WEBVTT - 28 - Disaster Medicine and Emergency Care 0:00:00.090 --> 0:00:02.970 From Kerkow media coming up on the show, 0:00:03.750 --> 0:00:06.030 when I became an EMT in high school, one of 0:00:06.030 --> 0:00:08.730 my history teachers who was an EMT in L.A., he 0:00:08.730 --> 0:00:10.410 looked me square in the eye and he said, I 0:00:10.410 --> 0:00:11.950 know you're going to get out there and do great things. 0:00:11.970 --> 0:00:15.720 He says, you just better remember one thing. You're OK. 0:00:16.170 --> 0:00:19.380 Your patient is not. And that has stuck with me 0:00:19.380 --> 0:00:22.750 my entire career. Doctor, Dr.. 0:00:25.130 --> 0:00:31.910 Disasters, earthquakes, pandemics, hurricanes, floods, fire, nuclear accidents, poisoned water, 0:00:31.910 --> 0:00:37.070 heart attacks, drug overdoses, strokes, car accidents, all common issues 0:00:37.070 --> 0:00:42.090 that don't necessarily occur in convenient, clean or even accessible locations. 0:00:42.380 --> 0:00:45.589 One thing is constant, however. Our assumption that in such 0:00:45.590 --> 0:00:49.220 an event, emergency care will be available to us. We 0:00:49.220 --> 0:00:52.339 even take for granted that that emergency medical care will 0:00:52.340 --> 0:00:56.360 be organized, practiced and prepared to deal with an onslaught 0:00:56.360 --> 0:00:59.750 of critical patients at a moment's notice. How does that 0:00:59.750 --> 0:01:04.130 work exactly? Well, in our continuing series with top hospital 0:01:04.130 --> 0:01:06.890 Johns Hopkins. We ask that they give us access to 0:01:06.890 --> 0:01:11.089 a doctor that specializes in disaster emergency medicine. We take 0:01:11.090 --> 0:01:15.320 for granted that they will be ready. Well, on today's show, 0:01:15.620 --> 0:01:17.929 we're talking to the guy who makes that a reality. 0:01:18.110 --> 0:01:22.959 This is medicine. We're still practicing. I'm Bill Kurtis. And first, 0:01:22.959 --> 0:01:26.740 of course, my co-host, the quadruple board certified doctor of 0:01:26.740 --> 0:01:28.149 internal medicine, pulmonary 0:01:28.150 --> 0:01:29.649 disease, critical care 0:01:29.650 --> 0:01:33.280 in neuro critical care, and my very best friend, Dr. 0:01:33.280 --> 0:01:34.990 Steven Tayback. How are you doing, Steve? 0:01:35.180 --> 0:01:36.369 Hey, Bill, good to see you. 0:01:36.580 --> 0:01:39.520 Are you still feeling the covid starting to wane a 0:01:39.520 --> 0:01:39.910 little bit? 0:01:40.240 --> 0:01:43.420 Definitely starting to wane at my facility. Just found out 0:01:43.420 --> 0:01:46.330 today where we had one hundred and seventy three covid 0:01:46.330 --> 0:01:49.060 patients in January. Today we have seven. 0:01:49.330 --> 0:01:52.960 Oh, that's fabulous. Well, we got an interesting guest today. 0:01:52.960 --> 0:01:56.410 Our special guest, Dr. Matthew Levy, is an associate professor 0:01:56.410 --> 0:02:00.400 at Johns Hopkins Department of Emergency Medicine. He leads Hopkins 0:02:00.400 --> 0:02:04.930 Division of Special Operations, which provides for Central Command and 0:02:04.930 --> 0:02:08.920 coordination of emergency medicine operation. And Dr. Levy is board 0:02:08.919 --> 0:02:13.710 certified in emergency medicine and a subspecialty certified in EMS. 0:02:13.720 --> 0:02:16.750 He's the guy who sets up the teams and strategies 0:02:16.750 --> 0:02:19.420 that we don't even know we need until, God forbid, 0:02:19.419 --> 0:02:21.940 we need them. Thanks for joining us, Dr. Levy. How 0:02:21.940 --> 0:02:22.420 are you doing? 