February 5, 2025 • 43 mins
Dr. Peter Antevy is a physician, entrepreneur, and originator of the Handtevy® product for pediatric patients. He is a respected voice in EMS, and in this episode, he shares 7 things that he believes are practice-changing for EMS providers. From pediatric bradycardia and cardiac arrest to seizures, whole blood administration, and more, Dr. Antevy will challenge your thinking and improve your practice.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Welcome to Seven Things EMS, a continuing education offering from LEMUR Education.
(00:12):
Seven Things EMS is designed to give you what you need to succeed in EMS, it's conversational,
informational, and without the fluff.
And welcome to another Seven Things EMS podcast. My name is Dan LEMUR, your host.
(00:34):
And I'm incredibly excited here today to have Dr. Peter Antevi as our guest today. Dr. Antevi is,
well, things probably too much I could put in here, but medical director for multiple services in
Florida EMS schools, perhaps most known for the Hantevi products for pediatric care, which are
(00:57):
outstanding just for the record. I'm not paid to say that, but I've got to put it in here.
Great respect for you as a physician, a researcher, and an entrepreneur. I'm really happy to have you
here today. Dan, I'm so happy to be with you today. We've been friends for a long time.
I've followed your journey for many years and just happy to be here.
As have I. We've had some great conversations and we're going to have a great one today.
(01:21):
And of course, our motto here is to get right to business. We have lots of stories we could tell,
but we have a lot of really good information here. You put together some really great things.
So we're going to start with the concept of measurement, how we improve, how we help,
how we make a difference. We don't always measure that well. And this is going to feed
(01:41):
through everything we talk about today. Right. So I would ask the audience to think about this.
If you were the city manager and a road in your city was curved and it was dark,
and every year a hundred people died on that road, you would say, well, we took a measurement,
(02:02):
a hundred people died. That's not good. What would you do? Oh, we put lights up.
When you put lights up, what you owe yourself to do the following year is to look at how many people
died after that change. And it turns out that when you add lights to a dark curved road,
the lights causes the death rate to increase to 150. Why? Well, because when people see a
(02:25):
lit road, they don't take their foot off the gas and they fly off the road even faster and they
die at a higher rate. Same thing goes for EMS, that if you're going to do something,
you need to measure it. And then if it's not good, that measurement is not good, you need to improve
it. And we're going to go through some items today that we, we and my team, we've gone through this
(02:53):
process and we've modified things, even though the standard of care may have set something
different. We saw in our data and in other people's data that the outcomes were not good. And so we
changed it. But when you do change it, you have to improve it. That's number one. Second item real
quick is that there's two types of errors people make. One is called an error of commission. That
(03:18):
means you gave the wrong drug or the wrong dose of a drug. I gave a tenfold dose of EPI, which I
did by the way in 2005. Okay. That's an error of commission. But more importantly than, and
probably happens way more than the errors of commission are the errors of omission, meaning I
have a kid seizing in the back of the ambulance, the ER is three minutes away. You know what, I'm
(03:41):
just not going to give the versed because I don't want to make that calculation and I don't want to
make the error. So now we deliver a kid to the ER still seizing, but I didn't make a mistake.
Those need to be counted as mistakes. So as part of the measurement thing, I'm going to ask everybody
today, don't just measure the errors people are making, but also measure when people are not
(04:04):
getting that dose of fentanyl, people are not getting the albuterol, people are not getting
the versed. Those are just as important. I think what I heard as we discussed leading into this
today is that you're really not afraid to look at things differently. And I think when doing that,
though, you've got to back that up with facts and numbers. And I think that's the big thing,
(04:25):
not only finding other people's research, research you've done, and that if you want to change
practice for the better, looking at those things is really important.
100% correct. That's so well said.
All right. Well, let's start with pediatric cardiac arrest. Now, we're going to do things
that might not be all pediatric here. I know that you're looked at as the pediatric guy with
(04:47):
hand-tevi and doing that, but really as a medical director in the research, as you've dipped your
toes and a lot of things. But I'm glad we're talking about some PEDES things here, because
that's one of the things that you're looked at for pediatric cardiac arrest. Let's go there.
Yeah. So pediatric cardiac arrest. So, Dan, there's 20,000 kids every year who go into cardiac arrest.
(05:08):
And if you look at the numbers, only 5% leave the hospital neurologically intact.
Wow. So if you do quick math, 5% of 20,000, there's only 1,000 kids. And we've been told since the
80s that that's the number. But when we finally dug into it and started to realize what we were
doing differently between the adult cardiac arrest and the pediatric cardiac arrest, it turned out
(05:34):
that it was very obvious what was going on. What was going on is that for the adult, we would stay
on scene, move the furniture, pull the guy from the bathroom, put him right here, tell the spouse
we're staying here for 20 minutes, and then run a beautiful arrest. Nice. That same shift, the next
call is a five-year-old cardiac arrest outside by the pool, and everything is not done the same.
(05:59):
It's done exactly different, meaning that someone comes and grabs the kid, we run to the back of
the ambulance, and we say ER is only five minutes away, and we end up just bringing a kid with really
bad CPR, no airway management, and we just drop this kid off now that's been 20 minutes of really
bad CPR, and the kid has a bad outcome. And so what I want to just explain to everybody is there's
(06:24):
some basic things you can do to make sure that the pediatric arrest that happens in your city,
in your community tomorrow, actually gets out of the hospital. And number one is to remove this myth
that adult and pediatric cardiac arrest is any different. Look at your protocol, they're the same.
Look at the compression rate, it's the same. Look at the ventilation rate, it's the same.
(06:47):
All you're doing is you have to convince yourself that that kid should get the same
high-quality care right where you find them. And if you're removing this kid from where you find them,
to go bring them to another place where you think they can do better CPR than you're gravely mistaken,
(07:08):
and let's go to the measurement part. Look back at your cardiac, your pediatric arrest for the last
24 months, find out how many of those kids have actually walked out of the hospital, that's your
baseline. Now you have to say, how do I compare versus another city or versus the country? And
if your number is zero, like no survivors, well then you have some work to do. And the biggest point
(07:34):
that I will tell anybody is that the most important time for a pediatric cardiac arrest
is the six to eight minutes before you get to the scene. Why? Because that's when you're,
you know the age, you can figure out the airway size, you can figure out the epi dose,
you can figure out the jewels. If you know those three things and people have assignments,
(07:56):
you can actually stay on scene for the first three rounds of great BLS and ALS care, that's
about 10 minutes. And that kid now has the best chance of survival because EMS is where lives are
saved. Listening to this, and I've had the good fortune that you know I've had many conversations,
one of the things, you're right that the code is run the same, but the two things I see are
(08:21):
different. One is the mindset. People freak out about the kids and you say, you know there's a
lot of kid stuff that really is, they are small adults, but also they're so portable, you feel
you can pick them up and you can move them, you can't pick me up and move me to the ambulance,
one person like that, but a kid you can. I think we have to not only be trained better, we have to
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fight some of those things that are almost brought to us as instincts to be able to do.
I love that point. People have these instincts and they feel they're doing something to benefit
the parent. I'm going to take child from the ground and take him to the hospital because mom
will think we're doing better by the kids. It turns out that's exactly the opposite, right?
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And the other thing that is more subtle, if you cannot make eye contact with a family member,
because of your nerves are so high because you haven't prepared prior to arrival,
the parents not going to trust you, their anxiousness is going to go up. They're going to start saying,
hey, why are we leaving? And all of a sudden the entire scene is lost. You've lost control of the
(09:29):
scene. And so it's not just knowing the dose. It's not just knowing how to place an airway.
It's understanding how to control yourself, control your emotions and knowing how to interact with
family the minute you walk off of that vehicle. I think we're focusing on the wrong things.
