S1: From Kerkow media coming up on the show,
S2: when I became an EMT in high school, one of
S2: my history teachers who was an EMT in L.A., he
S2: looked me square in the eye and he said, I
S2: know you're going to get out there and do great things.
S2: He says, you just better remember one thing. You're OK.
S2: Your patient is not. And that has stuck with me
S2: my entire career. Doctor, Dr..
S3: Disasters, earthquakes, pandemics, hurricanes, floods, fire, nuclear accidents, poisoned water,
S3: heart attacks, drug overdoses, strokes, car accidents, all common issues
S3: that don't necessarily occur in convenient, clean or even accessible locations.
S3: One thing is constant, however. Our assumption that in such
S3: an event, emergency care will be available to us. We
S3: even take for granted that that emergency medical care will
S3: be organized, practiced and prepared to deal with an onslaught
S3: of critical patients at a moment's notice. How does that
S3: work exactly? Well, in our continuing series with top hospital
S3: Johns Hopkins. We ask that they give us access to
S3: a doctor that specializes in disaster emergency medicine. We take
S3: for granted that they will be ready. Well, on today's show,
S3: we're talking to the guy who makes that a reality.
S3: This is medicine. We're still practicing. I'm Bill Kurtis. And first,
S3: of course, my co-host, the quadruple board certified doctor of
S3: internal medicine, pulmonary
S4: disease, critical care
S3: in neuro critical care, and my very best friend, Dr.
S3: Steven Tayback. How are you doing, Steve?
S2: Hey, Bill, good to see you.
S3: Are you still feeling the covid starting to wane a
S3: little bit?
S2: Definitely starting to wane at my facility. Just found out
S2: today where we had one hundred and seventy three covid
S2: patients in January. Today we have seven.
S3: Oh, that's fabulous. Well, we got an interesting guest today.
S3: Our special guest, Dr. Matthew Levy, is an associate professor
S3: at Johns Hopkins Department of Emergency Medicine. He leads Hopkins
S3: Division of Special Operations, which provides for Central Command and
S3: coordination of emergency medicine operation. And Dr. Levy is board
S3: certified in emergency medicine and a subspecialty certified in EMS.
S3: He's the guy who sets up the teams and strategies
S3: that we don't even know we need until, God forbid,
S3: we need them. Thanks for joining us, Dr. Levy. How
S3: are you doing?
S2: Oh, good afternoon. Greetings. It's wonderful to be here. Thank
S2: you so much for having me and for that very
S2: warm introduction.
S3: So Division of Special Operations, what exactly is that?
S2: Sounds more military than civilian? Well, it's structured is what
S2: I would say. And and indeed, our division of special
S2: operations at Johns
S4: Hopkins, the division
S2: really got its roots nearly two decades ago in being
S2: the central
S4: focus for all
S2: of the out of hospital medicine
S4: activities that Johns Hopkins
S2: Emergency Medicine oversees. And that includes the entire facility transport
S2: program and includes some of our operational medical programs and
S2: support of tactical and law enforcement medicine, special event medicine
S2: and a few other topics, and initially had some roots
S2: in disaster medicine, which has also grown into its own
S2: unique and blossoming flourishing specialty area or focus area. So
S2: we work closely with some of our disaster colleagues as
S2: well nowadays.
S3: So are you coordinating and training the guys on the line,
S3: the guys who show up for those first responders that
S3: were so appreciative for?
S2: Well, it certainly is a team effort. I would say
S2: that I'm one of the people doing that training in
S2: my role as an EMS medical director. I certainly work
S2: very closely with our EMS educators and helping to design,
S2: implement and facilitate the delivery of that educational content. And yes,
S2: I do spend a good portion of my time as
S2: an
S4: educator, not only educating
S2: our physician colleagues, but also
S4: educating our pre
S2: hospital emergency medical services clinicians in those lifesaving conditions, recognition,
S2: treatment management. So I don't understand, though, because obviously you're
S2: handling all the ops relative to Johns
S4: Hopkins, but every
S2: hospital has their own emergency room or most hospitals, not
S2: an emergency room. And how do you interface and coordinate
S2: their process with your process? It seems like institutions that
S2: generally work in silos now suddenly have to coordinate.
S4: How does that take place?
S2: Well, it's such a great question. And to answer it,
S2: we have to take a bigger step back and look
S2: at how emergency medical care in the U.S. is currently
S2: delivered nowadays. And we'd like to think that there is
S2: one national EMS system the end user calls nine one one.