0:02:22.820 --> 0:02:25.510 Oh, good afternoon. Greetings. It's wonderful to be here. Thank 0:02:25.510 --> 0:02:26.770 you so much for having me and for that very 0:02:26.770 --> 0:02:27.489 warm introduction. 0:02:27.940 --> 0:02:32.050 So Division of Special Operations, what exactly is that? 0:02:32.350 --> 0:02:36.760 Sounds more military than civilian? Well, it's structured is what 0:02:36.760 --> 0:02:39.550 I would say. And and indeed, our division of special 0:02:39.550 --> 0:02:40.330 operations at Johns 0:02:40.330 --> 0:02:41.709 Hopkins, the division 0:02:41.710 --> 0:02:45.580 really got its roots nearly two decades ago in being 0:02:45.580 --> 0:02:46.149 the central 0:02:46.150 --> 0:02:47.470 focus for all 0:02:47.470 --> 0:02:49.239 of the out of hospital medicine 0:02:49.240 --> 0:02:51.010 activities that Johns Hopkins 0:02:51.010 --> 0:02:55.149 Emergency Medicine oversees. And that includes the entire facility transport 0:02:55.150 --> 0:02:58.810 program and includes some of our operational medical programs and 0:02:58.810 --> 0:03:02.859 support of tactical and law enforcement medicine, special event medicine 0:03:03.040 --> 0:03:06.220 and a few other topics, and initially had some roots 0:03:06.220 --> 0:03:09.549 in disaster medicine, which has also grown into its own 0:03:09.550 --> 0:03:14.650 unique and blossoming flourishing specialty area or focus area. So 0:03:14.650 --> 0:03:16.420 we work closely with some of our disaster colleagues as 0:03:16.419 --> 0:03:17.109 well nowadays. 0:03:17.800 --> 0:03:21.339 So are you coordinating and training the guys on the line, 0:03:21.340 --> 0:03:24.130 the guys who show up for those first responders that 0:03:24.130 --> 0:03:25.730 were so appreciative for? 0:03:26.260 --> 0:03:28.690 Well, it certainly is a team effort. I would say 0:03:28.690 --> 0:03:30.850 that I'm one of the people doing that training in 0:03:30.850 --> 0:03:33.430 my role as an EMS medical director. I certainly work 0:03:33.430 --> 0:03:37.270 very closely with our EMS educators and helping to design, 0:03:37.270 --> 0:03:40.690 implement and facilitate the delivery of that educational content. And yes, 0:03:40.690 --> 0:03:42.670 I do spend a good portion of my time as 0:03:42.670 --> 0:03:42.760 an 0:03:42.760 --> 0:03:44.380 educator, not only educating 0:03:44.380 --> 0:03:45.700 our physician colleagues, but also 0:03:45.700 --> 0:03:47.140 educating our pre 0:03:47.260 --> 0:03:51.610 hospital emergency medical services clinicians in those lifesaving conditions, recognition, 0:03:51.610 --> 0:03:55.660 treatment management. So I don't understand, though, because obviously you're 0:03:55.660 --> 0:03:58.180 handling all the ops relative to Johns 0:03:58.180 --> 0:04:00.190 Hopkins, but every 0:04:00.190 --> 0:04:03.460 hospital has their own emergency room or most hospitals, not 0:04:03.480 --> 0:04:07.300 an emergency room. And how do you interface and coordinate 0:04:07.450 --> 0:04:11.200 their process with your process? It seems like institutions that 0:04:11.200 --> 0:04:14.130 generally work in silos now suddenly have to coordinate. 0:04:14.350 --> 0:04:15.670 How does that take place? 