Peter Antevy on the Top EMS Research of 2022

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This episode is sponsored by Hand Tevy, the industry leader and trusted source for pediatric EMS care in the United States. Welcome to another episode of EMS World Podcast. I'm your host, Mike McCabe and I am super excited today because this is. Not only do we. Not only do we have a great podcast for you, but. But this is actually the inaugural Vodcast, the video podcast premiere for EMS World Podcast. And what better guest could we have than Dr. Peter Antevi with us today? Peter, thanks for joining us, pal.

Oh, Mike, I'm so excited for inaugural Vodcast. This is incredible.

This is him.

Thank you so much for doing that.

Listen, people are going to be able to get to see us in real time, aren't they? Lucky, huh?

Yeah, it's lucky them.

All right, so. So all joking aside, we are, we are grateful to have you on anybody that does not know Peter. And Dr. Peter Antevi, he is the medical director for several EMS agencies down in Southern Florida. He is a huge advocate of ems. He is the founder of the Hand Tevy system. He is everywhere. If you do not know Dr. Peter Anteavy, I think that you're possibly living under a rock. So he is the guy that we want to talk to, especially during this podcast Vodcast. We basically putting a bow on 2022, and we're rapping about some of the really great things that have come out of 2022, some of the things that we've learned from and some of the things where we're going to move forward with. So, Pete, again, thanks for joining us. Let's just jump right into this. Now.

It'S official in your eyes from Dr. Peter and Tevy. Cardiac arrest should be worked where you find them. Talk to me.

Let me tell you. Let me tell you. We have worked so hard on this for so many years. The data is there. It's been there for years. And it's interesting if you look at ILCOR 2022 on November 6, literally a couple weeks ago, ILCOR just published their newest recommendations. And one of the highlights of those recommendations is, guess what, Mike? You need to stay on scene to treat cardiac arrest. And if you're an agency out there who's not doing this today, you must, you have to train on it, you have to teach on it. And interestingly, another paper that just came out by Brian Clementy out of Buffalo and Susie Burnett, they actually said if you're in the pre arrest, you have a patient that you know is about to arrest in front of you, right? The EMS witnessed arrest, right? They say that if you, if you move that person there, let's say in the supine position and then you sit them up to take them down the stairs, what have you, and in your heart you knew they were about to arrest, you owe it to the patient to resuscitate them before you move them. So we're finally there. It's 2022 going into 2023. And I would say look at your data, look at every cardiac arrest and if you're scooping and running diesel fuel, load and go, you're doing it wrong, you have to change it.

Talk to me about the merits of this and why this is so important as opposed to the antiquated way that we have always done this in the minds of the receiving ED docs who are saying, just get that patient to us. Why do we need to stay in play?

Let me tell you what, I was that guy for so long and I can tell you that I was so wrong. And that's where EMS really changed my life. And that's really why it's been the focus of my career since 2010. So here's the problem with that, is that when you have a patient who's dead or dying and you think that that five or ten minute ride to the hospital is going to make them better, or if they're in cardiac arrest, that someone magical at the hospital is going to revive that person. Well, now we know that couldn't be further from the truth. There's data that's come out this past year that has suggested that the agencies who stay on scene longer have better neuro intact survival. And I think there's one big reason for that. If you're an agency who transports every single patient right to the hospital, imagine the ER doc on the other end that they're getting dead guy after dead guy after the guy has rigor and lividity and he's been dead, dead, dead, and then number 10 patient actually has a chance, that ED physician is already saying, you know what? The last nine these people just bring me dead people. They have no idea what they're doing. It turns out that if you're an agency who treats people on scene, you terminate those who aren't going to make it. And you only bring the viable ones. Now that Ed Dr. Is saying, aha, if EMS is coming in with a patient in cardiac arrest and maybe just got rosc, I'm going to stand at attention. I'm going to see that patient quickly and do the right thing for them. So it does matter what we do on scene to the hearts and mind of the ED doctors who are receiving those patients, number one. But more importantly, it matters that we're giving the patient the best BLS care followed by ALS care that they deserve. And if you do that, guess what? You have a higher number of patients who walk out of the hospital alive and well. So those are the two big reasons to do that.