We're looking at that micro level when macro level is where the issue is. I mean, if we're going into,
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we're doing pediatric resuscitation, the placement of the I.O. is a big thing. And I think you're
going to tilt that on its head a little bit for us now again, aren't you? Yes. And I'll do that for
kids and for adults. So many people know, yeah, many people know that for many years they've been
telling us to put the I.O. in the proximal tibia, right? And I'm not even going to go into the fact
(10:22):
that the packaging of the I.O. needle has some incorrect information. It says three to 39 kilos
for the pink 15 millimeter needle. Well, that's incorrect. Well, there was a study that came out
years ago, probably four or five years ago that showed that there's a 50 percent
malpositioning of the proximal tibial I.O. needle in infants. There's a 39 percent
(10:48):
malpositioning in kids over the age of one. All of us know who have put in those proximal tibial I.Os
that that bone is so thin that and the needle is longer if you use the blue needle, you're either
going to go around it or through it or or or not into the bone at all. And it's very hard to keep
(11:10):
that needle stabilized. Well, we started doing the distal femur I.O. about seven years ago.
Once you put in one distal femur I.O., you'll never do anything else again. And so we owed it
to ourselves to measure and improve. And so we just published our paper last month. And we
(11:32):
showed that we have an 89 percent success rate of the distal femur. And the only ones that we missed
is because the wrong needle size was used. And so what we learned is that at around a four or
five year old, you have to go to the 45, the yellow needle on a kid to get to the distal femur.
(11:54):
Again, these are things that we're learning along the way. In San Antonio, David Muir Montes and Dave
Wampler published a paper several years ago where they actually allow the use of the distal femur in
the adult. They studied it and they found that once they led it into the wild, all of their
medics said we're never doing proximal humor again because when you have a Lucas going or when you
(12:20):
pull the arms back on the patient to move them, that needle just pops right out. Now, something
that's kind of like analogous to all this is that there's some data coming out on whether or not
medications going through the I.O. during cardiac arrest are good compared to the IV. We'll table
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that for now, but I will say that from a distal femur perspective for pediatric cardiac arrest,
you need to go to the distal femur. There are now trainers that are out there and every agency
who has gone to distal femur has called me and said, Pete, best thing we ever did. So look into it
if you haven't seen it yet. All right. And we will put references for some of these things you
(13:07):
mentioned in the show notes for the episode. So people will have those. All right. Now,
I think that this one might be the most controversial. We talked to how that would be. And
symptomatic bradycardia and peeds. And this one I found was just fascinating. And I think people
will find the fascinating when they're listening. Thanks, Danny. This took me a long time to wrap
(13:33):
my head around. And I finally realized that symptomatic bradycardia is being told to us as a
cardiac arrest rhythm. What I mean by that, if you look at pals and it's a child is in symptomatic
bradycardia, meaning they have bradycardia and have an altered level of consciousness. That means
(13:53):
you should start pushing on the chest, which I agree with. But then they say that the first drug is
cardiac arrest epi. What are we doing about cardiac arrest epi? It's epi one to 10,000.
And you're supposed to give the cardiac arrest dose 0.01 milligrams per kilogram.
So let's say a one year old will need 0.1 milligrams or 1 ml. Well, it turns out in a study in 2019
(14:16):
by Matthias Holmberg, where they had about 6,000 patients, they showed very clearly that giving
cardiac arrest epi to symptomatic bradycardic children leads to harm. It was very clear for
some reason the guidelines, because it was only one study and it was matched patients, etc., they
(14:39):
said, not good enough. We want a randomized controlled trial. And then that paper was ignored
and never looked at again. We ended up saying, you know what? Why is symptomatic bradycardia
considered an arrest rhythm when an adult it's not, you would never give cardiac arrest epi to
a symptomatic bradycardic adult. And ever since I've been kind of going around the country talking
(15:02):
about this, I've had people send me, there's some folks up in Canada on Left Bridge, they've sent me
their Zool case review, all the vital signs, and they showed me they had a patient that they gave
epi to symptomatic bradycardia. The patient subsequently right away went into cardiac arrest
and they said to me, we're never doing that ever again. And about a month ago now, right before
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Halloween, we had a two year old drowning. We gave him five doses of push-pressor epi,
which is epi one to 100,000. That's our protocol for symptomatic bradycardia. And we delivered
a patient who's alive, who's neurologically normal, who's running around outside, playing soccer again.
(15:47):
Right? So it's very interesting that measure and improve, because if you're seeing the same thing
that we're seeing, the same thing that the Canadians are seeing, the same thing that
Mattias Holmberg saw, perhaps we're way off course, and we're treating in a non arrest rhythm
incorrectly. Do you think, this requires some fortune telling here, but do you think that the
(16:13):
Heart Association and their guidelines that'll be coming out within the next year or so, right?
We're due for an update. I think they'll keep the same approach. So ILT-COR, it turns out,
which is the international consortium, just dropped their guidelines last week. And so I
took a very deep dive because I gave a talk on this on Friday. And so we're waiting for the AHA
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to come out with their version of it. But the answer is no. They are not going to look at it,
and they only will look at it then when there is new data to support it. Imagine, how are you going
to do a study, another study, on symptomatic bradycardia, that's a randomized control trial?
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I mean, just imagine A, that may not be ethical to do. B, in order to get thousands of patients
you have to have a big multi-center trial. That would take years to do. I think the Holmberg
study is perfect. I think it's good enough. And for many of us who've been doing this for a long
time, I've been doing pediatric ER for 25 years, I can tell you that giving cardiac arrest epi
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to somebody who has a heartbeat is deadly. So I don't think they're ever going to come back around
to this unless someone does a very big trial, which I don't think is in the works.
Is it difficult for you as a medical director? Do you think it's difficult for medical directors
to put out protocols that go against AHA guidelines? Do we kind of stick with the norm?
(17:47):
No. Many years ago, I thought that was the case. Remember, I'm in Florida, we have a delegated
practice state, meaning that as a medical director, I can make changes as long as it has some backing,
and as long as I can show that there's data behind it. So if you live in a place, another state,
where it's a statewide protocol, much harder thing to do. But that's why, Dan, I've taken the stands
(18:12):
of everything that we do will be backed with evidence. And unless someone can show me evidence
to the contrary, then I can go to the court of law and I can show a jury that this is why we do
what we do. Remember, the AHA guidelines, they're not protocols, they're not written in stone,
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and they also give you a level of evidence. And all of these things that we do in pediatrics,
most of them have very limited evidence and it's very weak data. And they even say weak
level of evidence, C, limited data or expert opinion. So I think people think that if I don't
(18:57):
do it, the guidelines show that I'm going to be concerned about it. If you look at my protocols,
Dan, a majority of the things we do are not in the guidelines. As an example, I've removed epinephrine
from all of my shock-cooled rhythm protocols. I give Esmalal to refractory VF. We start AP for
(19:20):
our pad placement. I mean, there are lots of things that we do currently. And my outcomes,
which I put on LinkedIn and I put on Twitter, I have double the survival of what you would find
nationally. Measure and improve. Awesome. All right. That was a great answer. Well, we're
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moving on now in this and we're going to go a little bit now away from the PEDs,
but certainly anything that can apply to PEDs. An interesting conversation on RSI versus DSI.
Tell us. This is a fascinating one. And I have to give all the credit to people like Scott Weingard
(20:03):
and Jeff Jarvis. Jeff Jarvis is great guy, EMS Medical Director up in Fort Worth.
Great voices in EMS. Yes. Great. Great voices. And Jeff said, hey, RSI, when I look at my data,
I'm looking at significant hypoxia. I'm looking at significant patients with hypotension.
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I'm looking at patients who are arresting right after we paralyze them. And it turns out,
RSI, the R, is rapid. What is rapid about it? It's the induction. So you give
atomic, as a sedative, you give rock, your own EMS, a paralytic, and then you flush it,
and then you intubate. So you go boom, boom, boom, right? One, two, three, rapid succession.
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The problem is, is that when you have a patient who's sick, whether they're
teetering on the edge of hypoxia, whether they're barely maintaining a blood pressure,
that's the fifth percentile. If you paralyze that patient, what you're doing is you're taking away
their negative pressure that they're using, that they're creating when they inspire. So if I breathe
(21:11):
in, I'm creating negative pressure, air is rushing into my lung, and blood is rushing into my right
ventricle. So the act of breathing in, it actually increases your cardiac output. When you remove
that cardiac output by paralyzing somebody who is hypoxic and who is quasi-hypotensive,
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like let's say blood pressure of 90 over palp, they will die immediately, and that's the periintubation
arrest. So Jeff said, okay, what if we do DSI? The D is a delay. Instead of a tomate, I use ketamine.
