NAEMSP 2023 Abstract Preview (1/3/2023)

What day and what time? Because it's all going to be in Tampa. It'd be great. So we could all go in there and either put our fingers on our noses or give you a thumbs up there. Okay, so.

And wear a pirate outfit.

Yeah. So Des, do you want to start off or, or.

Yeah, that sounds great. Dr. Van Dylan, I don't, I don't think I have the, the times of when this is being presented yet. If you have that, great. If not, we'll move forward.

I don't. But, but we can. I'm gonna try putting that in the chat while you're talking.

Yes, no, that sounds great.

So.

So this was actually take two of a study that we actually did probably 10 years ago, maybe nine or 10 years ago and learned a whole bunch from the first round of the study. So what we initially put out and about 10 years ago we're talking about putting ultrasounds in the field was pretty novel. And so what we tried to do is we wanted to show a non inferiority study showing that our crews after some training were able to produce images at least non inferior, at least as good as trained residents, residents who had completed ultrasonography rotations and were at least senior residents. So second or third years. And so we got standardized model. We actually did a training session with our crews and the first round of the study, which was a really long time ago, we found that the training was not long enough, it was not comprehensive enough. And we found that this was a negative study unfortunately. So our crews received two full days of ultrasound training and one hands on and then had a follow up session. We found that that was not enough. And so we actually replicated this study a couple years ago using a more intensive.

Model. Basically we had a one day five hour course of ultrasound teaching to our crews followed by once a week, five weeks in a row, hands on training with a live human model. We then replicated the same idea where we had a standardized model be ultrasounded by the crews that were trained and senior residents who had received ultrasonography training. And at that point this study actually was positive in terms of our crews. Our crews actually were non inferior and in fact in this study showed slightly superior images on a standardized model. It was graded blinded by ultrasound and other EM faculty. So all the images that were obtained were graded blinded by experts in the field. And then we analyze the data and so I think the big takeaway from this is ultrasound for E fasts in the field, something our crews can do with a significant, a reasonable amount of training. This Is not something where you take a couple days, put them on a one day, show them on the body course. That was round one and that failed. This was a round two type study. This was the only one we published. Basically, if they have a pretty good intensive course with a lot of hands on, they're able to show that they do a great job in image acquisition.

Then Des, let me ask a quick question. Just make sure I was clear. The one thing you were checking them on was for the, like a fast exam. And when you say efast, what do you mean by that?

So we're looking at the lung sliding and then evaluation for pneumothorax.

Okay, got it. All right. I just want to make sure we knew what you were. I remember this before, so I just wanted to make sure everybody knew exactly what you're doing. So. So that's really cool then in a way. Right? So that's good. Now, did you have a select group of people? Was there a selection bias or is it everybody across the board?

Yeah, so we had to basically use one of our agencies. It was in Lake county at the time. So it was an agency that was able to be available for this amount of time in this intensive training. So it was a single agency, paramedic level group. They were all different ranks. So we had captains, lieutenants, and general field medics.

But that's fine, just as long as it just was a slick group. You went across the whole board and that's even stronger.

So, yeah, they allowed the whole agency to train on this, which was really neat.

So when you present, that'd be a great comment to make. And you know that. So they're, you know, because that's the first thing that came to my mind. So that's very cool. Anybody else have any questions? What's good about this is it gives us a chance to kind of critique it a little bit so that when he gets there, he does a much better job. So this is really cool that all the Florida people are presenting. So that's great. Anybody else have a comment for him or suggestion or critique?

Okay, Christy, do you have anything you want to comment about?

Just to thank Dr. Fitzpatrick for letting me be a part of this, and I'm excited to see everyone there. Okay, good. So did you find out. Oh, sorry, I just dropped my phone. Did you find out yet where this is, when and where you guys are gonna present it? No, but I will, as we're on the call. I will continue to work on that. Okay, got it. Okay, good.

Hey, guys.

Hey, Peter. How are you? We just got through Des's talk about, you know, looking at the E.

The FAST exam and all that, and it was great. And we gave him some suggestions or thoughts about it. And then so it's time to move on. If that's okay, Peter, I could turn it over to you, but I just. Let's go ahead and we can hit up right away with Terry. Okay.

Yeah. Do you have the numbers for the. For the meeting so I could put it up on here? Is it.

Hopefully someone did it for me, but it's 1-659-816598.

And then what about Maine?

Main Eagles is going to be 991-6599.

Okay, perfect. So I have a. Just a quick PowerPoint with all the stuff on it. So I'm gonna. I'm gonna just share my screen real quick.