0:04:15.790 --> 0:04:18.820 Well, it's such a great question. And to answer it, 0:04:18.820 --> 0:04:20.560 we have to take a bigger step back and look 0:04:20.560 --> 0:04:23.620 at how emergency medical care in the U.S. is currently 0:04:23.620 --> 0:04:26.169 delivered nowadays. And we'd like to think that there is 0:04:26.170 --> 0:04:29.770 one national EMS system the end user calls nine one one. 0:04:29.770 --> 0:04:32.110 They ask for help. And we're very fortunate in the 0:04:32.110 --> 0:04:34.420 United States that the vast majority of the US is 0:04:34.420 --> 0:04:37.360 covered by nine to one coverage and the rest happens 0:04:37.360 --> 0:04:40.750 by magic, when in fact, what really is occurring is 0:04:40.750 --> 0:04:43.960 we have a system of systems and these systems are 0:04:43.960 --> 0:04:48.610 oftentimes designed, implemented and operated at the regional level, maybe 0:04:48.610 --> 0:04:51.400 in large metropolitan areas that's occurring at the city or 0:04:51.400 --> 0:04:53.290 the county level. But in other parts of the country, 0:04:53.410 --> 0:04:57.130 it's groupings of cities and counties and communities. And sometimes 0:04:57.130 --> 0:04:59.469 they're regulated at the state level, but more often they're 0:04:59.470 --> 0:05:02.980 regulated at that local community level, the regional level. And 0:05:02.980 --> 0:05:05.080 within that comes this network 0:05:05.080 --> 0:05:06.310 of specialty 0:05:06.310 --> 0:05:10.659 assets, hospital emergency departments, trauma centers, stroke centers, all the 0:05:10.660 --> 0:05:12.520 types of facilities that we want to be able to 0:05:12.520 --> 0:05:16.000 get these patients with very high acuity conditions, too. And 0:05:16.000 --> 0:05:19.750 so that coordination, that planning is guided by expert recommendations 0:05:19.750 --> 0:05:23.650 from from professional organizations like the American Heart Association, as 0:05:23.650 --> 0:05:27.700 well as other organizations who help credit these centers. But ultimately, 0:05:27.700 --> 0:05:31.960 to your point, Stephen, it's really a local implementation. And 0:05:31.960 --> 0:05:34.390 so when you have a city that has a dozen 0:05:34.390 --> 0:05:37.960 hospitals that those facilities have to work together and have 0:05:37.960 --> 0:05:40.930 to ensure that they're going to collaborate with EMS system 0:05:40.930 --> 0:05:43.420 to get the patient the best care possible and to 0:05:43.420 --> 0:05:45.130 get the patient to the closest appropriate facility. 0:05:45.470 --> 0:05:51.550 Are you busy coordinating with police departments, fire departments, local municipalities, 0:05:51.550 --> 0:05:53.800 government officials? How do you manage all this? 0:05:54.430 --> 0:05:58.089 Yes, it really is a collaborative effort, as you would imagine. 0:05:58.089 --> 0:06:00.729 As you mentioned, some of the different disciplines that are 0:06:00.730 --> 0:06:02.979 present at the table. A lot of it comes down 0:06:02.980 --> 0:06:06.220 to how EMS is operationalized and in your neck of 0:06:06.220 --> 0:06:08.620 the woods, if you will, in many parts of the country, 0:06:08.620 --> 0:06:12.310 the predominant delivery system for EMS through the fire department. 