Live From Expo 2024: Peter Antevy and Charlie Coyle on the Game Changers in Prehospital Care

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Welcome back to EMS World Podcast. Live from the exhibit floor Las Vegas 2024. In the booth with me, two of my faves. You're probably sick of me talking about them, but they're interesting, so I keep having them back. And that is Chief Charlie Coyle, Dr. Peter Antevi, Palm Beach County Fire Rescue. Gents, thanks for being back and in this case, thanks for staying. From the last one we're gonna do. We're gonna talk about some of the up and coming things in EMS and expect to see some of the things that you have seen, done some of the outcomes, the research on that, and the data that have proven why we have to continue down this pathway. So listen, let's, let's start off right away with this. Let's talk about plasma for tbi. Who's hitting it?

Hey, Mike, again, thanks for having us. This is a tough one because I'm not, I'm not the brainchild of this. So this.

Say this all the time, except you are.

No, no, no, no.

This was actually, this was discussed a couple of months ago at the national whole symposium that was done in San Antonio. And this is something that Dr. Holcomb was talking about that he's researched previously. And then he's also, you know, kind of picked apart some of the trials that are out there that showed some profound benefit for TBI with plasma administration. So this is in the early stages for us. Obviously, we're trying to figure out how do we practically do this and make sure we have inclusion criteria not for our patients, but for our trauma centers to make sure that they don't just completely come unglued because we're doing something different, which has happened to me before. So, you know, Dr. Holcomb is really helping us out with this concept. He's going to be. He was down in Miami talking about this topic at one of the trauma centers last week, and now he's going to be working with our trauma centers on Monday. So we're super excited about it. From my perspective, TBI has been all over the place for pre hospital. Right. We know that hypotension is bad. We know that hypoxia is bad. So everyone started trying to fix Those things. Then the blood pressure shifted. Right. First it was 110, 120, then 130, 140. But how do you get there? Do you give 1 liter, 2 liters? Do you give a push dose pressor? What is that magic formula? So from the simplicity. I have to give simplicity because I'm stupid. So the simplicity style, from what I understood it to be, is when you have something that's bleeding and the capillaries are leaking, what do you do to stop that? Do you just continue to load that up with fluid? Do you give that a pressure? Or do you give something that could potentially change the clotting cascade?

Right.

So in Dr. Holcomb, the way he explained it to me was very simple, was essentially that area that's in danger, the penumbra. This can also protect the glycocalyx around the penumbra. So, again, I say it confidently. I don't know it well. I'm interested to hear Dr. Holcomb talk about it, but I really think that it's something that when I talked to a couple different trauma surgeons from our agency, they were very excited about the concept. I know there's some other talks about people using it for burns as well as sepsis. So it's really innovative. It's really different. It's not as expensive as whole blood or anything like that to carry. And it could be a game changer. So much like everything else, the data is there to start what we do and how it affects our agency. That's what I'm interested to see.

All right, so we got to wait on that one. Right now it looks promising, but we're going to see how it goes. Because like you said, this could certainly be a game changer.

Oh, we're going to do it.

Okay, Peter, let's. We've spoken about this in the past, but let's talk about dual sequential. You know, we spoke about this, actually. Not far off, but I think some things are still in the mix here and possibly changing.

Yeah. You know that paper that Dr. Chesky's published in the New England Journal in November 2022, and if my watch is correct, it's almost two years since that publication when I asked for a raise of hands. How many people are doing dual sequential? Very few people are doing it. And the question is, why? So it's that translation of practice where if you have a patient refractory VF coming into your local emergency department, there's a pretty much 100% chance that that patient's gonna Die because there's nothing else to do unless you can go to ecmo, right. Which many people can't around the country. So why not just throw on another defibrillator and shock them at double the energy, either 720 or 400. Why not just do that?

Right.

So the data is clear. You can double neuro and tax revival from refractory VF just by doing double sequential. So everybody should be doing it. That's number one. Okay. Now the folks in Europe are looking at whether or not we shouldn't wait for the fourth shock. Now it's standard, standard, standard shock. And then the fourth one is double sequential.