Mike, I love it. Talk to me about the psychological element of the termination.

Right.

So when we tre, let's be honest, that's not comfortable. Now again, I know that doctors do this all the time in the ed, but the providers on the inside, when you start something and don't finish it, it's a, it's a total mind, you know, it's, it's a whole mind boggling thing for the provider and for the family.

You're right. And I think this is one of the big issues that we have to focus on in 2023 because there's also a lot of logistical issues that occur. Right. All of a sudden when you say this person is, is terminated, all of a sudden you have to turn and speak to people. You have to, the police have to come in, the medical examiner, the coroner or whatever, you may have to wait on scene now until the other people show up. And I know in my systems, and unfortunately we have a lot of work to do in my systems, they just find it easier to just package the guy up. It's a show code. We get into the emergency department, we transfer care, and we're back in service. Yep. Places like Austin, Travis County, I think do a great job for both kids and for adults in termination.

Sure.

And they practiced it. You know, Ed Rock, who, as a legendary EMS medical director now with gmr, he initiated that. So it does take leadership. And then once you get that going and you start to make everyone understand we're going to help you not stay on scene for so long, we're going to help you with all the logistical issues, then it could be done. So there are a lot of kind of pieces of red tape that are in the way for the hearts and minds of the paramedics who have to do that job. Which is, which is secondary to the fact that they actually have to learn how to do it kind of from the emotional, psychological perspective, like you mentioned, 100%.

I think 2023 is a big year for us to start to learn to be vulnerable and allow us to have that emotional coming to Jesus moment where you actually have to speak. You can't hide behind the medicine, right? You can't hide behind the ER doc. If you want to be providers, if you want to be true medical clinicians, you have to know how to deal with death. And there's a lot of stuff out there that. That lends us, you know, this reminder constantly that we need to really do better at this.

Well, you know what I mean? I'll finish with this. That's the concept that you just said beautifully, is what I call closure. And I don't care if you're a paramedic, a nurse, or a doctor, if you don't know how to get to closure with the patient or with the family of that patient, that will haunt you for years and decades to come, for your entire career. And so it doesn't matter if it's a broken arm, you get to closure with the patient. That's an easy one. But when it's a death and you haven't done the right things by talking to the people on scene, that will haunt you for a long time. So it is time to come. It's a come to Jesus moment. That's 2023. Well said.

And we need to train more on it, which we will. And we'll talk to Rob Luckridge from Austin, Travis, good friend of ours. And. And he does a good job, you know, former Jersey guy. So maybe we'll get a podcast with him as well. All right, let's move on to something that is near and dear to you. We actually did a great impromptu podcast at Expo on this with you and some of our very dear friends from Southern Florida on whole blood. It is the. This is it, man. I mean, I know how passionate you are about this. I know that this really is the. Is the birth child of C.J. winkler out in. In Texas. Huge advocate of this, huge proponent of this. But let's talk about whole blood and what that's what that looks like now in ems.

Let's be realistic. This is the biggest accomplishment or movement in trauma care in the last hundred years. Then we have to give the military Credit. People like Dr. John Holcomb, who's been a proponent of this. And we know that the military is always first on this stuff. Right? Because they have to be. Then you have incredible people like CJ Winkler in San Antonio who said we're going to do it here. And they did and they've proven it. That's been our pilot project. Right. So now you have pockets around the country. And we're proud here that we're one of those pockets who have basically we've gone to San Antonio, we R and D, we ripped off and duplicated everything because they just said come learn, take everything. Right. Love it. We figured out the best equipment, you know, basically the life flow, the Q and flow and so forth, the right coolers, everything. We got that and we just put it into play. Right. And I can tell you, Mike, I got a text this morning from Chief Coyle who was on the podcast back at Expo. We had a 20 year old girl who shot yesterday. We found her in arrest. We got her back to life with one unit of blood on scene. Right. I mean just think of that, the traumatic arrest, coming back to life and then those who are not in arrest, who are pre arrest before we get to them, we have right now about a 90, 80 to 90% depending on what agency you're looking at chance of survival if the patient was not an arrest by the time we got to them. We had a police officer about three weeks ago who would have been dead if it wasn't for that unit of blood that he got. So I think now we're in the phase of the high performance systems are going to start incorporating blood, the helicopters, the inner facilities and I think we need to get it into the SWAT teams. Right. For sure. So here we are in 2022, Mike. I would say by 2026, 2027, we're going to be looking back and saying how could it be that we weren't doing this a long time ago?