Ketamine maintains your airway reflexes. It keeps you breathing, and now I'm going to give you three
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minutes to hyperoxygenate, and I'm going to buff up your blood pressure with fluids and push press
your epi. And now I'm going to have a patient who, at the three-minute mark, I can give the
paralytic to knowing that their oxygenation is fine, that their blood pressure can tolerate it.
And in his paper that he published, again, four or five years ago, he showed a dramatic difference.
(22:19):
Sky Winegard's paper showed a dramatic difference. There was another paper, I believe, out of India,
a trauma paper in hospital. A dramatic difference. Every DSI paper has shown that you don't get the
significant hypoxia, hypotension, or periintubation arrest. Why isn't everybody doing this? My
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agencies, we flip to it right when Jarvis's paper came out, and we look at every single one of our
airways, our DSIs, and it shows the same thing that Jeff did. We measure, we improve. So that
change that we made, we didn't just take Jeff's word for it. We actually said we're going to
evaluate our own cases, and it looked exactly like Jeff's. So that's what I think everybody
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should be doing. If you do RSI today, please look at DSI. Well, just the R, the rapid part,
certainly can lead to errors. Stress and rapid really don't go together. Could you just walk
through once more? I think people that are used to RSI may not have the DSI concept,
(23:26):
walk through that intubation process. Could you walk me through those three minutes one more time?
Sure. Sure. So you have a patient who's in respiratory failure. It could be a kid, it could
be an adult, and obviously they have airway reflexes. They feel pain. So if you put plastic,
plastic tube in their trachea, they wouldn't be happy with you. And obviously they're going to
clench down on the tube. So the first thing you want to do is you want to give them a sedative. A
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lot of people that end up using a tomodate, which basically cause you to relax and not really worry
about what's going on around you. And then what you want to do is also give a paralytic to allow
you to actually innovate without the person clenching down and kind of, let's say, ruining the
(24:12):
view that you have. So it allows you to nicely and gently innovate somebody. The problem is, is that
you're giving the sedative and you're giving the paralytic back to back, right? You're not allowing
yourself time to optimize the patient's oxygenation and blood pressure before you hit the paralytic.
(24:35):
What DSI does uses a different drug for the sedative. And by the way, ketamine is very good for pain,
which it is not. You give the ketamine, they're sedated, they're not feeling any pain.
For the next three minutes, you're now hyper oxygenating them with nasal cannula.
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We put the BVM over their mouth, but we're not squeezing the bag and they're breathing in on
their own. Remember, ketamine allows you to breathe on your own. So now they're inspiring 100%
oxygen for the next three minutes. If their saturations are 94% or higher for those three minutes
and during that time, their blood pressure is normal. And if it's not normal, you give them
(25:20):
fluid, you give them push, press, or epinephrine. So you're using that three minutes as a time to
optimize your patient's vital signs and their physiology. And then you give the paralytic.
So it's the same thing. You're sedating someone, you're paralyzing them. But in between,
(25:41):
you're optimizing the physiology so that they don't have a bad outcome during the process
of passing the tube through. It's a very simple concept, but the reason people don't want to do it
is because that three minute pause feels like three years for people. And not until you do it
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and understand it and let your body and let your own physiology not get anxious.
You can say, you know what, I did it better. It's better for my patient. It was hard to do once or
twice. But once you do it then, you'll never go back. I think much like we talked about in the
pediatric cardiac arrest, our sense of urgency is sometimes misplaced. Exactly. You know, as we're
(26:27):
writing books, we have to do... We're writing a book on that. It sounds more like a Tull
Gawande book or a checklist manifesto book or something like that. But yeah, that three minutes,
I think is both a short time and a long time. And it's a matter of perspective.
And you know what? There's a great book that I just read from Malcolm Gladwell. People may remember
(26:51):
his book, The Tipping Point, 25 years ago. He just wrote another book, a 25 year update.
I think it's called like Revenge of the Tipping Point or something like that. But he talks all
about what makes people change from their current practice to something completely different.
And I'm not going to go into the book, but people should read it. But there is a mechanism and a
(27:17):
way to change hearts and minds. But it's not as obvious as people may think.
I think that the concept of EMS and emergency involves some rushing and involves some
sense of urgency again, which I think we have to replace with thinking. I did a podcast earlier,
(27:38):
I recorded one. And one of the things I observed is that EMS doesn't have the maturity level of
emergency medicine or other things. We're newer, we're raw. And valuing education and valuing
the research and measurement like you're talking about has got to be a big part of that.
Well said.
Whole blood.
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I got to tell you that, yeah, I mean, it just only seems a couple of years ago, but I said, oh,
we can't do blood in the field. It's like, because you can't do this, you can't do this,
can't do this. But all of a sudden we're seeing a lot more of it and seeing some good results
coming from it.
Yes, yes. So this is fascinating that back in the Vietnam War, they were using whole blood
(28:22):
for the soldiers. The war ended. And then some point in between then and now, someone came up
with this concept of, I can take blood from you after you donated and you get your two movie tickets.
I can take your blood, I can send it to the factory, if you will, to the distribution center.
(28:45):
We can actually break it up into three different components. So they siphon off only the red cell,
they siphon off only the platelets, and they siphon off only the plasma, and they bag those up,
and they sell them as three separate things. And one can say that they're probably making
more money. There are patients who only need red cells, who only need plasma, who only need
(29:09):
platelets, cancer patients, et cetera. But we can all agree that a bleeding out trauma
patient or hemorrhaging pregnant woman, postpartum, they're bleeding out the whole blood, they
need whole blood back. Well, the military started saying, in recent history, they said,
(29:33):
you know what, we're going to go back to whole blood. And they did, and they're probably in
the late 90s. And then finally, I believe it was 2016, that's when the folks in San Antonio,
big military base there and all the trauma doctors said, you know what, we've been doing
in the military for a long time, let's bring it into the hospital. They spend a long time,
(29:56):
they finally powered through, they got it into the hospital. In 2018, San Antonio finally put
it on the helicopters. And when you look at their initial data that they put out there,
it was like something like a 95% survival rate on their first 21 trauma patients. It was insane.
So they then put it on to San Antonio ground and slowly but surely we started it here in 2021.
(30:22):
And since then, Dan, we have now given 400 units of blood. You know, our survival rate is
before the patient goes into cardiac arrest. If they get their blood before their arrest,
it's a 90% survival. Holy cow, holy cow. Washington, DC, they've given a couple
(30:43):
of 100 units, 90% survival. Atlanta, 90% survival. New Orleans, 90% survival. And
you know, there are people out there in the Northeast, some, there's some, there's some people
who own like the helicopter companies who are losing business because if the ground ambulance
has whole blood, then they're not going to be calling the helicopter anymore. There are some
(31:08):
people out there who are saying the whole blood doesn't work in the ground. So this measurement,
measuring and improved concept we've published, New Orleans is published, Washington, DC puts out
every month, every patient is so transparent and all their numbers are being put out on the internet.
We are at a stage Dan where this is going to be the most important thing that we do in trauma care
(31:33):
in our lifetimes, period, end of story. And there's no one who's going to find an article out there
done by a municipal 911 system in the United States where everyone's collecting their data,
we're giving it to a registry. This is something that's going to transform trauma care in the next
(31:54):
five to 10 years, hopefully sooner. All right, a couple of things come to mind here. And I think,
I think we can figure out the answer relatively easily, but you've talked about bigger cities,
a little bit of knife and gun club cities in some cases where there's some serious trauma.
Are we relegated in smaller communities, rural communities that it stays with the helicopter?