0:06:12.310 --> 0:06:15.910 And so in those cases, you have fire rescue agencies 0:06:16.060 --> 0:06:19.000 that also spend a big portion of their time delivering 0:06:19.000 --> 0:06:22.540 EMS care. And so in that model, there's. Coordination and 0:06:22.540 --> 0:06:26.529 there's overlap with other essential missions and services to the 0:06:26.529 --> 0:06:29.289 public in other parts of the country. It's done through 0:06:29.290 --> 0:06:33.280 a third party model where you have an independent government 0:06:33.279 --> 0:06:36.760 organization or a local government contract with a private vendor 0:06:36.910 --> 0:06:40.120 to provide that emergency medical services care. What's interesting is 0:06:40.120 --> 0:06:43.570 that any and all of those models can work any 0:06:43.570 --> 0:06:46.840 and all those models cannot work very well also without 0:06:46.839 --> 0:06:51.400 proper oversight, proper planning and execution of those plans. So 0:06:51.400 --> 0:06:53.860 it really comes down to, as I mentioned a moment ago, 0:06:53.860 --> 0:06:58.330 implementation and also comes down to a degree of coordination. Now, 0:06:58.330 --> 0:07:01.330 the larger the system, the more complex inputs and outputs 0:07:01.330 --> 0:07:03.670 you have, the more players you have at the table. 0:07:03.940 --> 0:07:05.620 But at the end of the day, and this is 0:07:05.620 --> 0:07:07.870 something that we talk about. And Stephen, although I've never 0:07:07.870 --> 0:07:10.210 met you personally before, I would imagine with your background 0:07:10.210 --> 0:07:13.030 you might agree or feel free to disagree if we 0:07:13.030 --> 0:07:16.600 keep the patient at the center of what we want 0:07:16.600 --> 0:07:19.510 to do and the center of the mission and the 0:07:19.510 --> 0:07:23.170 center of what we're about is providing the best patient care, 0:07:23.590 --> 0:07:26.680 regardless of where that emergency is, regardless of what resources 0:07:26.680 --> 0:07:27.490 we do, we don't have. 0:07:27.610 --> 0:07:28.570 If we anchor 0:07:28.570 --> 0:07:32.560 on providing the best patient care possible, the rest has 0:07:32.560 --> 0:07:35.080 a way of figuring itself out. And so when we 0:07:35.080 --> 0:07:37.780 build these systems, it's one of those paradigms that I 0:07:37.780 --> 0:07:39.670 believe very strongly in. It's also one of the ones 0:07:39.670 --> 0:07:42.460 we try to teach. And when we teach our EMS 0:07:42.460 --> 0:07:44.860 clinicians or EMTs and our paramedics 0:07:44.860 --> 0:07:46.239 about how to deliver high 0:07:46.240 --> 0:07:50.350 quality patient care under sometimes suboptimal conditions, we really try 0:07:50.350 --> 0:07:53.620 to remind them that it's about that patient. And that's 0:07:53.620 --> 0:07:55.210 true on a daily basis. 0:07:55.600 --> 0:07:56.200 We can talk 0:07:56.200 --> 0:07:58.750 about when that sometimes gets really challenging, when we have 0:07:58.750 --> 0:08:01.860 resource limited situations that we've experienced this past year with 0:08:01.870 --> 0:08:04.540 covid we've experienced during disasters. But then we have to 0:08:04.540 --> 0:08:06.070 kind of look at how do we do the greatest 0:08:06.070 --> 0:08:07.870 good for the greatest number? And that's a whole other 0:08:07.870 --> 0:08:08.830 layer of complexity. 0:08:09.580 --> 0:08:11.110 I wonder if you could take us for a little 0:08:11.110 --> 0:08:16.330 tour about how things have progressed with emergency medical care 0:08:16.330 --> 0:08:19.990 covid was during this past year. Maybe you could tell 0:08:19.990 --> 0:08:22.390 us what you've learned, what treatment has 0:08:22.390 --> 0:08:23.830 changed and how you've 0:08:23.830 --> 0:08:26.470 handled the emergency side of this pandemic. 