Can you guys see. One second.

That's the answer.

You guys. You guys see this?

Here we are. Now we got it. Yep.

Okay, good. So that. So that's that. I'll move quickly. So welcome, everybody. Sorry, I know we're recording. So let's just keep moving on here just for everyone's knowledge and we'll get the tech stuff figured out for next week. My apologies, but 3pm on Tuesday, NMSP is coming up starting on the 24th. The precons, we're doing a Florida RA and then the main conference is 26 to the 28th. It's in Angus's territory there. And then Fire Rescue east is in January.

Hey, Peter was very near the convention center, just like a little bit down the street. And is that where the Resuscitation Academy will take place there as well?

I don't have the spot. But it's in the same hotel. It's in the same place.

That's the Marriott. Whatever. The Marriott. Whatever it is it's called, I forgot. It's got the JW Marriott, I think. Okay, good. So it's in the hotel, not in the conference center.

The conference, I believe so. I'll have to get back to you on that. Tom probably knows better than me. He's on the call, I believe. Tommy, you there?

Or let us know next week. Okay, good.

Yeah, I'll do that. Okay, so what I wanted to do is to go through the NSP abstracts and you guys already started talking about one of them. But just a quick overview and that there's 210 of these that have already been published. These will all be presented during the NMSP meeting. They are ranked from 1 to, I believe, 210. So the higher the number the better it was scored. And the higher ones get oral presentations and the rest get posters. We're right here at this point, I believe is where I'm merging into where Kerry is going to be presenting the neuroprotective cpr. Without any further ado, Kerry, I'll stop presenting here. And you wanted to talk and you and Paul wanted to talk about the data from this abstract.

I'll have a Carrie present. But this is a lead in. We've already had this other proof of concept. This thing is specifically going to be looking at those with non shockable rhythms. We know that across the board it makes a difference. But is it specifically also applied to non shockable? So take it away. Yeah.

I also like to say that the scoring rubric does take into attractiveness of authors.

That why we weren't number two.

That's maybe why I'm only 12.

Yeah.

And maybe why. All right, so I mean it comes as no surprise that, you know, we've been doing heads up CPR for the past couple of years. We started a pilot project with places that were doing heads up CPR a couple years ago. That way we have a registry of all the places that are doing it. But this is Paul's exactly right. We wanted to look at non shockable rhythms. We know that non shockable is the majority of cardiac arrests. And like we said in the past, there's really not much we can do for these people. So we want to look at that data specifically at this early stage of the registry and compare that to some known conventional cpr. We had five qualifying EMS agencies that are doing all pretty much the same or similar protocol utilizing heads up cpr, some sort of suction based cardiac arrest device, either the manual rescue CPR or the Lucas itd. And then of course the heads up component and all instituting this relatively quickly. They also all rigorously collect their data, every data point from implementation time and all of the demographics that you would look at, including being able to get outcomes.

Lots of numbers. But for our registry we had about 965 people. I'm going to refer to my sheet here. We had about 965 people in the registry.

Of that we selected out 467 of those people. The 422 that were excluded initially from the numbers were they didn't meet inclusion criteria for a variety of things. Usually data gathering, couldn't get outcomes, those kinds of things. And then we were left with 467 people within the registry. Right now we took out the V fibs and vtachs, left us about 380 people that were in the registry.

Then propensity score matched them with known conventional CPR patients. And we used the ROC prime study and the rescue trial study. And these were used because the, the data within them is.

Extensive. We're able to match them. We have the outcomes on those people. But it was also used because these are good systems. These are systems that were known to be doing a good job. We were able to.

Again exclude people because of missing values. Left us about 1800 conventional CPR people. And then we matched them up one for one on a propensity score analysis. We matched them up, starting with time to CPR and then matched up all the other covariables to a 1 to 1. Basically everything matched with those people and then looked at the outcomes. What we found when we looked at the outcomes was the unadjusted numbers. The unadjusted survival to hospital admission was 7.4 versus 3%.

The neuro intact survival, unadjusted, this is, is 4.2 to 1.4%. When we did the propensity matching of the matched patients, the survival was 7.6 versus conventional CPR 2.8% and the neuro intact survival was 4.2% versus 1.1%.

So and all of these confidence intervals, odds ratios, all panned out. They were all statistically significant. And then one of the additional findings after the propensity match was we found that the time interval was important.