S2: They ask for help. And we're very fortunate in the
S2: United States that the vast majority of the US is
S2: covered by nine to one coverage and the rest happens
S2: by magic, when in fact, what really is occurring is
S2: we have a system of systems and these systems are
S2: oftentimes designed, implemented and operated at the regional level, maybe
S2: in large metropolitan areas that's occurring at the city or
S2: the county level. But in other parts of the country,
S2: it's groupings of cities and counties and communities. And sometimes
S2: they're regulated at the state level, but more often they're
S2: regulated at that local community level, the regional level. And
S2: within that comes this network
S4: of specialty
S2: assets, hospital emergency departments, trauma centers, stroke centers, all the
S2: types of facilities that we want to be able to
S2: get these patients with very high acuity conditions, too. And
S2: so that coordination, that planning is guided by expert recommendations
S2: from from professional organizations like the American Heart Association, as
S2: well as other organizations who help credit these centers. But ultimately,
S2: to your point, Stephen, it's really a local implementation. And
S2: so when you have a city that has a dozen
S2: hospitals that those facilities have to work together and have
S2: to ensure that they're going to collaborate with EMS system
S2: to get the patient the best care possible and to
S2: get the patient to the closest appropriate facility.
S3: Are you busy coordinating with police departments, fire departments, local municipalities,
S3: government officials? How do you manage all this?
S2: Yes, it really is a collaborative effort, as you would imagine.
S2: As you mentioned, some of the different disciplines that are
S2: present at the table. A lot of it comes down
S2: to how EMS is operationalized and in your neck of
S2: the woods, if you will, in many parts of the country,
S2: the predominant delivery system for EMS through the fire department.
S2: And so in those cases, you have fire rescue agencies
S2: that also spend a big portion of their time delivering
S2: EMS care. And so in that model, there's. Coordination and
S2: there's overlap with other essential missions and services to the
S2: public in other parts of the country. It's done through
S2: a third party model where you have an independent government
S2: organization or a local government contract with a private vendor
S2: to provide that emergency medical services care. What's interesting is
S2: that any and all of those models can work any
S2: and all those models cannot work very well also without
S2: proper oversight, proper planning and execution of those plans. So
S2: it really comes down to, as I mentioned a moment ago,
S2: implementation and also comes down to a degree of coordination. Now,
S2: the larger the system, the more complex inputs and outputs
S2: you have, the more players you have at the table.
S2: But at the end of the day, and this is
S2: something that we talk about. And Stephen, although I've never
S2: met you personally before, I would imagine with your background
S2: you might agree or feel free to disagree if we
S2: keep the patient at the center of what we want
S2: to do and the center of the mission and the
S2: center of what we're about is providing the best patient care,
S2: regardless of where that emergency is, regardless of what resources
S2: we do, we don't have.
S4: If we anchor
S2: on providing the best patient care possible, the rest has
S2: a way of figuring itself out. And so when we
S2: build these systems, it's one of those paradigms that I
S2: believe very strongly in. It's also one of the ones
S2: we try to teach. And when we teach our EMS
S2: clinicians or EMTs and our paramedics
S4: about how to deliver high
S2: quality patient care under sometimes suboptimal conditions, we really try
S2: to remind them that it's about that patient. And that's
S2: true on a daily basis.
S4: We can talk
S2: about when that sometimes gets really challenging, when we have
S2: resource limited situations that we've experienced this past year with
S2: covid we've experienced during disasters. But then we have to
S2: kind of look at how do we do the greatest
S2: good for the greatest number? And that's a whole other
S2: layer of complexity.
S3: I wonder if you could take us for a little
S3: tour about how things have progressed with emergency medical care
S3: covid was during this past year. Maybe you could tell
S3: us what you've learned, what treatment has
S4: changed and how you've
S3: handled the emergency side of this pandemic.
S2: It's a great question, certainly we continue to learn
S4: every day there was so much we didn't know earlier
S4: on about covid and we drew from
S2: metaphore experiences and prior tranches, including the H1N1 pandemic that
S2: occurred in August 2009 and then more recently, the SARS
S4: and
S2: murres coronavirus pandemic and then also recent experiences with other
S2: highly
S4: infectious pathogen
S2: conditions such as Ebola. And we had to start making
S2: certain assumptions very early on. Steve, I'm sure you guys
S2: did the same thing in the ICU and about about
S2: how do we safely care for people? How do we
S2: minimize the spread? And one of the things that we
S2: started doing very early on and many Ms. Abrams' did
S2: this around the country, was we began we started at
S2: the start and that started with a 911 call asking
S2: the 911 operators to ask some additional
S4: questions to help understand is this person
S2: displaying signs or symptoms of potential covid-19 illness? And that
S2: would get them
S4: identified as what we call a pouye or person
S2: under investigation for covid-19 illness and to give the EMS
S2: clinicians a heads up and a warning that they could
S2: be walking into a potentially dangerous situation.