(32:19):
Can we use this? With life, there's no economy of scale, yet we know that a lot of times our
things are needed most if ultrasound sometimes isn't in the low volume places, but it's in the
agency that's right near the trauma center. And there's this balance, how do we balance those
cities versus rural? And what's your prediction? How it goes next? Oh, I already have the answer
(32:44):
for you because it's already happening. So if you look at the map, so we have a live map now
saying we, there's some folks that I'm in a group with now that they put up a live map and you can
see all the, there's about 200 agencies around this country who are live today. And I would say
it's split right down the middle of urban versus rural. So if you look at North Carolina, if you
(33:11):
look at Western North Carolina where they got hit by the hurricane, et cetera, there's a big cluster
of agencies all rural who have whole blood. And the question was, well, how do you do that? Very
simple. Whole blood is just another medication. Take it like an amiodarone drip, right? But
logistically, you have to get it. You don't want to waste it. And someone's got to pay for it.
(33:34):
Really, that those are the big things there. So how do you get it? Right? They just went to their
trauma center and said, Hey, can we have the whole blood? If we don't use it in 21 days,
because it's good for 28 days, we'll give it back to you. And then you have a week to use it. They
said, yes. Because they have a relationship with that hospital, the hospital said, we're getting
(33:55):
those patients anyway. So don't worry about the cost of it. And basically, they had to buy the cooler.
Right? So it's about 12,000 bucks to kind of get started, just to have all the things you need.
And then it's a matter of each patient needs a unit of blood and a few consumables. So it costs
(34:15):
you about 1000 bucks a patient. The future I will predict is it's costing us $600 per unit today. Why?
Because from the moment you give your arm, you did, you gave a unit of blood, you guys are two
movie tickets. Those people then do something with it, magical, right? They're testing for
(34:35):
testing for diseases, etc. And then they turn around and sell it to the agency for $600.
Here's what the future is going to be. And they do this in the military today.
You hold out your arm at your local hospital, all the firefighters, police officers who are
low, tighter, O positive, that's a blood type we need. Imagine we had 300 people that were donors.
(34:58):
You got a text and said, Hey, Dan, we need you to come donate. It's been six months. Okay. You put
out your arm, the hospital in that rural place takes the blood, tests it for the couple of things
that need to be tested for. And then they say, here you go, EMS. Here's Dan's blood.
The only thing that costs was the laboratory time of the people testing your blood. There's no
(35:21):
increase in cost. This is called the walking blood bank. And my team, we've put together a team of
educators. We went to rural Alaska. This is like four months ago now. And we taught them how to do
a walking blood bank methodology. So the future holds where anywhere you just have to get the people,
(35:43):
test the people, and then get the hospital to say, So once that becomes standard of care,
every single location will be able to have whole blood. The only thing you have to pay for is
the consumables, which, you know, it's a couple hundred bucks. Let's put it that way. And
there's no one who could tell me that a couple hundred bucks is not worth a life because these
(36:05):
lives are not the 80 year old cardiac arrest. These are the 17 year olds who got into a car accident.
It's the 23 year olds who got shot. It's the, you know, 30 year olds who fell off a ladder.
So that's the future I will predict. I am so glad I asked that question. That is,
that is fascinating stuff. And I'm sure the listeners will find that too. We're moving right
(36:28):
along here. We have one more thing. And that's ketamine for stats. Tell me, I mean, I guess
what I do, I, I serve them up and I say, tell me about it. Here's another. So have you ever been
in the back of an ambulance and you've exhausted your dose of Versed for a seizing patient, and you
still have 20, 30 minutes to the hospital. What do you do? And a lot of people say, my next thing
(36:55):
is diesel fuel, right? You drive faster. But it turns out when you look at a guy like John Travolta,
his son, Jett died because of status epilepticus, meaning that this is a refractory status. You
try to give the medication, didn't work. And you have to give something else. That's something
else has typically been something like KEPRA, phosphenitone. These are hospital side drugs that
(37:21):
have been used for a long time. We said, but we're in EMS, we want to stop that seizure now.
And everyone said, well, there's, you know, you could carry KEPRA if you want. And
someone I work with, brilliant guy, Dr. Ken Chepke, we work together at Palm Beach County
and other places. He's a medical director as well. He said, there's data on ketamine. So I started
(37:46):
looking at all the data available in this, I mean, ever published on ketamine, I have a folder on it.
And all the ketamine for seizure data is from intensive care units. And that ketamine is always
given like as the fourth or fifth option. And invariably, ketamine was working at a very high
(38:07):
rate. So we said, let's, let's add a protocol. And we've been doing this for like six or seven years.
Let's add a protocol and let's do it. And let's see what our outcomes are. So our paper has been
accepted. And the results are really astonishing. Then we had a over 90% success rate in stopping
(38:28):
refractory status epileptics, meaning seizures that don't go away after what most people do
in an adult world is give a max of 10 milligrams of versed. After the 10 of versed, what do you do?
The answer is now ketamine. We saw a problem. We knew that there was another answer. We implemented
a protocol. We measured it. It showed significant improvement. And we feel this is not just going
(38:54):
to change practice out of hospital, because many physicians in hospital have seen our data and the
people who have reviewed our paper and they said, this is maybe one of the most game changing
things in seizure care in a long time. And most of us carry the drug anyway. You should add it to
your protocol. And once our paper is published, hopefully it'll be live in another in days to a
(39:19):
week from now, I'm presuming. I'll send that to you. So you can post it. Yeah. And what, what,
what dosing are you using for ketamine in that? So for the adult, it's 100 milligrams IV slowly.
And for kids, it's two milligrams. I am two milligrams. I am because a seasoned kid, you're
(39:39):
not going to start an IV on, you probably shouldn't start an IO on that kid. If you can just give
ketamine I am so two per kilo I am. And an adult, it's 100 milligrams IV. And again,
the only fallouts we had were intranasal. And so we've removed that since from our protocol.
(40:02):
We actually still allow it, but we're actually veering away from it because we saw what happened
in our data. So now we're advising that most of that ketamine be given intramuscular,
two milligrams per kilo. Interesting. Fascinating. All right. Well, that gets, that was a,
this is a well rounded episode. We ended up finishing at a perfect time. The way I end these
(40:24):
sessions is I love to give the guests the opportunity to have a last word, right? Primacy and recency.
You get a chance to say something big at the end that people are going to remember and listen to.
What would that be? So here it is. We as EMS professionals, we are a specialty that is very
different in the house of medicine. We are an ignored specialty in the house of medicine.
(40:50):
People don't recognize that for sepsis, EMS matters more for cardiac arrest, EMS matters more,
right? We need to take ownership as a profession of what we do. We need to take ownership of the
guidelines. So the guidelines are being given to us as like two tablets from the top of the mountain
(41:11):
by intensivists, people who work in intensive care unit. So what I would say is that understand if
you work in EMS, you work in a different place. You do things that are different. You see patients
at a different moment in time. And I think we as a profession need to own it. We need to own the
(41:32):
fact that we are better at resuscitative care than they are at the hospital. And part of being good
at something is not being intimidated by those at the hospital. Part of being good at something
is owning the fact that you're better at it. And that's what I would tell people and leave as a
final word is that this is a very special profession. Unfortunately, the house of medicine hasn't
(41:57):
recognized who we are, but we are going to make a difference and we're going to make them recognize
that EMS belongs as the number one cog in that wheel. That's where we belong. Well, if there's
anyone that I believe could start carving out those stone tablets for emergency medicine and EMS,
(42:18):
it would be you. That's Dr. Peter Antevi, who is a medical director, an entrepreneur, and I have to
put in a plug in only because I'm a believer with a hen-tevi system if you haven't looked at it.
And seeing your work, you really can't go on social media without looking at
at pediatrics and things like that without seeing your stuff. You're obviously a brilliant man
(42:39):
and a heck of a nice guy. Well, I've enjoyed knowing over the years and I thank you very much for being here.
Thank you so much, Dan. Right back at you, my friend. You're amazing. Appreciate it.
That's the end of this seven things. It's been a great episode. Take a look at the show notes for
some references on this. If you want continuing education, you can get that too. Thanks for
listening to another episode of Seven Things EMS. Thank you for listening to a Seven Things EMS podcast
(43:06):
by Limber Education. If you've listened to this podcast on a streaming service and you're interested
in getting continuing education credit, please go to lc-ready.com for more information.
