between. That's not good. So watch what we do now. We go to review and submit. All we ask you for here now is your name. So this is the person who did it. And now you can see everything that we did is listed here.

And now I simply just say I agree to everything that I've done and I'm just going to submit that. And you can see what just happened here. My chart's been submitted. And so, so, and that's the only step that required WI fi number one. You could do that on airplane Mode. But if you want to send, you need WI fi for that one step. So now I move over to eso. So this is again just a demo with eso, because that's who we've integrated with, is that, you know, here's your patient, you go to the flowchart, you click on import and you see here that, here's that 2 year old, 11 treatments. I designate that as my patient. I say receive.

And now this information is now walking across the cloud right into your medical record, as if you were documenting it in your medical record. Now this for me was the holy grail to say, you know, if my medic can now have that information walk across and get inserted into the medical record just like that. And here we go. And you can see here, there's the epi, automata, mag, calcium, and all they did was just click a button. That's a win because now I know, going back to the data slide I had, that this data is accurate. I know my medic doesn't have to think of a dose, the volume has been calculated. And then you look, we actually documented in milligrams. And so that's something that we're really, we worked really hard on. We're working again with image, trend, EMS charts. Zoho will be a 2018 project. We're also working with Cerner now and EPIC to do the same exact thing.

Another very cool thing that we've worked on really hard is let's say that you don't have the integration. Well, it turns out right from the application, you can actually have this send to a fax machine or an email. This is just a PDF of a sequence chart of exactly what you did so you can get to the hospital. This could be ready for you in the fax machine, even without the integration that I just showed. So as a medical director, as someone who cares about data, as an academic person, as someone who wants my medics to feel confident not only in treating the child, but in documenting their care and feeling good about it after the fact. This was really, really important to me. So I'm going to move on to the last segment here, which is outcomes, really, because I can talk here for days on end. But if we can prove that what we're doing shows value and that's really the key, right? Because.

There are people out there who have widgets and who have other types of tools. We need to look at outcomes and we need to say, is this changing? Is this moving the needle at all? And that's really the important part. And so let me start on a single case and then I'll take you to larger data set. Alejandro is a 2 year old in Miami Dade, has been using our system for years now, probably six years. They stay on scene for pediatric arrest. They know the dose before they get there. They look at the mother right in the eye and say, we're going to do this right here. And that's what they did for this little two year old boy who was underwater for six minutes. He was in a coma for nine days. No one ever thought he would wake up. And lo and behold, after nine days, they extubated him. It took a few more days. He started saying some words. He had to go to rehab, he had to learn how to walk again. He had to learn how to say mommy again. And I had a chance to meet him. And the lieutenant who saved his life, Lieutenant Tammy Napolis, God bless her. Because really, this is not about me. This is not about Han Tevi. This is not about, this is really about the provider. This is really about making people wake up in the morning and say, if I have this case today, I'm gonna feel just as good about treating this 2 year old as I am treating a 62 year old. And so again, it's not about the child either. It's about you. Right. And the only way to get you there is to give you the tools and the confidence to do that. And we have a training program which is four hours long that'll transform how you think about pediatric treatment. You know, it'll transform at 180 degrees, right? Because what we now tell people is that maybe you don't need pals in ems. Maybe you need your ACLS background. We use your ACLS foundation to then train you up on pediatrics. And that's really our goal, is to create providers out there who don't see a difference between adults and children, who don't see a difference between adult cardiac arrest and pediatric cardiac arrest, who, who don't see a difference between adult seizure and pediatric seizure, who have the same confidence as Tammy did when walking up to the scene before she opened the door and said, I'm here to have that same confidence that you exude that confidence and that you leave the scene saying, you know what? I did everything I could. That's the critical part of it. And then here's data from Polk county. And I love Polk County. I love all the people there. I love the medical director there. Why? Because not only did they make this change in 2014, but they recorded every single arrest after that, this is data that's going to be. And this is a slide they gave me back in 2016. They're not going to be publishing this, I should say. They've submitted it to American Heart association for the November conference. You can see that ever since they implemented Hen Tevi in 2014, the ROSC rate went up and then the survivorship. So this is 71% of the 33. And this is 70 of the 29, 87 of the 56. This is 25 children, neurologically intact children who walked out of the hospital. Why? Because a paramedic and an EMT stayed on scene instead of running. Right. That was the difference. It was those first couple of minutes. And it has nothing to do with having a tool in. It's about having the mental tools and the confidence on top of knowing the dose, on top of being able to document it. This is a complex problem that we're trying to fix and this is the kind of data that we're looking for. Because this graphic that I showed you early on, this is where Pole county is right now. Right. So what we're looking to do now is create a repository where we actually not just have one county, we, we're going to create almost like a pediatric resuscitation registry of people who are using this type of system, people who are staying on scene. And we're going to prove that it's not that the medic doesn't know how to do it, they have to be given the tools to be able to do it. And those tools are not just in a book, those tools are not just on a tape. This is a comprehensive system that has to come together in your mind for you to say, I'm going to do this tomorrow. And that's what I learned from Jonathan Robbins. Where eight years later, after that event, it turns out that Robbins was circling the drain for many years and he didn't tell anyone how anxious he was. He was at the bottom of the barrel. And we taught him this in 2015. And the only things we taught him, let's just clarify, we gave him the en route information, right, that a 2 year old needs 1.2 cc's of epi, a 3 year old needs 1.5 cc's. Very simple. Gave them the confidence to do that.