S3: So how did you advise them in that kind of situation?
S3: How did they stay safe? Well, actually executing on this job,
S2: one of the things that we did very early on
S2: and there was variability in this across the country is
S2: everyone implemented higher levels of PPE, personal protective equipment, to
S2: be warned all times. Now, it's one thing to wear
S2: a gown and gloves and masks.
S4: And for me to do it in the
S2: emergency department, for Steve to do in the ICU, it's
S2: another thing to do it inside an ambulance or in
S2: someone's living
S4: room.
S2: And so one of the things that we started
S4: seeing, our
S2: EMS clinicians are very talented and very smart. And we
S2: can build processes, protocols and algorithms. They'll follow them. But
S2: we began to see some of the unintended consequences of that.
S4: And let me give an example.
S2: Take the emergency that is cardiac arrest, sudden cardiac arrest.
S2: When someone spontaneously goes into a lethal arrhythmia and their
S2: heart is no longer pumping and they need immediate CPR
S2: and immediate defibrillation. And for every minute that their body
S2: is in that
S4: state where they don't get
S2: those resources, their chance of survival goes down by 10 percent. Well,
S2: if it takes those EMS clinicians an extra few minutes
S2: to get all that PPE on and to safely get
S2: into the house, that's negative energy. That's the consequence of that.
S2: The unintended consequence of that was it was actually quite huge.
S4: But we have to protect our responders.
S2: We have to protect our personnel. I just recently
S4: looked at the death numbers of EMS personnel
S2: in the country who died of covid-19 illness in the
S2: past year. And they are some of the unsung heroes
S2: of this pandemic, as are so many others.
S4: But what I would say
S2: is that the problem got even more amplified, because if
S2: you remember early in covid-19, Steve, I know how it
S2: was in your in your hospital. I could tell you
S2: in mine, census dropped really, really quick. We couldn't get
S2: people to come to the hospital who needed to
S4: come to the hospital and our
S2: rates of heart,
S4: attacks of stylization,
S2: demise of of an emergency where there's a blocked coronary
S4: artery. Those rates
S2: went way down
S4: and the rates of cardiac arrest went up. That's not coincidental.
S2: People were afraid to come to the hospitals.
S4: So people were afraid
S2: to call 911 early on because they didn't want to
S2: get sick at the hospital, something that we had to
S2: work very hard from a public education campaign to reassure
S2: the public that, know, if you're having an emergency, we
S2: want you to come in.
S3: So it wouldn't every EMT have to arrive on scene,
S3: assuming that there was covered in a house?
S2: Well, it's interesting that you frame it that way because
S2: it quickly became that way.
S4: Early in
S2: covid-19, we were still asking questions about had you traveled
S2: to a hotspot area or had you had known contact
S2: with a covid-19 positive person or someone
S4: under investigation? And I'm not
S2: a public health expert, but I've learned a lot this
S2: year with the intent of trying to still isolate and
S2: contain and mitigate this. But once we began experiencing community
S2: spread of covid-19 illness, the scenario that you described, Bill,
S2: is exactly correct. At that point, everybody is presumed potentially infected.
S2: And there's all these metaphore cliches of during the pandemic,
S2: we had to pivot. We had a change, again, our
S2: operating construct and say, OK, from here on in the
S2: paramedics that work under my medical direction, we said we
S2: want the wearing and then the ninety five
S4: mask on any time you're coming in
S2: contact with a patient in eye protection. And we took
S2: those measures because we couldn't tell early on in the
S2: symptomatology of who was going to be positive became so
S2: broad it could have been someone with a febrile respiratory
S4: illness which was pretty passive demonic
S2: armonica, pretty typical. Or could could've been someone with a
S2: runny nose. And it was very hard to tell who
S2: was truly covid positive. What we're witnessing now and you
S2: tell me whether you're seeing it as well
S4: now that the surge,
S2: at least in our area, has really
S4: subsided.
S2: The acuity level is extreme with multisystem organ issues that
S2: we've not seen before. I mean, we always see patients
S2: here and there with multisystem
S4: disease, but the numbers
S2: of people who are coming in with complex medical issues
S2: that quickly turn to renal failure or. Stems and non
S2: stem is the various forms that the heart attacks, as
S2: I'm describing, and strokes, that they seem to be at
S2: a much higher number, as if these
S4: were people who left their
S2: health go for the past year and now they're suddenly
S2: flooding into the hospital once they tip over their threshold.