Yeah, for sure. And you mentioned Charlie Coyle, he, he's the chief of Palm Beach County Fire Rescue. Huge, huge advocate of this. Heath Clark down in Broward, they were on the podcast with us and just their stories that you just told us that story. You know Pete, you and I spoke literally, I think last week and you showed me a picture of motor vehicle accident, the car. Maybe share with the listeners about that because it's incredible. This is what listeners need to hear, providers need to hear.

Yeah. So it was late at night, There was a 19 year old kid driving on I95, the main highway here in Palm beach county. And it was, I mean if you saw that photo that I showed you, I mean this was.

Major intrusion on his. Major intrusion. He had a femur fracture. He had significant abdominal trauma. And when we get there, his level of consciousness is diminishing to the point that we're thinking, do we take this kid's airway? Well, lo and behold, we. We happen to have our EMS captain on scene who has the blood. We give him a unit, and he. The kid, like, literally wakes up and he says, give me more. That's what he says. He says, give me more. Now, this is. This is not the first time we've heard this. We've had patients. The police officer said it. We had a guy who was run over by a propeller. He swam a mile into shore with his intestines hanging out. This was in Broward Charis with Chief Clark and Dr. Roach. That guy said, whatever you're giving me, keep giving me more. All of these patients are living today. That.

That in itself is exciting to hear for the providers. And also, I love the stories and even the text. Pete, you showed me the text about the provider that gave the blood, that said, the first time I feel alive that I did something for somebody with this much of an accelerated traumatic injury.

Yes. I could tell you that we have people trying to get into our agencies now, singly, because of this point right here.

We have EMS captains who are going to retire, who are not retiring. We have people who have said this has revived their careers. These are people who've been doing this, Mike, for 25, 30 years. So imagine coming into a system where that system is doing it. We're going to attract more people, better people. We're going to retain them, because this is where the lives are saved. It's incredible.

It really is. And there are so many exciting things. And I know it's easy sometimes to get down on this industry because, listen, we'll touch upon some of those things. We still aren't out of, you know, the difficulty in where we're at with COVID and everything else. However, we are moving in the right direction in so many other ways. Talk to me a little bit about the guidelines that are written and how they've always been written and why now with so many of these exciting things, it should be different, right? We should be writing these things.

Oh, my God. This is a huge, huge topic. I'm so glad that you brought it up. Listen, when you. When you walk into a hospital today and you see the type of care being provided, and then you leave that hospital and go into the EMS system that delivers patients to that same hospital, you are automatically five years ahead of what they're doing in the hospital. And I mean, people may be listening to this and saying that's not true, but it is true. And there's so many things. I'll just give you an example. Let's take a look at how we perform cardiac arrest care resuscitation, right? Anyone in South Florida would benefit from a paramedic crew giving them their cardiac arrest care than being in a hospital, right? Our paramedics call me all the time saying our care is better than what they're doing out there. Right? I'll give you another example. Dsi, right? Which is instead of now rsi. So rsi, you would just give the sedative, give the paralytic and go, go, go, right. Dr. Jeff Jarvis said, no, big mistake. He said, let's go ahead and give this sedative ketamine, resuscitate them over the next three minutes and keep their O2 sat above 93%. And then you can give the paralytic and look what happened. The episodes of hypoxia went down significantly. The peri arrest or the peri intubation arrest almost went away completely. But you walk into a hospital today and you say the word DSI and they have no idea what you're talking about. No, I. No idea. Right. Heads up. Cpr, right? We've not proven, and I was very privileged to be on the paper that was just published in Resuscitation that you look at these saves from a systolic arrest, right? Significant versus what the standard of care used to be. Where did that originate? It originated in emso. To your point? To your point, why are we accepting guidelines written by ICU doctors who work in those hospitals rather than evaluating the same evidence that they're evaluating? But have the EMS community, the national association of EMS Physicians, write those guidelines so that it's for EMS by EMS and not for EMS by the ICU doctors who really don't understand the field that we are in.