We practice how to work on scene with how to talk to parents, how to assess a child, you know, how to work as a team, just like we do for adults. The debrief still happens, but it's much different. Right. We don't we don't kind of hang our heads down anymore in the debrief. And now Robbins can get the closure. And let me. Let me explain to you how I learned about that. Robbins, a week after the four hour course that we gave him, had an 18 month old who choked on a grape. Cop was on the third floor, brought this kid down bleeding from her mouth because the mom was doing blind finger sweeps. Robbins looks at the cop and says, put this kid down right here. Puts the kid down, gets his blade, suctions all the blood out, gets his McGill, pulls out the grape. The kid walks out of the hospital 36 hours later, perfectly normal. Okay? We wrote him up for that. A few months later, a week after that, he had this little boy who. This is a famous case because this kid was on the Today show, but this little boy was drowning as his mother was giving birth to his little brother. We transported this kid James to the same hospital his mother just gave birth at. Robin's got pulses back on this kid because he stayed on scene. And so Robbins came to me a few months after these two cases, and we were at a benefit event, and he comes up to me and says, doc, I got to tell you something. He says, I'm the one who had those two saves, but I want to tell you something that I've never told anyone before. I said, what's that? He says, well, for the last eight years, I've been anxious. For the last eight years, I've been depressed. I never wanted another pediatric call again. He says, now that I got closure on these two cases because I know I did all that I could. He says, I'm a different person today. And I said, who have you told? He says, I haven't told anyone that. And so the sad part to me is that I was that person, right? I made those mistakes. I didn't tell anyone. I didn't tell my wife. I didn't tell anybody because I was so embarrassed of myself. Now that I know the problem, I want to change it for everybody. And not everyone has had the opportunity to actually benefit from this. This is David Dangerfield.

Some folks in the call may know him. I never knew him personally, but this is his story. He's a 27 year chief in Indian River Fire Rescue here in Florida. One hour before he went outside and shot himself, he wrote this on Facebook. He wrote, PTSD for firefighters is real. If your loved one is experiencing signs, get them help quickly. 27 years of deaths and babies dying in your hands is a memory that you will never get rid of. It haunted me daily until now. My love to my crews. Be safe. Take care. I love you all. If you read that line right here, 27 years of deaths and babies dying in your hands is a memory you'll never get rid of. What he's saying there is that if you don't get closure on each of these cases, it's going to stack up on you. Right? I have cases that I'll never close out on. I've changed that now. Right. I've changed my hospital system. I've changed the EMS system so that I can leave every call saying I did everything I could. I can look at the mother and father in the face and say, we did everything that we could for your little son or daughter. And that's where we all have to be. That's why I'm focusing on the provider and not on the child anymore. And this is the child. This is the family he left behind. And his wife tells a story that as he was walking out in his class a uniform, he put his wallet on the kitchen counter. And his son said, hey, dad, you forgot your wallet. And he says, no, son, I won't be needing that. And he walked out, and that was the last they've ever saw of him. And that's so sad to me, right? We've lost people in our departments. I know many of you know this across the country. This has to change. And I think that making a simple change like this for pediatrics is a place to start. And so pediatrics, again, is like the McDonald's milkshake. It's like these roads that people want to put lights on to help people stop crashing on. I think we have to come to the agreement that we have to make a significant change in pediatrics. We have to tear up these roads and build a new one. And so I hope that this last 50 minutes or so has given you some insight into what we're doing, that it's a lot deeper than.

A calculation tool. This is a lot deeper than that. This is about us as providers, and it's really, truly about the pediatric outcomes at the end of the day. So I would like to invite everyone to download the demo of the Hand Tebi Mobile. So when you download it, it'll ask you for username and password. You can use EMSC2017 and then you can kind of play around with it and so forth. My personal email address is listed here peterhantevy.com if you want more information on what we do, it's infoantebi.com I could tell you that. And before I open it up for questions, we have courses now that we have instructor courses that are going on at Las Vegas, at EMS Expo, Houston, Massachusetts. We have several other places across the country that we're going to be, and there are trainers now that exist in places like Oregon, San Antonio, and so forth. And so we've really tried to make an impact by creating a system of care that's easy to implement and that is cost effective. So I'll stop there. So, again, thanks everyone for your time. I greatly appreciate it and just really blessed that I can work in EMS and work with you all. Have a great day. Thank you.