S2: Are you seeing that more in the EMS system or
S2: is this just something locally that I'm seeing just in
S2: my region? You know, I certainly wouldn't
S4: dispute
S2: what you're saying. I think I've had similar observations. I
S2: think of it somewhat akin to something that we've probably
S2: seen in our clinical practice,
S4: which is no one wants to
S2: be in the hospital over the holidays. So everybody tries
S2: to stay home. And then after the holidays is when
S2: we get really busy and everyone who tried to kind
S2: of hold off and could no longer do so. And
S2: I think while that's probably a crude metaphor, I think
S2: the principal is probably similar here. We saw a decline
S4: in overall
S2: EMS call volume, at least in my region over the
S2: past year. And that call volume is starting to pick
S2: back up a normalized.
S4: But indeed,
S2: it seems as though the acuity at least certainly feels
S2: that way, is getting back up there is getting
S4: higher. One of the
S2: things that we also
S4: saw which experienced
S2: it firsthand during the height of the
S4: pandemic, particularly over the winter, was
S2: as people were still home and kind of socially isolating
S2: and trying their best to adhere to public health recommendations.
S2: There was a lot less traffic on the roadways.
S4: And I saw and respond
S2: to some of the worst motor vehicle collisions in my
S2: career because I guess people were driving a lot faster.
S2: And that's my own observation. I noticed that as well,
S2: just because, you know, with knee, they weren't going to
S2: be stopped by the police because police were afraid to
S2: stop people for fear of covid.
S4: And so
S2: people felt that they could just speed and they were
S2: suddenly on the American autobahn, going just as fast as
S2: they wanted
S4: to go.
S3: OK, guys, we're going to take about a 30 second break.
S3: And when we come back, Matt, I'd like to dig
S3: into the process that EMT goes through when they arrive
S3: on a scene and get that illustration from you. We'll
S3: be right back.
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S3: So I wonder, Matt, before we dig into process, could
S3: you define the different types of individuals, EMS, the EMT,
S3: and tell us what their role is in the process?
S2: So EMS is the system. The emergency medical services is
S2: a system that is comprised of human beings and equipment
S2: and technologies to save lives within that system. There are
S2: a variety of levels of training, certification, licensure. The most
S2: common
S4: level of EMS
S2: clinician or emergency medical services personnel in the country is
S2: someone that's called an EMT or an emergency medical
S4: technician.
S2: And on average, these individuals have around one hundred and
S2: twenty to one hundred and sixty hours of training. It's
S2: the equivalent of about a college semester's course,
S4: and their scope
S2: of practice and knowledge
S4: includes CPR to some basic airway
S2: management. How to ventilate somebody
S4: with a bag valve
S2: mask resuscitator, how
S4: to deliver a baby, how to control
S2: severe bleeding, how to immobilize someone and safely transport them
S2: to the hospital and the basic operations of an ambulance.
S2: There are other variant levels of an intermediate type levels
S2: of EMS provider, but
S4: keeping it big and simple,
S2: the other very common level
S4: of EMS clinician or provider that staffs
S2: these ambulances and helicopters, for that matter across
S4: the country would be a paramedic.
S2: And in order to be a paramedic, you have to
S2: first be an
S4: EMT and paramedic
S2: is an EMT
S4: who's gone through about the
S2: equivalent of a thousand to 1500 hours of
S4: training in all
S2: aspects of advanced cardiac life support
S4: and the recognition
S2: and diagnosis or field interpretation of a medical emergency and
S2: the advanced interventions. These folks can do things like inserting
S4: breathing tubes to secure
S2: someone's airway, to put in
S4: IVs, to give a host
S2: of different medications, to stabilize someone having an emergency, and
S2: to deliver a variety of types of other interventions, including
S2: the specialty types of
S4: defibrillation or pacing someone's heart.
S2: So these folks
S4: really are experts
S2: in the resuscitation of people outside the hospital. The other
S2: group that I do want to specify and clarify is
S2: there are emergency medicine physicians. These are physicians. These are
S2: doctors who graduated medical school, have gone and done a
S2: residency in the field of emergency medicine. They are then
S2: board
S4: certified in emergency
S2: medicine and staff, many of the emergency departments, if not
S2: the vast majority across the country. There are other folks
S2: who are not emergency medicine trained who also staff those
S2: front lines, particularly in smaller hospitals. And by no means
S2: is
S4: that meant to deflate or to minimize their role.
S2: My specialty practice is in that of emergency medical services medicine.