Right. That's what I was going to ask you about, is that we're changing when we should do this. Possibly.

Possibly. So there, the theory is that you should. The earlier you move double sequential, the better outcome the patient has. There's still data that we have to wait for. But my prediction, it's going to be one shock doesn't work. Second shock should be double sequential. Logistically, a little harder. You have to have the second monitor, they're quicker. But I will tell everybody that you should already be doing AP pad placement first. That's another big thing. The impedance is lower when you're ap. Therefore you can have a better outcome of getting that patient out of VF. So it should be AP first. Then when you're going to do DSED, it's AL goes on second.

So we should be doing AP right from the jump.

100%. 100%. Now it also helps with the chest compressions though.

Right. So just imagine if you have a device that either wraps around the chest or it's, you know, a piston driven like the Lucas. If you do AP first, it allows you to get right hands on the chest the whole time, sit the patient up, put the posterior pad on, go right back to chest compressions. But once you meet that criteria to get to the double sequential, now the chest compressions continue and you just go anterior lateral without moving the patient.

That's a big change. That's a big change that I don't think everybody is, you know, signed on for. So I think that's important to note.

Again, that data came from Cesky's study. Right. But he showed that the ap, the vector change didn't happen until the fourth shock. Right, Right. Three standard first, it's, it's clear that if you go AP first, you're going to have better outcomes. So it should be AP first, double sequential, you should be doing today. And then It'll end up moving earlier in the stack. As we move along.

Is Dr. C.J. winkler, right?

There he goes.

Okay, so good. Let's move on to. What do you want to move on to?

Yeah, let's do the cardiac arrest bundle.

Okay.

Last year, Mike, if you remember, Charlie and I were here, we talked about things that we're doing that people thought were crazy. Removal of epinephrine from the shockable rhythm protocol. That's heresy. How could you do that? Well, we've come today with receipts, Right? So when I say receipts, it's the CARES database. So if you're an agency out there and you're performing cardiac arrest, you should be submitting your data to the registry so that nationally, you can compare yourself to Seattle and Houston and all the other people. So we removed EPI years ago from a shockwave rhythm protocol. And here is our receipt. So I have our CARES data right in front of us, Mike. And so our overall survival to discharge all rhythms. So let's not go shockable yet is 13.1% year to date. And national, it's only 7.5%. So almost double.

Wow.

And this is, by the way, 560 cardiac arrests that we run year to day. Palm Beach County Fire Rescue. Now, let me go just to the shockable group we have, and that's called Utstein. Right. So the Utsteen means it's a witness and a shockable rhythm. So Palm Beach County's survival. 41.7% nationally, 23.9. Wow. So for the. For the population that should have gotten EPI that we removed EPI from, we have almost double survival then Utstein bystander, which means it was a witness arrest. It was a shock of rhythm, and it got bystander CPR. We have a 38.5% survival nationally. It's 27.2. So I believe very strongly that epinephrine should be removed from the shockwythm protocol at a minimum. A friend of mine in Colorado just called me and said he removed it completely from his entire. I'm not sure I believe in that just yet, but his numbers are better than national, too, so there's something here, but definitely the shock rhythm. And just one more thing, Mike. We added esmolol. It's a beta blocker, does the opposite of what EPI does. We have a number of cases, including a gentleman named Alan who was down for 32 minutes. He got six double sequential shocks. He got esmolol, no epi. The guy walked out of the hospital. He Just went to Disney World last week.

Wow.

So what you're saying is you're. Are you under the belief that you're going to start to see this happen more rapidly throughout the country?

Well, I mean, it's like everything else. Like, even whole blood, it takes time. There's a paper on esmolol that showed five times the survival. Five times the survival if you use esmolol in refractory vf. That paper was done years ago.

But why does it take so long? I don't understand that.