0:08:27.440 --> 0:08:30.440 It's a great question, certainly we continue to learn 0:08:30.440 --> 0:08:33.469 every day there was so much we didn't know earlier 0:08:33.470 --> 0:08:36.080 on about covid and we drew from 0:08:36.080 --> 0:08:40.820 metaphore experiences and prior tranches, including the H1N1 pandemic that 0:08:40.820 --> 0:08:44.809 occurred in August 2009 and then more recently, the SARS 0:08:44.990 --> 0:08:45.470 and 0:08:45.470 --> 0:08:48.949 murres coronavirus pandemic and then also recent experiences with other 0:08:48.950 --> 0:08:49.340 highly 0:08:49.340 --> 0:08:50.569 infectious pathogen 0:08:50.809 --> 0:08:53.270 conditions such as Ebola. And we had to start making 0:08:53.270 --> 0:08:56.840 certain assumptions very early on. Steve, I'm sure you guys 0:08:56.840 --> 0:08:59.309 did the same thing in the ICU and about about 0:08:59.350 --> 0:09:01.100 how do we safely care for people? How do we 0:09:01.100 --> 0:09:04.160 minimize the spread? And one of the things that we 0:09:04.160 --> 0:09:08.179 started doing very early on and many Ms. Abrams' did 0:09:08.179 --> 0:09:11.179 this around the country, was we began we started at 0:09:11.179 --> 0:09:14.480 the start and that started with a 911 call asking 0:09:14.480 --> 0:09:16.640 the 911 operators to ask some additional 0:09:16.640 --> 0:09:19.969 questions to help understand is this person 0:09:19.970 --> 0:09:24.439 displaying signs or symptoms of potential covid-19 illness? And that 0:09:24.440 --> 0:09:25.010 would get them 0:09:25.010 --> 0:09:27.890 identified as what we call a pouye or person 0:09:27.890 --> 0:09:31.610 under investigation for covid-19 illness and to give the EMS 0:09:31.610 --> 0:09:34.069 clinicians a heads up and a warning that they could 0:09:34.070 --> 0:09:36.530 be walking into a potentially dangerous situation. 0:09:36.860 --> 0:09:39.380 So how did you advise them in that kind of situation? 0:09:39.380 --> 0:09:43.610 How did they stay safe? Well, actually executing on this job, 0:09:44.110 --> 0:09:46.280 one of the things that we did very early on 0:09:46.280 --> 0:09:48.560 and there was variability in this across the country is 0:09:48.559 --> 0:09:53.000 everyone implemented higher levels of PPE, personal protective equipment, to 0:09:53.000 --> 0:09:55.370 be warned all times. Now, it's one thing to wear 0:09:55.370 --> 0:09:56.929 a gown and gloves and masks. 0:09:56.929 --> 0:09:57.949 And for me to do it in the 0:09:57.950 --> 0:10:00.859 emergency department, for Steve to do in the ICU, it's 0:10:00.860 --> 0:10:03.110 another thing to do it inside an ambulance or in 0:10:03.110 --> 0:10:03.830 someone's living 0:10:03.830 --> 0:10:04.170 room. 0:10:04.520 --> 0:10:06.470 And so one of the things that we started 0:10:06.470 --> 0:10:07.490 seeing, our 0:10:07.490 --> 0:10:10.370 EMS clinicians are very talented and very smart. And we 0:10:10.370 --> 0:10:13.729 can build processes, protocols and algorithms. They'll follow them. But 0:10:13.730 --> 0:10:16.270 we began to see some of the unintended consequences of that. 0:10:16.490 --> 0:10:17.870 And let me give an example. 0:10:18.140 --> 0:10:21.920 Take the emergency that is cardiac arrest, sudden cardiac arrest. 