S2: So after doing a residency in emergency medicine folks and
S2: then go on to do additional training, additional time called
S2: a fellowship in Emergency Medical Services, which is really
S4: focusing on how to
S2: do many of the things we've talked about already oversee, run,
S2: facilitate emergency medical services systems and how to practice out
S2: of hospital medicine. And that represents the highest level of
S2: emergency medical
S4: services specialty
S2: that exists in the country. There are a couple other levels,
S2: but for the sake of simplicity, I would stop there.
S3: Are these fields properly funded? Is there enough of a
S3: political and governmental dedication to the field that we need?
S3: Is it working or is it a mess? Where are we?
S2: I think the
S4: answer is it's not a yes or no
S2: answer. Certainly we could do a lot more with a
S2: lot more funding. It is the easy answer. What I
S2: would say is that historically EMS has not been very
S2: well funded. Most EMS programs operate based upon a billing
S2: and reimbursement structure that was intended and designed with the
S2: recognition that ambulances were just a service, a transportation service
S2: to move a patient from point A to point B,
S2: not a highly
S4: sophisticated mobile, in some
S2: cases intensive care, capable environment capable of delivering that level
S4: of care. So certainly there is a need for greater funding.
S2: I will say specifically regarding medical direction and the physician
S2: oversight of EVMs that historically had been very poorly funded
S2: on average across the country. And it wasn't very long
S2: ago that many medical
S4: directors served in their roles
S2: as a community service and didn't even get a salary.
S2: I mean, Steve, imagine working in the ICU to serve
S2: your community at a voluntary level in addition to your
S2: other practice and pulmonary medicine or in another one of
S2: your other disciplines. I mean, that's to be asked nowadays.
S2: It's like, wow, that's a lot to ask of people.
S2: But it wasn't very long ago that that's where this
S2: evolved from. So, again, we're moving in the right direction
S2: of opioid. We we have some way to go. Is
S2: funding local or national or the combination of both. Most
S2: EMR systems are funded locally. The reimbursement structure is usually
S2: set by at the federal level and through Medicare and
S4: Medicaid reimbursement
S2: amounts for ambulance transports. But those reimbursement amounts, we're talking
S2: about hundreds of dollars per ambulance transport. That's not usually
S2: a lot to sustain these operations. So that helps augment
S2: the operation. It doesn't actually completely sustain it. Most E.M.S.
S2: programs do receive local funding, in some cases they're funded
S2: better than others. And with that comes the ability to innovate,
S2: to implement cutting edge technologies. But there are plenty of
S2: places where the rate limiting step is there lack of
S2: funding to do more.
S3: So I can't help but bring up the difficult subject.
S3: I want to talk about insurance for just a minute,
S3: because this is one of those cases where the better
S3: the job that you do and the better the job
S3: that the EMTs do, the more it costs the insurance company.
S3: So it must kind of keep the two at loggerheads
S3: a little bit. Are you having challenges there?
S2: By no means am I an expert in health care economics.
S2: But from my perspective, what I would say is that
S2: EMS has actually been in some ways a victim of
S2: this in a different manner because there are only two
S2: or three levels of reimbursement that EMS programs can bill
S2: for bill insurance or bill Medicare for. So you quickly
S2: reach that cap and it's just the rest of it
S2: is just part of the service. It's part of the
S2: public safety service that's delivered.
S4: For example,
S2: if a patient is in the hospital and Stephen are
S2: taking care of them and we have to put a
S2: central line in or put a breathing tube in, each
S2: of those things are billable procedures that because there is risk,
S2: there's expertise there, sophistications need
S4: to do that.
S2: That's not necessarily the way that it works in EMS billing,
S2: where you bill for either a basic life support level
S2: of care or an advanced life support level of care.
S2: And there are some echelons in there.
S4: So it is a
S2: bit of a challenge. The opportunity, I think, that we're
S2: seeing now and there is a national initiative, it's a
S2: pilot initiative that CMS, the Centers for Medicare and Medicaid
S2: has implemented.
S4: That's called ETTY
S2: three. And this is an initiative that started before the pandemic.
S2: And this is the Emergency Treatment Transport Initiative where they're
S2: looking at allowing EMS agencies to be reimbursed even when
S2: they don't transport someone.
S4: So it used to be
S2: that the only way these EMS programs could actually be
S2: reimbursed is if they transport someone to a hospital. That,
S2: to me, seems like a flip logic. What that then
S2: does is it then incentivizes to not transport people or
S2: to not transport them to other locations, such as alternative destinations,
S2: urgent care centers, other
S4: places that if the patient
S2: meets the appropriate triage criteria,
S4: could safely and
S2: effectively get their care in a manner that's both appropriate
S2: and also fiscally prudent,
S3: which is why the consumer often goes to an emergency
S3: room for something that really isn't an
S4: emergency.