Welcome to Seven Things EMS, a continuing education offering from LEMUR Education.
(00:12):
Seven Things EMS is designed to give you what you need to succeed in EMS, it's conversational,
informational, and without the fluff.
And welcome to another Seven Things EMS podcast. My name is Dan LEMUR, your host.
(00:34):
And I'm incredibly excited here today to have Dr. Peter Antevi as our guest today. Dr. Antevi is,
well, things probably too much I could put in here, but medical director for multiple services in
Florida EMS schools, perhaps most known for the Hantevi products for pediatric care, which are
(00:57):
outstanding just for the record. I'm not paid to say that, but I've got to put it in here.
Great respect for you as a physician, a researcher, and an entrepreneur. I'm really happy to have you
here today. Dan, I'm so happy to be with you today. We've been friends for a long time.
I've followed your journey for many years and just happy to be here.
As have I. We've had some great conversations and we're going to have a great one today.
(01:21):
And of course, our motto here is to get right to business. We have lots of stories we could tell,
but we have a lot of really good information here. You put together some really great things.
So we're going to start with the concept of measurement, how we improve, how we help,
how we make a difference. We don't always measure that well. And this is going to feed
(01:41):
through everything we talk about today. Right. So I would ask the audience to think about this.
If you were the city manager and a road in your city was curved and it was dark,
and every year a hundred people died on that road, you would say, well, we took a measurement,
(02:02):
a hundred people died. That's not good. What would you do? Oh, we put lights up.
When you put lights up, what you owe yourself to do the following year is to look at how many people
died after that change. And it turns out that when you add lights to a dark curved road,
the lights causes the death rate to increase to 150. Why? Well, because when people see a
(02:25):
lit road, they don't take their foot off the gas and they fly off the road even faster and they
die at a higher rate. Same thing goes for EMS, that if you're going to do something,
you need to measure it. And then if it's not good, that measurement is not good, you need to improve
it. And we're going to go through some items today that we, we and my team, we've gone through this
(02:53):
process and we've modified things, even though the standard of care may have set something
different. We saw in our data and in other people's data that the outcomes were not good. And so we
changed it. But when you do change it, you have to improve it. That's number one. Second item real
quick is that there's two types of errors people make. One is called an error of commission. That
(03:18):
means you gave the wrong drug or the wrong dose of a drug. I gave a tenfold dose of EPI, which I
did by the way in 2005. Okay. That's an error of commission. But more importantly than, and
probably happens way more than the errors of commission are the errors of omission, meaning I
have a kid seizing in the back of the ambulance, the ER is three minutes away. You know what, I'm
(03:41):
just not going to give the versed because I don't want to make that calculation and I don't want to
make the error. So now we deliver a kid to the ER still seizing, but I didn't make a mistake.
Those need to be counted as mistakes. So as part of the measurement thing, I'm going to ask everybody
today, don't just measure the errors people are making, but also measure when people are not
(04:04):
getting that dose of fentanyl, people are not getting the albuterol, people are not getting
the versed. Those are just as important. I think what I heard as we discussed leading into this
today is that you're really not afraid to look at things differently. And I think when doing that,
though, you've got to back that up with facts and numbers. And I think that's the big thing,
(04:25):
not only finding other people's research, research you've done, and that if you want to change
practice for the better, looking at those things is really important.
100% correct. That's so well said.
All right. Well, let's start with pediatric cardiac arrest. Now, we're going to do things
that might not be all pediatric here. I know that you're looked at as the pediatric guy with
(04:47):
hand-tevi and doing that, but really as a medical director in the research, as you've dipped your
toes and a lot of things. But I'm glad we're talking about some PEDES things here, because
that's one of the things that you're looked at for pediatric cardiac arrest. Let's go there.
Yeah. So pediatric cardiac arrest. So, Dan, there's 20,000 kids every year who go into cardiac arrest.
(05:08):
And if you look at the numbers, only 5% leave the hospital neurologically intact.
Wow. So if you do quick math, 5% of 20,000, there's only 1,000 kids. And we've been told since the
80s that that's the number. But when we finally dug into it and started to realize what we were
doing differently between the adult cardiac arrest and the pediatric cardiac arrest, it turned out
(05:34):
that it was very obvious what was going on. What was going on is that for the adult, we would stay
on scene, move the furniture, pull the guy from the bathroom, put him right here, tell the spouse
we're staying here for 20 minutes, and then run a beautiful arrest. Nice. That same shift, the next
call is a five-year-old cardiac arrest outside by the pool, and everything is not done the same.
(05:59):
It's done exactly different, meaning that someone comes and grabs the kid, we run to the back of
the ambulance, and we say ER is only five minutes away, and we end up just bringing a kid with really
bad CPR, no airway management, and we just drop this kid off now that's been 20 minutes of really
bad CPR, and the kid has a bad outcome. And so what I want to just explain to everybody is there's
(06:24):
some basic things you can do to make sure that the pediatric arrest that happens in your city,
in your community tomorrow, actually gets out of the hospital. And number one is to remove this myth
that adult and pediatric cardiac arrest is any different. Look at your protocol, they're the same.
Look at the compression rate, it's the same. Look at the ventilation rate, it's the same.
(06:47):
All you're doing is you have to convince yourself that that kid should get the same
high-quality care right where you find them. And if you're removing this kid from where you find them,
to go bring them to another place where you think they can do better CPR than you're gravely mistaken,
(07:08):
and let's go to the measurement part. Look back at your cardiac, your pediatric arrest for the last
24 months, find out how many of those kids have actually walked out of the hospital, that's your
baseline. Now you have to say, how do I compare versus another city or versus the country? And
if your number is zero, like no survivors, well then you have some work to do. And the biggest point
(07:34):
that I will tell anybody is that the most important time for a pediatric cardiac arrest
is the six to eight minutes before you get to the scene. Why? Because that's when you're,
you know the age, you can figure out the airway size, you can figure out the epi dose,
you can figure out the jewels. If you know those three things and people have assignments,
(07:56):
you can actually stay on scene for the first three rounds of great BLS and ALS care, that's
about 10 minutes. And that kid now has the best chance of survival because EMS is where lives are
saved. Listening to this, and I've had the good fortune that you know I've had many conversations,
one of the things, you're right that the code is run the same, but the two things I see are
(08:21):
different. One is the mindset. People freak out about the kids and you say, you know there's a
lot of kid stuff that really is, they are small adults, but also they're so portable, you feel
you can pick them up and you can move them, you can't pick me up and move me to the ambulance,
one person like that, but a kid you can. I think we have to not only be trained better, we have to
(08:43):
fight some of those things that are almost brought to us as instincts to be able to do.
I love that point. People have these instincts and they feel they're doing something to benefit
the parent. I'm going to take child from the ground and take him to the hospital because mom
will think we're doing better by the kids. It turns out that's exactly the opposite, right?
(09:06):
And the other thing that is more subtle, if you cannot make eye contact with a family member,
because of your nerves are so high because you haven't prepared prior to arrival,
the parents not going to trust you, their anxiousness is going to go up. They're going to start saying,
hey, why are we leaving? And all of a sudden the entire scene is lost. You've lost control of the
(09:29):
scene. And so it's not just knowing the dose. It's not just knowing how to place an airway.
It's understanding how to control yourself, control your emotions and knowing how to interact with
family the minute you walk off of that vehicle. I think we're focusing on the wrong things.
We're looking at that micro level when macro level is where the issue is. I mean, if we're going into,
(09:56):
we're doing pediatric resuscitation, the placement of the I.O. is a big thing. And I think you're
going to tilt that on its head a little bit for us now again, aren't you? Yes. And I'll do that for
kids and for adults. So many people know, yeah, many people know that for many years they've been
telling us to put the I.O. in the proximal tibia, right? And I'm not even going to go into the fact
(10:22):
that the packaging of the I.O. needle has some incorrect information. It says three to 39 kilos
for the pink 15 millimeter needle. Well, that's incorrect. Well, there was a study that came out
years ago, probably four or five years ago that showed that there's a 50 percent
malpositioning of the proximal tibial I.O. needle in infants. There's a 39 percent
(10:48):
malpositioning in kids over the age of one. All of us know who have put in those proximal tibial I.Os
that that bone is so thin that and the needle is longer if you use the blue needle, you're either
going to go around it or through it or or or not into the bone at all. And it's very hard to keep
(11:10):
that needle stabilized. Well, we started doing the distal femur I.O. about seven years ago.