Yeah. Hey, if you don't mind, Terry, let me interrupt you. What you're about to bring up is a really important point because prospectively when we came up with the design, we said we're going to look at everybody across the board. And it turns out that about 20% of the people were having really long delays in getting there, but we still include those even though their survival rates are going to be much lower. And so you're losing it. But when we did look at the data, it turns out the median time, which means half the people to time for both groups to get there and do CPR from the time of the 911 call was eight minutes. Okay. But the time to get the device on the head up Device on was 11 minutes was the median time. But we got it on board within 60 minutes and 80% of the time. So I just want to set up what you're about to tell us because that we specifically said, hey, let's look at 11 minutes and let's look at, you know, half the people and let's look at 80% of the people you know in 15 minutes. So what did you find when you did that?

I think if the, if the device and everything is set up within 11 minutes, we found that the survival neurologically intact survival was 6% versus 0.6% in the conventional arm. That's with an odds ratio of 10.59.

So basically the faster you did this, and this is where the saying, where I guess Paul was saying this is almost like an AED for PEA and asystoles because we can finally do something for these people and affect some of their outcomes. One of the other things, Paul, do you want to talk about unwitnessed. The unwitnessed asystoles?

Let me go in, but I want to add to your point because that was an excellent point you brought up. It actually it not only was like the AED for, you know, in a sense for these non shockables, but it had a wider one. It helps AEDs as well, by the way. It helps people who are shockable rhythms. But more importantly is that it has a much wider window. If you got, if you're having. It was like a 14 fold odds ratio if you got it on board within 16 minutes. Right. And so that's really tells you a lot right there. You have a wider window of opportunity, et cetera and, and so on. And the time is of the essence. And the system that did the best in all this were the ones that had that backpack system that we've shown before where they just brought it in, open it up, boom. It's a real true, true pit crew approach. But to answer your question, we drilled down later people when they, I went and made these presentations before people wanted to know, well, what about pea? Well, if you just look at pea unadjusted, it was still like a 10% versus whatever it was 3%. It was, you know, survival neurologically intact. But the thing I found was most interesting if I was to ask anybody there in the audience, if you had a person who had was unwitnessed arrest and you get there and they got asystole, some systems just pronounced them dead with that, right? So any of that. So I don't know if anybody else works those. And if you do what, you know, it's still pretty. Most people say it's pretty futile. But what were you finding out there, Kerry? What did you find out? Was there any survivors at all in the unwitnessed asicly?

The percentage of the survival was 1.8% in the unwitnessed asystole and in the conventional CPR was 0.3%.

Yeah. So it's like six fold higher and that's what the odds ratio was, right?

Exactly. 6.95.

Yeah, but that's no big deal. 2%, that's all they're getting back. But the point is it's 2% versus zero, you know, close.

Those are 2% you. You kind of write off.

That's people walking out. Yeah. Let me put this in perspective. There are 500 asystole cases a day in the US alone. 500 out of hospital cardiac arrest with asystole presentations. Of those in our study about, you know, anyways, overall about 70% are unwitnessed. In both. In both the. What's the word? The control group in ours, et cetera. So the point is, is that if you're talking about 570, so 350 people, whatever it is, and then you get back 2% of them. It might be seven or eight people, but over a year it's several thousand people who will go back with function. That's neuro intact. Survival.

Yeah, it's neuro and tech that's the important part.

And it's just because the sheer magnitude of the cases, it's kind of cool that you're giving them the chance and it may change our hold. And the other thing is these are when we lump everybody together, including those long responses. So if we are really looking at the ones we can get to in 15 minutes, that may be a lot higher percentage than that's. The next thing we're going to do is drill down on that. That's the next phase of the study. Okay.

This is amazing, amazing data. My question for you, Carrie and Paul is, would you say then that agencies implementing this device need to have it on their frontline vehicles so that they are getting there first without it being on a, let's say a chase car or captain's vehicle, that type of thing.

Yeah.

It makes it easier to also to do the training. If it's always there and it's always right up front, you have to have it there. I think that, you know, just like anything when you come late to the game and we talked about this with what with Paramedic two, you bring EPI late to the game. It didn't have any effect. Yeah, no kidding.

So, but why not have a. Why don't you have a. Why don't you make your chance 4% to going home instead of 2%, you know, whatever it May be the earlier to get there. The other issue about that, Peter, is that it was interesting because when I presented the preliminary data without all the stuff you just heard asap, someone said, hey, can we use this in the icu? I said, yeah, the person firefighters could use it. The, you know, lifeguards could use it. Right. So and then when they said, how about can it be used in the ICU or the ed? And I go, well, yeah, well, why not? You have it right there. Just like people have the Lucas standing by. Why not add these other things there as well and then they may even have better outcomes than us as a result. Because you're restoring normal flow is what you're doing.