S2: Yeah, I am always interested when I speak with my
S2: patients in the emergency department. We have a finite amount
S2: of time that we can really spend at the bedside
S2: with our
S4: patients because it's
S2: just the acuity and the volumes. But when I talk
S2: to my patients and I ask them some questions about
S2: you have a primary care doctor? Oh, yes, I do.
S4: I spoke. Have you
S2: talked to your primary care doctor about the condition that
S2: brought you in today in circumstances when it's not a
S2: time critical or high acuity emergency, to your point, at
S2: least
S4: some of them don't necessarily
S2: recognize it. Oh, wow. I could have called my doctor
S2: for some of this. Let me be clear. I'm not
S2: saying that we don't want them coming to the emergency
S2: department if they need to be. But another example of
S2: how the pandemic has really revolutionized care delivery and it's
S4: really been a
S2: catalyst I think has sprung us forward probably a decade
S2: or two, has been the use of
S4: telemedicine where people can now have
S2: a television with their doctor from the comfort of their
S2: own
S4: home and then
S2: decide what the right intervention or right diagnostic workup is.
S3: So I imagine there's a moment of real stress that
S3: occurs when an EMT has to make a decision about
S3: do we put this poor fellow in the back of
S3: the ambulance or do we call for air transport? Tell
S3: me about how you train people for that kind of decision.
S2: So one of the things that we do really well
S2: in EMS is we try to bring
S4: structure to chaos
S2: and we try to bring an organized and methodological
S4: approach to
S2: a complex and chaotic and potentially life threatening situation to
S2: the point that the same assessment that I do, the
S2: same fundamental assessment that I do now is a practicing
S2: emergency physician for over a decade and a half is
S2: based upon the routes that I learned as an EMT
S2: 25 years ago, because it works. And so what we
S2: teach and it starts off in the classroom, it starts
S2: off with an assessment of the safety of the environment.
S2: Is there a potential for harm for the clinician, for
S2: the EMS personnel responding? And and then they use a
S2: very structured approach at looking for the life threats.
S4: First, severe bleeding and airway issue.
S2: Someone's in respiratory
S4: distress or circulatory
S2: issue like shock or cardiac arrest.
S4: And then they build and they start
S2: fixing the fixable problems. They find them in that order
S2: and then they build upon that.
S4: And then
S2: very quickly, they are then able to fill in the
S2: blanks of additional information, what we would call the history
S2: of present illness or what's going on at that
S4: moment in time that led to that
S2: emergency happening and the patient's background and medical history. And
S2: all this is done very sequentially for two reasons. Number one,
S2: to be time efficient.
S4: We'll get back to that in a second. But number two,
S4: so that we
S2: can
S4: avoid variability
S2: and avoid unintendedly missing a potential injury illness, because there
S2: is no rule that says patients can only have one
S2: emergency going on at once. And we do see that,
S2: particularly in traumatically injured patient. So based upon that assessment
S2: and the interventions that are done then need to make
S2: a decision about where this person needs to go to
S2: get the care they need, and that decision is informed
S2: based upon geography.
S4: It's based upon
S2: whether it's based on a variety of things. And how
S2: do they get that person to the closest appropriate facility,
S2: which is the doctrine that we teach and we operate
S2: under the closest appropriate facility for the emergency that they're having.
S4: And once
S2: that decision is
S4: reached, it then becomes a
S2: means of, OK, how do we facilitate that transportation, if
S2: it's going to be many, many miles or there's going
S2: to be severe traffic or other barriers, it's going to
S2: translate to time delay. The right answer may be to
S2: utilize an air asset such as a helicopter that can
S2: quickly move that patient from the scene to that definitive care.
S2: Or alternatively, the answer might be we're going to go
S2: to the closest appropriate facility by ground or close the
S4: facility because this
S2: patient is so unstable, we just have to get them
S2: stabilized and then secondarily transfer them. Are you familiar with
S2: the Israeli drone
S4: system for EMS
S2: delivery?
S4: And could you
S2: speak to that a little bit? And is that something
S2: that could be translatable to a country as expansive as
S2: ours with a population of three hundred and thirty two
S2: million versus a tiny geographical parameter? If you're referring to
S2: the drone delivery of automatic external defibrillators program, is that
S2: what you're referring to? Exactly. Super exciting and super hopeful
S2: technology that is now realistic and
S4: is now within reach.