Perfectly said. Also a paradigm shift from what we're used to. And I think now is the time where we have our forum to make it known that look at what we're doing, right? I mean, all of these things. Why are we having those ICU docs and everybody else write this when they truly don't have a grasp on what it is we're doing? Listen, EMS fellow, right? Board certified EMS physicians is relatively new, right? I mean, for the most part, that I believe is. Is the turning point for us. I think that having physicians that are specific to ems.

Hello.

That's what's going to carry us over into within this profession. I think it's going to take us, you know, to the whole next, you know, vortex of EMS and the profession as a whole and how we're advancing.

I can't tell you how many people, Mike, you're right. Come up to me, call me. They want to zoom with me about, hey, I'm an emergency medicine resident and I want to go into ems. I want to be an EMS medical director. I gave a talk at the hospital to the residents the other day and I had a whole group of residents come up to me and one of them was a paramedic. And they're all like, this is the best field in the world. Why? Because they see the innovation, they see the opportunity to make change on a big population scale rather than one patient at a time. So the time is now. There's over a thousand EMS board certified physicians. We've had the board specialty. Now it is time to take it to the next level and own the part of medicine that we own, which is the pre hospital portion. That's where the lives are saved. That's on us. Dying in a hospital is a very different animal than having a cardiac arrest at home or on the highway or at Home Depot. Very different.

Totally. Yeah, totally. You know, again, let's, let's stick with some of these arrest issues. Let's, let's go into your wheelhouse, pediatrics. Let's talk about ventilation rates with pediatrics. Holy moly. Right? I think that thing changes all the time and everybody's always petrified of kids, which is why everybody should be involved with the hand heavy system. Little cheap plug Pete. But anyway, ventilation rates and things like that. Where are we.

Today?

So, so listen, this is the exact point and you know, I'm going to be the squeaky wheel for all of us in EMS who are, who are, who are trying to treat patients, specifically kids who are in the pre hospital arena who are dying. And if you go and you say breathe them 20 to 30 times a minute, when we were doing 10 times a minute, and you base it on data where a majority of those kids were sitting in the cardiac ICU, right. And 60% or more of them have congenital heart disease, it just doesn't make sense that we're using that data. Right. So that's number one. Then we're using cardiac arrest doses of epinephrine for symptomatic bradycardia, which is really not even an arrest rhythm. They call it an arrest rhythm for kids, not for adults. So we have stopped doing that in Our protocols.

They want you to restrict fluids for kids who are in shock. I mean, that was based on a study done in sub Saharan Africa on kids who have malaria who are anemic. That doesn't make sense. That has to go out, right? They want us to put IVs in kids who are in cardiac arrest. No, we'll use the distal femur that has equivalent flow rates to the proximal humerus, and we'll have great outcomes. And so it goes along with the story that you and I were just talking about, which is we need to make, you know, very smart changes to these guidelines that go along with the profession that we are in, which is trying to save the lives of people before they get to the hospital.

There's zero question. I do hope that people are listening to this, and I do hope that those people stamp their feet a little bit and start pushing. Right? I mean, this is what we're trying to do. We're trying to get that audience, you know, get that awareness out there. There are so many cool things going on in EMS in this profession. And what we're able to in medicine. And to get people to buy in isn't the problem. To get people to understand it and to truly, you know, make. Make that change is where we need to be. Quick, some quick, rapid fire here. Let's talk about.

Let's talk about neuroprotective cpr. Specific.