Once you put in one distal femur I.O., you'll never do anything else again. And so we owed it
to ourselves to measure and improve. And so we just published our paper last month. And we
(11:32):
showed that we have an 89 percent success rate of the distal femur. And the only ones that we missed
is because the wrong needle size was used. And so what we learned is that at around a four or
five year old, you have to go to the 45, the yellow needle on a kid to get to the distal femur.
(11:54):
Again, these are things that we're learning along the way. In San Antonio, David Muir Montes and Dave
Wampler published a paper several years ago where they actually allow the use of the distal femur in
the adult. They studied it and they found that once they led it into the wild, all of their
medics said we're never doing proximal humor again because when you have a Lucas going or when you
(12:20):
pull the arms back on the patient to move them, that needle just pops right out. Now, something
that's kind of like analogous to all this is that there's some data coming out on whether or not
medications going through the I.O. during cardiac arrest are good compared to the IV. We'll table
(12:44):
that for now, but I will say that from a distal femur perspective for pediatric cardiac arrest,
you need to go to the distal femur. There are now trainers that are out there and every agency
who has gone to distal femur has called me and said, Pete, best thing we ever did. So look into it
if you haven't seen it yet. All right. And we will put references for some of these things you
(13:07):
mentioned in the show notes for the episode. So people will have those. All right. Now,
I think that this one might be the most controversial. We talked to how that would be. And
symptomatic bradycardia and peeds. And this one I found was just fascinating. And I think people
will find the fascinating when they're listening. Thanks, Danny. This took me a long time to wrap
(13:33):
my head around. And I finally realized that symptomatic bradycardia is being told to us as a
cardiac arrest rhythm. What I mean by that, if you look at pals and it's a child is in symptomatic
bradycardia, meaning they have bradycardia and have an altered level of consciousness. That means
(13:53):
you should start pushing on the chest, which I agree with. But then they say that the first drug is
cardiac arrest epi. What are we doing about cardiac arrest epi? It's epi one to 10,000.
And you're supposed to give the cardiac arrest dose 0.01 milligrams per kilogram.
So let's say a one year old will need 0.1 milligrams or 1 ml. Well, it turns out in a study in 2019
(14:16):
by Matthias Holmberg, where they had about 6,000 patients, they showed very clearly that giving
cardiac arrest epi to symptomatic bradycardic children leads to harm. It was very clear for
some reason the guidelines, because it was only one study and it was matched patients, etc., they
(14:39):
said, not good enough. We want a randomized controlled trial. And then that paper was ignored
and never looked at again. We ended up saying, you know what? Why is symptomatic bradycardia
considered an arrest rhythm when an adult it's not, you would never give cardiac arrest epi to
a symptomatic bradycardic adult. And ever since I've been kind of going around the country talking
(15:02):
about this, I've had people send me, there's some folks up in Canada on Left Bridge, they've sent me
their Zool case review, all the vital signs, and they showed me they had a patient that they gave
epi to symptomatic bradycardia. The patient subsequently right away went into cardiac arrest
and they said to me, we're never doing that ever again. And about a month ago now, right before
(15:26):
Halloween, we had a two year old drowning. We gave him five doses of push-pressor epi,
which is epi one to 100,000. That's our protocol for symptomatic bradycardia. And we delivered
a patient who's alive, who's neurologically normal, who's running around outside, playing soccer again.
(15:47):
Right? So it's very interesting that measure and improve, because if you're seeing the same thing
that we're seeing, the same thing that the Canadians are seeing, the same thing that
Mattias Holmberg saw, perhaps we're way off course, and we're treating in a non arrest rhythm
incorrectly. Do you think, this requires some fortune telling here, but do you think that the
(16:13):
Heart Association and their guidelines that'll be coming out within the next year or so, right?
We're due for an update. I think they'll keep the same approach. So ILT-COR, it turns out,
which is the international consortium, just dropped their guidelines last week. And so I
took a very deep dive because I gave a talk on this on Friday. And so we're waiting for the AHA
(16:38):
to come out with their version of it. But the answer is no. They are not going to look at it,
and they only will look at it then when there is new data to support it. Imagine, how are you going
to do a study, another study, on symptomatic bradycardia, that's a randomized control trial?
(16:59):
I mean, just imagine A, that may not be ethical to do. B, in order to get thousands of patients
you have to have a big multi-center trial. That would take years to do. I think the Holmberg
study is perfect. I think it's good enough. And for many of us who've been doing this for a long
time, I've been doing pediatric ER for 25 years, I can tell you that giving cardiac arrest epi
(17:26):
to somebody who has a heartbeat is deadly. So I don't think they're ever going to come back around
to this unless someone does a very big trial, which I don't think is in the works.
Is it difficult for you as a medical director? Do you think it's difficult for medical directors
to put out protocols that go against AHA guidelines? Do we kind of stick with the norm?
(17:47):
No. Many years ago, I thought that was the case. Remember, I'm in Florida, we have a delegated
practice state, meaning that as a medical director, I can make changes as long as it has some backing,
and as long as I can show that there's data behind it. So if you live in a place, another state,
where it's a statewide protocol, much harder thing to do. But that's why, Dan, I've taken the stands
(18:12):
of everything that we do will be backed with evidence. And unless someone can show me evidence
to the contrary, then I can go to the court of law and I can show a jury that this is why we do
what we do. Remember, the AHA guidelines, they're not protocols, they're not written in stone,
(18:35):
and they also give you a level of evidence. And all of these things that we do in pediatrics,
most of them have very limited evidence and it's very weak data. And they even say weak
level of evidence, C, limited data or expert opinion. So I think people think that if I don't
(18:57):
do it, the guidelines show that I'm going to be concerned about it. If you look at my protocols,
Dan, a majority of the things we do are not in the guidelines. As an example, I've removed epinephrine
from all of my shock-cooled rhythm protocols. I give Esmalal to refractory VF. We start AP for
(19:20):
our pad placement. I mean, there are lots of things that we do currently. And my outcomes,
which I put on LinkedIn and I put on Twitter, I have double the survival of what you would find
nationally. Measure and improve. Awesome. All right. That was a great answer. Well, we're
(19:42):
moving on now in this and we're going to go a little bit now away from the PEDs,
but certainly anything that can apply to PEDs. An interesting conversation on RSI versus DSI.
Tell us. This is a fascinating one. And I have to give all the credit to people like Scott Weingard
(20:03):
and Jeff Jarvis. Jeff Jarvis is great guy, EMS Medical Director up in Fort Worth.
Great voices in EMS. Yes. Great. Great voices. And Jeff said, hey, RSI, when I look at my data,
I'm looking at significant hypoxia. I'm looking at significant patients with hypotension.
(20:24):
I'm looking at patients who are arresting right after we paralyze them. And it turns out,
RSI, the R, is rapid. What is rapid about it? It's the induction. So you give
atomic, as a sedative, you give rock, your own EMS, a paralytic, and then you flush it,
and then you intubate. So you go boom, boom, boom, right? One, two, three, rapid succession.
(20:48):
The problem is, is that when you have a patient who's sick, whether they're
teetering on the edge of hypoxia, whether they're barely maintaining a blood pressure,
that's the fifth percentile. If you paralyze that patient, what you're doing is you're taking away
their negative pressure that they're using, that they're creating when they inspire. So if I breathe
(21:11):
in, I'm creating negative pressure, air is rushing into my lung, and blood is rushing into my right
ventricle. So the act of breathing in, it actually increases your cardiac output. When you remove
that cardiac output by paralyzing somebody who is hypoxic and who is quasi-hypotensive,
(21:34):
like let's say blood pressure of 90 over palp, they will die immediately, and that's the periintubation
arrest. So Jeff said, okay, what if we do DSI? The D is a delay. Instead of a tomate, I use ketamine.