Are up there in the normal range, by the way, which is really cool about this. In other words, we got some surrogate variable saying that you are restoring normal flow.

Paul, do you think that the NFL could use this too?

I will tell you, if they couldn't get an AED there quick enough, this would have helped out a lot. But even if they did, it would have helped out a lot. And I think it would be. It's just I'm feeling like in the 1990s, the NBA trainers approached me to, you know, give them some advice about this. And I said, you got to have an AED and everybody's got to be trained in cpr. Haven't standing by and we got those. I see the future that if you're in a fixed location where you may have to do response, that might be part of what you do, right?

Yeah. Yeah. Hey, guys. Well, this is incredible stuff. Carrie, can you tell us when you're going to be presenting? Because I have two more abstracts I want to review with.

Thursday Was it the 28th at 5:30?

It's the first session Thursday, which was the poster session Thursday. Okay.

I believe it's at 5:30.

All right, well, really appreciate you representing us and also DEZ and Chrissy. I know I missed that part of the call, but I do have a couple of slides to that effect. So let me just put up.

Peter.

Okay, awesome. I feel bad because I have a couple of slides that I put up, but thanks for doing that.

Is there a reason why we can't. Next week?

What?

Do what next week? No, this will take a little three minutes when I'm about to. Yeah. Because next week I already have. I already have other people the whole month on schedule. So abstract number one and two is what I wanted to show everybody. This is interesting stuff. They actually looked at 65 EMS folks and 239 firefighters. And they, they, they looked at their BMI, waist circumference, smoking history, blood pressure. You see all on the screen. And then they took a look at. And the results of this were that in EMS, 70.8% had abnormal blood pressure, HDL or hemoglobin A1C, and 60%, approximately by BMI, and 64 by waist circumference had obesity. Of the firefighters, more abnormal blood pressure, HDL and A1C, a little lower obesity, 51 and 42%.

That's very interesting stuff. So that's abstract number one.

Okay.

Aspect number two, which I found interesting. This doesn't really relate to us in Florida for the most part, because not many of us are tiered. But it was very fascinating here that if you had. The question was, did the odds of downgrading a call from ALS to BLS increase depending on whether the ALS clinician arrived either via chase car on the fire apparatus or they were with the transport unit? And what they found was, so again, just to clarify.

The patient's on the ground, and then it's a BLS call or, sorry, the BLS folks show up. They say, hey, we need als. ALS shows up in one of these three ways. And then they looked at whether or not the ALS person downgraded that to a BLS call. If they downgrade it to a BLS call, they don't have to go, right? And so here's what they found. They found that if the paramedics arrived by chase car, they downgraded by 41.8% of the time. If they arrived by ALS fire apparatus 49.2% of the time. But if they arrived on the ALS transport unit itself, there was a much lower downgrade percentage because they had no choice. They had to go with the patient either way. So the summary here was that if you have a scenario where you allow the release of the ALS clinician from the transport, it led to a 2.3 higher likelihood of resulting in a downgrade.

So, in other words, the vehicle that they show up in will impact their decision to downgrade or not. And I just thought that was very interesting, that the conclusion was that if you do have a tiered system, you better look at these downgrades very carefully to make sure that they're being downgraded for the right reason and not just because.

They can leave faster on the vehicle that they came in.

And so that was that. And just real quick, you already went through this one, but just real good stuff here from DEZ and Chrissy, looking at the fact that.

The overall image quality was better in the paramedic group.

And in all these types of all these image sections, they were better as well. So I just wanted to stop that right there. So at 12:29 we are done. I did send in the link for the Mobilize site, the full abstract link for all 210 abstracts. So take a look at those. And that's about it. So we're at 1229, the rebound.

The number for Carrie was number 12. And what was it for Des?

11.

Wow, cool. Very good.

Yep. Yeah, we got 11 and 12.

They're better looking. They got 11. Okay, got it. Okay, good.

See it pans out.

And.

For those of you who don't know, these are just abstracts. So the actual paper may not come out for another year or so. So the beauty of the NMSP and the beauty of these abstracts is that this data is going to be published for quite a while in many cases. In some cases it won't be published ever. So just by going through these abstracts you really get a good inside view into the early papers that will be published over the coming years in ems. So that's why I really encourage everyone to go through these abstracts.

All right, I'll see you later. Okay.

All right. And Angus will switch us on over and we'll join Paul's group. Thanks Paul. Thanks Carrie. Thanks.

16598. Okay, thanks. Bye.

Bye. Okay.

All right, we'll get started.