Yeah, I think that neuroprotective CPR is basically getting the head up during cpr. And when you look at the physiology, and this has been proven in the laboratory, and now it's being proven out in the streets, right, that when you're laying someone flat and you're pushing on their chest, you're actually ramming their brain. On the venous and arterial side, you're just. You're ramming blood into the brain, but it has no way of coming out, right, because you're not circulating blood when you're pushing on the chest effectively, like you would be if you had the arterial side and the venous side working appropriately. So what do you do? You lift the head up slowly, head and torso. And now what happens is you allow the brain to drain itself of fluids during these cycles, and therefore you get better cerebral perfusion. And therefore you save the part of the body that is most important, which is the brain, and therefore neuroprotective cpr. And there are people out there who are kind of throwing rocks from the sidelines, right, While we are the ones who are doing the work in the Field to prove that this is true and the outcomes and the people who are coming back to life, Mike, is just incredible. What we're seeing. Time will tell. There's a lot of agencies now in Florida who are moving forward, one of them being my agencies. My agency. And it's just going to show into the future that we're going to get patients back that would have never had a chance before of coming back, such as those in asystole.

Yeah. From my, my agency here we are doing, you know, I implemented the heads up CPR bundle. So talk about the ITD and how important that is with the heads up.

Yeah, well, you know, it's, it's all about flow. Right. And yeah, when I tell, when I talk to people about the bvm, I say stop thinking about the BVM as an oxygenator and a ventilator. It is a, it's another flow device. Right. Because it's like Goldilocks. Right. If you don't open up those alveoli and open up those lung beds, you're not going to get flow through the lung and therefore you're not going to get good perfusion, and therefore you're not going to get a good outcome. The same thing with the itd, what the ITD is doing. You know, imagine having a hole in a plastic straw. You can't get any of that flow through the straw if there's a hole in it. Well, it turns out that your ET tube is a big straw. All the ITD is doing is when, when, when you're, when you're letting go, you're not allowing the equilibration of pressure between the outside and the inside. And that negative pressure that you're keeping inside is now allowing more blood flow into the heart and therefore out of the heart. So we have to start thinking about cardiac arrest management more in terms of flow rather than kind of thinking about it as I need to get this number higher. And so I think that's the way to think about it.

Ketamine for refractory seizures. Let's hear it.

That's another one. I mean, this is something that you probably will never see in a hospital for another couple of years. But basically, we're in the field. We've given our max dose of Versed, we've given two doses of Versed, and the patient's still having a seizure. 99.9% of protocols today in EMS just say drive fast. But most of us have the drug on the truck that's going to stop the seizure, which is Gonna prevent morbidity mortality. And that's ketamine. It's 3 milligrams per kilogram IM. You can give it 1 milligram per kilogram IV. We have an abstract on it. And we had over 90% of those patients had their seizures stopped in the field. And it's just an incredible, it's just an incredible drug. And I think most people should look at that data and implement that in their systems.

How cool is ketamine does everything such a drug?

Yeah.

Okay, here's one. Double sequential defibrillation. A lot of people doing it, a lot of people have implemented it. Not enough. Let's talk about that.

Double sequential. So you have a patient who is in V fib. You shock them once, you've shocked them twice, you shocked them three times and they're still in vfibs. Now they're refractory. Well, what did we have to do in the past? We didn't have much. Right. We just take them to the hospital and, and hopefully maybe they can put them on ecmo. Right, right. Well, there's a big paper that just came out of Toronto. It's the dose VF trial. Dr. Sheldon Chesky is an amazing guy. The Peel paramedics did an incredible job up there. That's 4,000 paramedics. They get a lot of credit up there. And they did a cluster randomized trial where they just put another set of pads on and then you don't push the button at the same time. It's push, push as fast as you can. Do them in sequence, therefore double sequential. And he, and he, he, he reported that you more than double neuro intact survival from refractory V fib. Listen to that. More than double refer survival, neuro attack survival. That was just published in the New England Journal. He also showed that just simply changing the vector from AL to ap. Right. Also increases your odds of ROSC and your, your odds of neuro attack survival. But it's just so it's the thing now. When are the guidelines going to change and what are they going to say? Here's my thought. That the strikers and the Zols and.