It's like everything else. You know, it takes some of the early adopter agencies, but then the people at the ivory towers want a randomized controlled trial. Cardiac arrest research is tough because it's a bundle of care. We can't just say that it's because of the one thing that we did. It's probably our high performance copy during a code. Our chest compression fraction is perfect. We don't over ventilate people. It's probably all of those things. It's hard to say that it was the one thing. And the academics refused to say, oh, Palm beach county did one thing and that was the difference maker. So they won't believe our data is what I'm trying to tell you.

Even though the data doesn't lie.

It's CARES data.

I get it. I get it. All right. Distal femur IO.

Yeah. So we just published our paper. Pediatric distal femur IO has never been published. The FDA had approved it for Teleflex years ago. We started at What, Charlie? In 2015. 2015. We just published our paper September 4th and basically showed that we had pretty much a 90% success rate with the distal femur. And now if you ask our medics, would they ever go proximal tibia, they'll tell you no. We've thrown away the pink needle. Wow. Yeah. And Charlie and I have been working with a couple of vendors on a distal femur IO trainer. The folks in San Antonio are using distal femur for adults, and Teleflex is coming out with a 65 millimeter harpoon for the distal femur in adults. My prediction, Mike, in the next couple years, this, the distal femur IO will be the go to site. Caveat. I don't believe amiodarone should be given through the IO because it's lipophilic and it stays in the bone marrow and there's data to that. So I think the IO is very good. I think there's some drugs that maybe we shouldn't be putting through the IO But I definitely think that the distal femur is the place to go.

Okay, Charlie, you know, Peter says about the medics saying that they will never want to go back. Why is that? What you're seeing from your folks? What are they telling you?

So what I'm seeing from my folks is they're absolutely just amazing.

Right?

Because the reason why I say that is if you look at our highest success rate for iOS in pediatric cardiac arrest and in IVs, it's distal femur IO. But here's a caveat to that. That whole time that they've been doing this procedure, there was no formal trainer out on the market. As a matter of fact, we make a reference in the paper. So imagine a protocol called coming out. That's procedural based, but there's no trainer to do the procedure. How do you have confidence level? It's not like we run a ton of pediatric cardiac arrest. So there's really no training. How are you going to get good at that? Right? So finally now on the market, there are trainers. We've trained our team up at the lower level, but we haven't went systemic wide. So basically what we're doing is they're using it, they're comfortable. Those that use it, have used it before, love it. We'll never go back, but our goal now is to look at the paper that we just published, look at the human behavior of actual the effects of training. Like, so we're going to cold test them. Not test, evaluate them. Yeah, no test, no test, buzzword. But basically look at their procedural process on the distal femur now, then train them, then evaluate that and then watch and see what it does retrospectively in the department. And I think. I think that we can get to a hundred percent of our attempts are going to be in the distal femur. So it seems like a long, drawn out process, but essentially we're going to look at the human aspect of this too and make sure that if teaching them and making sure that they understand the depth, making sure they understand the needle size, because some of the complications in that study for us were the needle popped out. So it basically was not successful because the needle was too small. So if you're not using the black lines on that needle and you bury it into the skin and it has nothing to grab into the bone, then you're going to have complications. That's simply, in my opinion, a training thing.

Okay, I like it. Peter, what else do we. What else we have coming down the pipeline here?

What else do we have coming up on the Pipeline. Oh, yes, Raboa. So Charlie, you know, he. He makes fun of himself and that he's not doing all these crazy good things.

Yeah, I'm on to him. I'm on to him.

Exactly. But obviously this concept of riboa, which is basically, you know, obviously if you have a non compressible hemorrhage, very hard to stop that bleed. You, you had the AAJT folks on there. But there's also a way of stopping the bleed internally. It requires a procedure, you have to catheterize the vessel, etc. But this guy sitting right here next to me is convinced that potentially we can do that in the field. Trauma is a very big reason people die in any community in this country. And so potentially that's something that we can bring the experts in. Because remember, in Palm beach county, we're very special. We have what we call EMS captains. These are the doctors. They're better than some doctors, especially procedurally. So if we could train a very small cadre of individuals, they do our finger thoracostomies, they do our ultrasounds. They're the ones who, if it's a difficult intubation, that they step in. So if we can train up a small cadre of individuals and just save one extra life, it's worth it for us. In Palm beach county, we have a great administration, people who believe in what we do. We have a great research machine now we've connected with people in Mount Sinai. So I would say that to anyone who's listening, if you have a crazy idea, make sure that you get the right people involved. Make sure you research it. Like even Charlie said, we're putting in a distal femur IO trainer and he wants to do a research project around it. So make a change, evaluate the change using data, and then if it's something that's worthwhile, other people could do it as well.