Ketamine maintains your airway reflexes. It keeps you breathing, and now I'm going to give you three
(21:56):
minutes to hyperoxygenate, and I'm going to buff up your blood pressure with fluids and push press
your epi. And now I'm going to have a patient who, at the three-minute mark, I can give the
paralytic to knowing that their oxygenation is fine, that their blood pressure can tolerate it.
And in his paper that he published, again, four or five years ago, he showed a dramatic difference.
(22:19):
Sky Winegard's paper showed a dramatic difference. There was another paper, I believe, out of India,
a trauma paper in hospital. A dramatic difference. Every DSI paper has shown that you don't get the
significant hypoxia, hypotension, or periintubation arrest. Why isn't everybody doing this? My
(22:40):
agencies, we flip to it right when Jarvis's paper came out, and we look at every single one of our
airways, our DSIs, and it shows the same thing that Jeff did. We measure, we improve. So that
change that we made, we didn't just take Jeff's word for it. We actually said we're going to
evaluate our own cases, and it looked exactly like Jeff's. So that's what I think everybody
(23:04):
should be doing. If you do RSI today, please look at DSI. Well, just the R, the rapid part,
certainly can lead to errors. Stress and rapid really don't go together. Could you just walk
through once more? I think people that are used to RSI may not have the DSI concept,
(23:26):
walk through that intubation process. Could you walk me through those three minutes one more time?
Sure. Sure. So you have a patient who's in respiratory failure. It could be a kid, it could
be an adult, and obviously they have airway reflexes. They feel pain. So if you put plastic,
plastic tube in their trachea, they wouldn't be happy with you. And obviously they're going to
clench down on the tube. So the first thing you want to do is you want to give them a sedative. A
(23:50):
lot of people that end up using a tomodate, which basically cause you to relax and not really worry
about what's going on around you. And then what you want to do is also give a paralytic to allow
you to actually innovate without the person clenching down and kind of, let's say, ruining the
(24:12):
view that you have. So it allows you to nicely and gently innovate somebody. The problem is, is that
you're giving the sedative and you're giving the paralytic back to back, right? You're not allowing
yourself time to optimize the patient's oxygenation and blood pressure before you hit the paralytic.
(24:35):
What DSI does uses a different drug for the sedative. And by the way, ketamine is very good for pain,
which it is not. You give the ketamine, they're sedated, they're not feeling any pain.
For the next three minutes, you're now hyper oxygenating them with nasal cannula.
(24:56):
We put the BVM over their mouth, but we're not squeezing the bag and they're breathing in on
their own. Remember, ketamine allows you to breathe on your own. So now they're inspiring 100%
oxygen for the next three minutes. If their saturations are 94% or higher for those three minutes
and during that time, their blood pressure is normal. And if it's not normal, you give them
(25:20):
fluid, you give them push, press, or epinephrine. So you're using that three minutes as a time to
optimize your patient's vital signs and their physiology. And then you give the paralytic.
So it's the same thing. You're sedating someone, you're paralyzing them. But in between,
(25:41):
you're optimizing the physiology so that they don't have a bad outcome during the process
of passing the tube through. It's a very simple concept, but the reason people don't want to do it
is because that three minute pause feels like three years for people. And not until you do it
(26:01):
and understand it and let your body and let your own physiology not get anxious.
You can say, you know what, I did it better. It's better for my patient. It was hard to do once or
twice. But once you do it then, you'll never go back. I think much like we talked about in the
pediatric cardiac arrest, our sense of urgency is sometimes misplaced. Exactly. You know, as we're
(26:27):
writing books, we have to do... We're writing a book on that. It sounds more like a Tull
Gawande book or a checklist manifesto book or something like that. But yeah, that three minutes,
I think is both a short time and a long time. And it's a matter of perspective.
And you know what? There's a great book that I just read from Malcolm Gladwell. People may remember
(26:51):
his book, The Tipping Point, 25 years ago. He just wrote another book, a 25 year update.
I think it's called like Revenge of the Tipping Point or something like that. But he talks all
about what makes people change from their current practice to something completely different.
And I'm not going to go into the book, but people should read it. But there is a mechanism and a
(27:17):
way to change hearts and minds. But it's not as obvious as people may think.
I think that the concept of EMS and emergency involves some rushing and involves some
sense of urgency again, which I think we have to replace with thinking. I did a podcast earlier,
(27:38):
I recorded one. And one of the things I observed is that EMS doesn't have the maturity level of
emergency medicine or other things. We're newer, we're raw. And valuing education and valuing
the research and measurement like you're talking about has got to be a big part of that.
Well said.
Whole blood.
(27:59):
I got to tell you that, yeah, I mean, it just only seems a couple of years ago, but I said, oh,
we can't do blood in the field. It's like, because you can't do this, you can't do this,
can't do this. But all of a sudden we're seeing a lot more of it and seeing some good results
coming from it.
Yes, yes. So this is fascinating that back in the Vietnam War, they were using whole blood
(28:22):
for the soldiers. The war ended. And then some point in between then and now, someone came up
with this concept of, I can take blood from you after you donated and you get your two movie tickets.
I can take your blood, I can send it to the factory, if you will, to the distribution center.
(28:45):
We can actually break it up into three different components. So they siphon off only the red cell,
they siphon off only the platelets, and they siphon off only the plasma, and they bag those up,
and they sell them as three separate things. And one can say that they're probably making
more money. There are patients who only need red cells, who only need plasma, who only need
(29:09):
platelets, cancer patients, et cetera. But we can all agree that a bleeding out trauma
patient or hemorrhaging pregnant woman, postpartum, they're bleeding out the whole blood, they
need whole blood back. Well, the military started saying, in recent history, they said,
(29:33):
you know what, we're going to go back to whole blood. And they did, and they're probably in
the late 90s. And then finally, I believe it was 2016, that's when the folks in San Antonio,
big military base there and all the trauma doctors said, you know what, we've been doing
in the military for a long time, let's bring it into the hospital. They spend a long time,
(29:56):
they finally powered through, they got it into the hospital. In 2018, San Antonio finally put
it on the helicopters. And when you look at their initial data that they put out there,
it was like something like a 95% survival rate on their first 21 trauma patients. It was insane.
So they then put it on to San Antonio ground and slowly but surely we started it here in 2021.
(30:22):
And since then, Dan, we have now given 400 units of blood. You know, our survival rate is
before the patient goes into cardiac arrest. If they get their blood before their arrest,
it's a 90% survival. Holy cow, holy cow. Washington, DC, they've given a couple
(30:43):
of 100 units, 90% survival. Atlanta, 90% survival. New Orleans, 90% survival. And
you know, there are people out there in the Northeast, some, there's some, there's some people
who own like the helicopter companies who are losing business because if the ground ambulance
has whole blood, then they're not going to be calling the helicopter anymore. There are some
(31:08):
people out there who are saying the whole blood doesn't work in the ground. So this measurement,
measuring and improved concept we've published, New Orleans is published, Washington, DC puts out
every month, every patient is so transparent and all their numbers are being put out on the internet.
We are at a stage Dan where this is going to be the most important thing that we do in trauma care
(31:33):
in our lifetimes, period, end of story. And there's no one who's going to find an article out there
done by a municipal 911 system in the United States where everyone's collecting their data,
we're giving it to a registry. This is something that's going to transform trauma care in the next
(31:54):
five to 10 years, hopefully sooner. All right, a couple of things come to mind here. And I think,
I think we can figure out the answer relatively easily, but you've talked about bigger cities,
a little bit of knife and gun club cities in some cases where there's some serious trauma.
Are we relegated in smaller communities, rural communities that it stays with the helicopter?