The Phillips of the world are going to have to make a defibrillator that has four pads on it. Yep. Right. To Al, two aps and you put them all on at the same time. And then if the first couple of shocks don't work standard, then maybe you do a vector change and then by the fourth shock the same one machine will go into a double sequential mode. That's what I think the future is. And hopefully the. The folks who are making these machines are listening and looking at the data, because to get two machines and to do that is a little complicated. If you haven't practiced it.

Such a forward thinker you are.

Listen. Look at you.

Listen. At the end of the day, Doc, we have come quite a long way. We don't get the credit that we deserve. In order to move this profession forward, we need to start thinking more like clinicians and treating ourselves as clinicians as opposed to living that antiquated lifestyle that we always have in ems, where we were ambulance drivers. And I think that that arm of medicine is really starting to shine now in a sense that we do have the capability of doing some really incredible things. What is lacking, and we've spoken about this a lot, is that voice, that collective voice of providers and. And trailblazers in this industry. I think we're getting better. I think that we're bridging a lot of great personalities together that have that collective voice. And I'm curious as to what your thoughts are about this and how we're going to push this forward in 20, 23 and beyond.

You know what? I completely agree with everything you just said. And it really came to me to. It came full circle for me when about five months ago, and this is personal. I went into afib. I was in Idaho. I was AFIB with rvr, and I stopped in and I had paramedics who were evaluating me. They happened to be stationed at the hospital. It was a helicopter crew, and they had the pads on me. We did the rhythm. They did everything they could have done that the hospital was about to do. So they said, hey, you got to go to the emergency department. So I went to the emergency department, and they did the same exact thing that EMS could have done, except on the hospital side, I got a $15,000 bill when EMS would have charged me about 800 bucks. So what does that tell you? What does it tell you? It tells you that we're doing the same thing. And we spent the last 30 minutes talking about how we're doing even more. Right, Right. However, we're getting paid 10% of what the same people in the hospital are doing now. What does that tell you? It tells you that the professions of hospital management, physicians, look at what the nurses have done.

They have done such so that they can get paid more and they're well respected and the laws are benefiting them in the meantime. In ems, it seems to be like we haven't done that. So I agree with exactly what you said. Now is the time to do it. Now is the time to get respect for what we do, to get paid for what we do. We save the system millions and millions and millions of dollars. And Covid really showed that, right with the number of vaccines we were giving. And hospitals are not taking our paramedics away from us to work in the emergency department. So EMS has now have to come. There has to be parity between the EMS and all the other health professions. But we as a profession have to lead that. We have to demand that. And I think that together as a community, naemsp, NAEMT and other organizations have to say this is who we are, this is what we deserve. And I'm going to keep fighting for as long as I can to help make this profession what it really is.

Beautifully said. You're going to have me right beside you. And I want to thank you, Pete, for coming out because this was a lot of fun. It really was. This was the, the best of 2022. The pearls from Dr. Peter and TV and, and you know, we're going to wrap up this year, looking forward to next year and everything else that's going to come out of it that we're going to just continue to drive from what we've learned here in 2022 and we're just going to keep moving forward. So Dr. Anteve, I really want to thank you for joining us today.

Thanks, chief. Thanks for having me. And 2023 is going to be an amazing year. EMS is the best profession to be in and if people are looking to come to great systems, come down to South Florida, we'd be happy to have you.

That's the truth there, folks. I'm going to take them up on that, Pete. Have a great holiday, man. Have a great holiday. We will talk to you in the new year. A lot of exciting things to follow up on. So thanks again for joining us. And once again, a special thank you to Han Tevy. Whether it's medication dosing, cpr, metronomes protocols, checklists or EMS specific education agencies who know turn to hand Tevy. And thank you for listening and watching EMS World Podcast. We will catch you next time. Have a wonderful holiday season and we will catch you real soon on the next episode. Take care.

Happy holidays. Thanks.

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