S2: Let me come back to that in a second. The
S2: other really neat
S4: thing that is done in
S2: Israel, there's a program called United Hatzalah, which is a
S2: smartphone based program that uses medical volunteers
S4: who are trained and
S2: equipped and given medical bags to serve as first responders
S2: before the first responders get there, because there's so much
S2: traffic and roadway congestion in Israel that
S4: they have
S2: a delayed response time in some
S4: parts of the country, no different than
S2: we have here. So they're able to use smartphone technology
S2: and if you will, a civilian reservist corps who's agreed
S2: to participate and be medically
S4: trained and carry some
S2: medical equipment to slice that
S4: time down the enemy
S2: here is
S4: time. The enemy when
S2: we have one of these emergencies is time. And that
S2: time directly translates
S4: to the absence or how long our body
S2: tissue is going without oxygen or perfusion for whatever the
S2: emergency is. If it's a stroke, it's how long the
S2: brain is going. That auction, if it's a heart attack,
S2: it's how long the heart is going. That oxygen.
S4: If it's someone who's bleeding on the street,
S2: it's how long they're bleeding for before someone stops the
S2: bleeding and can allow circulation to resume.
S4: So as we
S2: look towards exciting, innovative and disruptive
S4: technologies and disruptive technologies
S2: are a good thing because they force us to kind
S2: of
S4: rethink things.
S2: Drone delivery is one example. I think that we will
S2: see more of that in the U.S. I know that
S2: there's a lot of interest in it. There are some
S2: complexities with what are referred to as these unmanned aerial
S2: systems or these systems. The term drone has
S4: kind of an uncomfortable
S2: connotation for some people, but how do we leverage technologies
S2: to do that where we can get that lifesaving piece
S2: of equipment out to the scene, the emergency as quickly
S2: as
S4: possible? One of the very first research
S2: projects I engaged in when I was in graduate school
S2: was my graduate research project. We did an analysis of
S2: the location of cardiac
S4: arrests in a community and the
S2: location of AIDS.
S4: And what we found is
S2: that the lines
S4: crisscrossed quite literally
S2: the locations with the most AIDS, automated external defibrillators, those
S2: things that hang on the wall
S4: that you pulled them off the wall
S2: and someone's having an emergency and they can deliver a
S2: shock right away. And that, combined with CPR, can really
S2: help save a lot of lives. But it's got to
S2: be done quickly.
S4: Well, we found that the location
S2: of those things was inversely coordinated with where the cardiac
S2: arrests were occurring. You guys know where the most common
S2: location for cardiac arrest are
S4: in the home. So there
S2: is a movement
S4: afoot to
S2: have more beds and homes. There are certainly we've looked
S2: at and toyed with the idea of, boy, could we
S2: work with the automobile industry on having an IED that
S2: is part of your vehicle's purchase. And it's just equipment.
S2: You know, you have it in the car. There are
S2: some really neat technologies that are coming
S4: online that are linking IEDs
S2: and making them what's called smart ads, which will actually,
S2: instead of it just hanging on the wall like a fixture.
S4: If there's a cardiac
S2: arrest nearby, that IED would have the ability to be
S2: monitoring the nine one one system and can alert and
S2: see someone take me to this location using technology that
S2: we already have that's in all of our pockets on
S2: our smartphones. So drone delivery is very exciting. Steve, it's
S2: one piece of this, but really what it comes down
S2: to is
S4: how do we engage bystanders, engage the
S2: people around the emergency to do something, to see something
S2: and do something. And if I can just embellish for
S2: one minute, I want to talk about a topic that's
S2: very near and dear to my heart, which is to
S2: stop the bleed initiative because to Stop the Bleed Initiative
S2: is a program that I've been very involved with at
S2: the national level. And Stop the Bleed is a program
S2: that we've really
S4: focused on not. Just the actions of recognizing
S2: life threatening hemorrhage and what to do about it, but
S2: also empowering the public to do something.
S4: And, you know, what
S2: we find is that the same
S4: people who are going to stop to
S2: do CPR or who are going to stop to put
S2: an ad on or stop to hold pressure on a
S2: bleeding wound, these are the same people who are going
S2: to help jump start your car in the parking lot
S2: or change your flat tire. These are these civically minded,
S2: altruistic people.
S4: They're the helpers.
S2: So how do we empower the helpers to help and
S2: how do we use technologies to do that? More a
S2: more interesting thing.