(32:19):
Can we use this? With life, there's no economy of scale, yet we know that a lot of times our
things are needed most if ultrasound sometimes isn't in the low volume places, but it's in the
agency that's right near the trauma center. And there's this balance, how do we balance those
cities versus rural? And what's your prediction? How it goes next? Oh, I already have the answer
(32:44):
for you because it's already happening. So if you look at the map, so we have a live map now
saying we, there's some folks that I'm in a group with now that they put up a live map and you can
see all the, there's about 200 agencies around this country who are live today. And I would say
it's split right down the middle of urban versus rural. So if you look at North Carolina, if you
(33:11):
look at Western North Carolina where they got hit by the hurricane, et cetera, there's a big cluster
of agencies all rural who have whole blood. And the question was, well, how do you do that? Very
simple. Whole blood is just another medication. Take it like an amiodarone drip, right? But
logistically, you have to get it. You don't want to waste it. And someone's got to pay for it.
(33:34):
Really, that those are the big things there. So how do you get it? Right? They just went to their
trauma center and said, Hey, can we have the whole blood? If we don't use it in 21 days,
because it's good for 28 days, we'll give it back to you. And then you have a week to use it. They
said, yes. Because they have a relationship with that hospital, the hospital said, we're getting
(33:55):
those patients anyway. So don't worry about the cost of it. And basically, they had to buy the cooler.
Right? So it's about 12,000 bucks to kind of get started, just to have all the things you need.
And then it's a matter of each patient needs a unit of blood and a few consumables. So it costs
(34:15):
you about 1000 bucks a patient. The future I will predict is it's costing us $600 per unit today. Why?
Because from the moment you give your arm, you did, you gave a unit of blood, you guys are two
movie tickets. Those people then do something with it, magical, right? They're testing for
(34:35):
testing for diseases, etc. And then they turn around and sell it to the agency for $600.
Here's what the future is going to be. And they do this in the military today.
You hold out your arm at your local hospital, all the firefighters, police officers who are
low, tighter, O positive, that's a blood type we need. Imagine we had 300 people that were donors.
(34:58):
You got a text and said, Hey, Dan, we need you to come donate. It's been six months. Okay. You put
out your arm, the hospital in that rural place takes the blood, tests it for the couple of things
that need to be tested for. And then they say, here you go, EMS. Here's Dan's blood.
The only thing that costs was the laboratory time of the people testing your blood. There's no
(35:21):
increase in cost. This is called the walking blood bank. And my team, we've put together a team of
educators. We went to rural Alaska. This is like four months ago now. And we taught them how to do
a walking blood bank methodology. So the future holds where anywhere you just have to get the people,
(35:43):
test the people, and then get the hospital to say, So once that becomes standard of care,
every single location will be able to have whole blood. The only thing you have to pay for is
the consumables, which, you know, it's a couple hundred bucks. Let's put it that way. And
there's no one who could tell me that a couple hundred bucks is not worth a life because these
(36:05):
lives are not the 80 year old cardiac arrest. These are the 17 year olds who got into a car accident.
It's the 23 year olds who got shot. It's the, you know, 30 year olds who fell off a ladder.
So that's the future I will predict. I am so glad I asked that question. That is,
that is fascinating stuff. And I'm sure the listeners will find that too. We're moving right
(36:28):
along here. We have one more thing. And that's ketamine for stats. Tell me, I mean, I guess
what I do, I, I serve them up and I say, tell me about it. Here's another. So have you ever been
in the back of an ambulance and you've exhausted your dose of Versed for a seizing patient, and you
still have 20, 30 minutes to the hospital. What do you do? And a lot of people say, my next thing
(36:55):
is diesel fuel, right? You drive faster. But it turns out when you look at a guy like John Travolta,
his son, Jett died because of status epilepticus, meaning that this is a refractory status. You
try to give the medication, didn't work. And you have to give something else. That's something
else has typically been something like KEPRA, phosphenitone. These are hospital side drugs that
(37:21):
have been used for a long time. We said, but we're in EMS, we want to stop that seizure now.
And everyone said, well, there's, you know, you could carry KEPRA if you want. And
someone I work with, brilliant guy, Dr. Ken Chepke, we work together at Palm Beach County
and other places. He's a medical director as well. He said, there's data on ketamine. So I started
(37:46):
looking at all the data available in this, I mean, ever published on ketamine, I have a folder on it.
And all the ketamine for seizure data is from intensive care units. And that ketamine is always
given like as the fourth or fifth option. And invariably, ketamine was working at a very high
(38:07):
rate. So we said, let's, let's add a protocol. And we've been doing this for like six or seven years.
Let's add a protocol and let's do it. And let's see what our outcomes are. So our paper has been
accepted. And the results are really astonishing. Then we had a over 90% success rate in stopping
(38:28):
refractory status epileptics, meaning seizures that don't go away after what most people do
in an adult world is give a max of 10 milligrams of versed. After the 10 of versed, what do you do?
The answer is now ketamine. We saw a problem. We knew that there was another answer. We implemented
a protocol. We measured it. It showed significant improvement. And we feel this is not just going
(38:54):
to change practice out of hospital, because many physicians in hospital have seen our data and the
people who have reviewed our paper and they said, this is maybe one of the most game changing
things in seizure care in a long time. And most of us carry the drug anyway. You should add it to
your protocol. And once our paper is published, hopefully it'll be live in another in days to a
(39:19):
week from now, I'm presuming. I'll send that to you. So you can post it. Yeah. And what, what,
what dosing are you using for ketamine in that? So for the adult, it's 100 milligrams IV slowly.
And for kids, it's two milligrams. I am two milligrams. I am because a seasoned kid, you're
(39:39):
not going to start an IV on, you probably shouldn't start an IO on that kid. If you can just give
ketamine I am so two per kilo I am. And an adult, it's 100 milligrams IV. And again,
the only fallouts we had were intranasal. And so we've removed that since from our protocol.
(40:02):
We actually still allow it, but we're actually veering away from it because we saw what happened
in our data. So now we're advising that most of that ketamine be given intramuscular,
two milligrams per kilo. Interesting. Fascinating. All right. Well, that gets, that was a,
this is a well rounded episode. We ended up finishing at a perfect time. The way I end these
(40:24):
sessions is I love to give the guests the opportunity to have a last word, right? Primacy and recency.
You get a chance to say something big at the end that people are going to remember and listen to.
What would that be? So here it is. We as EMS professionals, we are a specialty that is very
different in the house of medicine. We are an ignored specialty in the house of medicine.
(40:50):
People don't recognize that for sepsis, EMS matters more for cardiac arrest, EMS matters more,
right? We need to take ownership as a profession of what we do. We need to take ownership of the
guidelines. So the guidelines are being given to us as like two tablets from the top of the mountain
(41:11):
by intensivists, people who work in intensive care unit. So what I would say is that understand if
you work in EMS, you work in a different place. You do things that are different. You see patients
at a different moment in time. And I think we as a profession need to own it. We need to own the
(41:32):
fact that we are better at resuscitative care than they are at the hospital. And part of being good
at something is not being intimidated by those at the hospital. Part of being good at something
is owning the fact that you're better at it. And that's what I would tell people and leave as a
final word is that this is a very special profession. Unfortunately, the house of medicine hasn't
(41:57):
recognized who we are, but we are going to make a difference and we're going to make them recognize
that EMS belongs as the number one cog in that wheel. That's where we belong. Well, if there's
anyone that I believe could start carving out those stone tablets for emergency medicine and EMS,
(42:18):
it would be you. That's Dr. Peter Antevi, who is a medical director, an entrepreneur, and I have to
put in a plug in only because I'm a believer with a hen-tevi system if you haven't looked at it.
And seeing your work, you really can't go on social media without looking at
at pediatrics and things like that without seeing your stuff. You're obviously a brilliant man
(42:39):
and a heck of a nice guy. Well, I've enjoyed knowing over the years and I thank you very much for being here.
Thank you so much, Dan. Right back at you, my friend. You're amazing. Appreciate it.
That's the end of this seven things. It's been a great episode. Take a look at the show notes for
some references on this. If you want continuing education, you can get that too. Thanks for
listening to another episode of Seven Things EMS. Thank you for listening to a Seven Things EMS podcast
(43:06):
by Limber Education. If you've listened to this podcast on a streaming service and you're interested
in getting continuing education credit, please go to lc-ready.com for more information.
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