Awesome.

So I want to tag in on the reboa. Thanks, Peter, for all your kind compliments. This was brought to us by the actual trauma team.

So.

So this wasn't us coming to them. This was the trauma surgeons coming to us and saying they believe that if they ride with our paramedics, that as a proof of concept can be done in the field. Essentially, the trauma surgeons will be doing the partial riboa in the field. And then essentially the goal would be is if we're able to show success like London was. In their paper, they published a feasibility that it's safe to be able to do in the field, then maybe our EMS captains will. Will be able to do it. So the one downside, and we've spoke a lot about whole blood on your podcast, right? Today, previous days, we are firm believers in the whole blood. I mean, I could. I'm not even going to waste my time talking about that again. But I will tell you this. We know from our data that if a patient's in traumatic arrest, that we have not seen any difference in whole blood because it's too late. You give it to them before they go in arrest. Drastic, drastic difference in the outcomes. But if they go into arrest, there's no hope. So if they're internally bleeding, we talk about tourniquets, right? If you look at the, the Boston Marathon, after the Boston Marathon, everybody started talking about commercial tourniquets, right? It became everyone was going to use them. Everyone was aware of how to use them. So that stop the bleed is a real thing. Putting blood back into the tank, that's a real thing. But when you're bleeding internally, how do you stop that bleed? This could, if it's in that right area in the trunk, this could potentially yield some benefit to our out of hospital traumatic arrests. From the trauma surgeon's perspective, this is what they're giving to us. We're excited to partner with them and we're looking forward to see can we, can we move the pendulum in the extremist case or the patient that's already in traumatic arrest in the streets?

Once again, this is exciting to me because the trauma surgeons are approaching you, and that's a different difference. Right. That's a shift that we're starting to see because of competent individuals like you, like your agency, like your medical director, who are progressive and want this to happen. Right. Typically, we're the ones going to the trauma surgeon saying, can we do this? Can we please do this and get slapped?

You know, Mike, there's a big transformation happening in this profession, and it's happened because of people like you, because of conferences like this, because of people like Charlie, because of our administration or fire chief who says, let's go do this. Because of the research that we're doing, we're shifting from EMS was in everyone's blind spot, actually. They would look around and not even know what EMS can do. For the first time, I'm feeling now that EMS is, they're starting to recognize that, you know, for antibiotics in sepsis. Yep, we're the ones doing that. Right. Look at all the trauma care, look at the stroke difference that we made in the state of Florida. We started an entire registry, the academic world, the healthcare world, is finally realizing that we are an essential service, not just for the community, but for healthcare in general, without question.

And again, it's the work that you guys are doing, right? But not just the work that you're doing, the data that you're proving and that you're able to show. So, again, I want to thank you guys for coming on with me. Always. It's almost like we're doing this thing, you know, together all the time. But like I say, it's so interesting because you guys are really trailblazing in, in the things that you're doing and you're accomplishing. And what you're doing is you're becoming an agency and an area that people look to, you know, for guidance. And that's why I think it's really important to have you on and to share this information. I look forward to following up very soon on the latest things that are going to happen because that'll probably bit be little a like it next week.

Charlie Coyle, Peter Anteve, thanks again for coming on with me.

Thanks, Mike.

Thanks, Mike. We appreciate it, buddy.

All right. And thanks for listening to the EMS World Podcast from the floor EMS World Las Vegas 2024. Stay tuned for new episodes coming to you soon. Thanks for listening.

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