S4: I wonder,
S3: Matt, I've had the opportunity to visit Johns Hopkins a
S3: number of times, a beautiful facility and in a nice
S3: part of Baltimore. And I have to ask you, you know,
S3: Baltimore is an interesting town. There's some areas of absolute
S3: beauty and there's some really difficult areas of Baltimore. I wonder,
S3: could you share with us an experience or two that
S3: you had in Baltimore that really was a deep challenge
S3: and had to do with some of the areas of
S3: Baltimore that need some cleaning up. And I'm sure you've
S3: been in some interesting situations there.
S2: Yeah, it's it's a hard question, to be quite candid.
S2: I was not born and raised in Baltimore, but I've
S2: been here more than half my life. It is my home.
S2: And Baltimore is a very special place. People who find
S2: their way to Baltimore for work or academia who live here,
S2: I have great pride in Baltimore is a city of
S2: neighborhoods like many other East Coast cities. And the disparities
S2: in health care or a huge challenge? You have life
S2: expectancies that can vary upwards of of a decade based
S2: upon zip codes in a small area. That's, you know,
S2: some of those challenges that we face in Baltimore revolve
S2: around a variety
S4: of issues that are
S2: finally OK and socially acceptable to talk about from systemic
S4: racism through health
S2: care inequities, through years and years of mistrust that that
S2: is rooted from someplace and it's likely from experiences and
S2: all those things come together and find themselves in the E.R.,
S2: sometimes not just the E.R. and my hospital, any E.R.
S2: across the country, because our emergency rooms, our emergency
S4: departments, our
S2: society safety net, it doesn't matter to me how many
S2: zeros in your paycheck and in what side of the
S2: decimal point those zeros
S4: are when you walk in that
S2: E.R.. I'm taking care of you like you're my family.
S2: That's what that's my oath. And that's what I'm going
S2: to do. And that's what my colleagues are going to do.
S2: US getting emergency physician with the hardest part of their job,
S2: as they will almost certainly tell you, it's telling the parent,
S2: a parent, that their child has died.
S4: If I never
S2: have to do it again, it'll be too soon. It
S2: is one of the hardest parts of my job. And
S2: how and why and by what means that happened, whether
S2: it's intentional violence or an unintentional mishap or an accident
S2: or flu thing, it's a tragedy nonetheless. But it is
S2: one of the hardest things that we have to deal
S2: with in emergency medicine.
S4: And I would
S2: say that that isn't necessarily unique to my institution or
S2: my city, but it's it's a tribute to the hardworking
S2: emergency physicians that are manning these front lines. And you're right,
S2: you don't know what's going to come through that door.
S2: And I find myself driving to work on my clinical shifts,
S2: going through a little bit of a meditation process and
S2: preparing myself for what those next eight or 10 hours
S2: might look like. And knowing that I am there and
S2: I think back to some of my earliest career mentors
S2: when I became an EMT in high school, one of
S2: my history teachers who was an EMT in L.A. I'm
S2: not from L.A., but he was an EMT in L.A.
S2: before moving to the East Coast. He looked me square
S2: in the eye and he said, I know you're going
S2: to get out there and you do great things. He
S2: says you just better remember one thing. You're OK. Your
S2: patient is not. And that has stuck with me my
S2: entire
S4: career because
S2: we're there to take care of others. That being said, violence,
S2: the trauma associated with violence is, I think, one of
S2: the things that that maybe some listeners are envisioning right now.
S4: But it goes beyond that.
S2: It goes beyond just the gunshot wounds and the assaults.
S2: It has to do with access to care, preventative medicine,
S2: preventing diseases like diabetes,
S4: obesity,
S2: dealing with nutrition, dealing with education, mentorship. It's all of
S2: these things that need to happen
S4: to unravel
S2: this very complex web that
S4: has been woven in America's urban environments.
S3: Well, Dr. Matthew Levy, thank you for joining us today.
S3: I hope you'll come back because I have a funny feeling.
S3: We just touched on the absolute outer shell of this subject.
S3: There's a lot for us to talk about. Thank you
S3: for joining us today.
S2: It's my absolute pleasure. Thank you guys so much.
S3: Matt, how can people follow you?
S2: My Twitter hashtag is at Dr. Matt Levy DRM levy.
S2: I'm on there. I'm on LinkedIn as well. My email
S2: address is just my last name, Levi Levi at JH.
S2: Am I ready? So those are my big ones.
S3: Matt, thanks for being with us today. And of course, Dr. Steve,
S3: as always, my good friend. Thank you for doing this.
S3: We really appreciate it. We're Still Practicing is produced and
S3: edited by A.J. Mosley, mastering by Steve Rexburg Music for
S3: We're Still Practicing as composed and performed by Celeste Anorectic.
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