0:10:22.070 --> 0:10:25.460 When someone spontaneously goes into a lethal arrhythmia and their 0:10:25.460 --> 0:10:28.010 heart is no longer pumping and they need immediate CPR 0:10:28.010 --> 0:10:31.250 and immediate defibrillation. And for every minute that their body 0:10:31.250 --> 0:10:31.700 is in that 0:10:31.700 --> 0:10:33.229 state where they don't get 0:10:33.230 --> 0:10:37.190 those resources, their chance of survival goes down by 10 percent. Well, 0:10:37.370 --> 0:10:39.860 if it takes those EMS clinicians an extra few minutes 0:10:39.860 --> 0:10:42.500 to get all that PPE on and to safely get 0:10:42.500 --> 0:10:46.460 into the house, that's negative energy. That's the consequence of that. 0:10:46.460 --> 0:10:48.920 The unintended consequence of that was it was actually quite huge. 0:10:49.130 --> 0:10:50.689 But we have to protect our responders. 0:10:50.690 --> 0:10:53.450 We have to protect our personnel. I just recently 0:10:53.450 --> 0:10:56.959 looked at the death numbers of EMS personnel 0:10:57.080 --> 0:10:59.600 in the country who died of covid-19 illness in the 0:10:59.600 --> 0:11:02.240 past year. And they are some of the unsung heroes 0:11:02.240 --> 0:11:04.130 of this pandemic, as are so many others. 0:11:04.140 --> 0:11:05.150 But what I would say 0:11:05.270 --> 0:11:08.570 is that the problem got even more amplified, because if 0:11:08.570 --> 0:11:11.750 you remember early in covid-19, Steve, I know how it 0:11:11.750 --> 0:11:13.609 was in your in your hospital. I could tell you 0:11:13.610 --> 0:11:17.330 in mine, census dropped really, really quick. We couldn't get 0:11:17.330 --> 0:11:18.710 people to come to the hospital who needed to 0:11:18.710 --> 0:11:20.000 come to the hospital and our 0:11:20.000 --> 0:11:21.469 rates of heart, 0:11:21.470 --> 0:11:23.420 attacks of stylization, 0:11:23.420 --> 0:11:26.360 demise of of an emergency where there's a blocked coronary 0:11:26.360 --> 0:11:27.679 artery. Those rates 0:11:27.679 --> 0:11:28.490 went way down 0:11:28.790 --> 0:11:32.580 and the rates of cardiac arrest went up. That's not coincidental. 0:11:32.720 --> 0:11:34.580 People were afraid to come to the hospitals. 0:11:34.730 --> 0:11:35.870 So people were afraid 0:11:35.870 --> 0:11:37.520 to call 911 early on because they didn't want to 0:11:37.520 --> 0:11:40.250 get sick at the hospital, something that we had to 0:11:40.250 --> 0:11:43.550 work very hard from a public education campaign to reassure 0:11:43.550 --> 0:11:45.170 the public that, know, if you're having an emergency, we 0:11:45.170 --> 0:11:45.969 want you to come in. 0:11:46.309 --> 0:11:50.540 So it wouldn't every EMT have to arrive on scene, 0:11:50.540 --> 0:11:53.209 assuming that there was covered in a house? 0:11:53.720 --> 0:11:56.750 Well, it's interesting that you frame it that way because 0:11:56.750 --> 0:11:57.950 it quickly became that way. 0:11:58.070 --> 0:11:58.699 Early in 0:11:58.700 --> 0:12:03.410 covid-19, we were still asking questions about had you traveled 0:12:03.410 --> 0:12:06.560 to a hotspot area or had you had known contact 0:12:06.559 --> 0:12:09.829 with a covid-19 positive person or someone 0:12:09.830 --> 0:12:11.420 under investigation? And I'm not 0:12:11.420 --> 0:12:13.940 a public health expert, but I've learned a lot this 0:12:13.940 --> 0:12:16.250 year with the intent of trying to still isolate and 0:12:16.250 --> 0:12:19.939 contain and mitigate this. But once we began experiencing community 0:12:19.940 --> 0:12:23.490 spread of covid-19 illness, the scenario that you described, Bill, 0:12:23.510 --> 0:12:27.380 is exactly correct. At that point, everybody is presumed potentially infected. 0:12:27.380 --> 0:12:30.500 And there's all these metaphore cliches of during the pandemic, 0:12:30.500 --> 0:12:32.300 we had to pivot. We had a change, again, our 0:12:32.300 --> 0:12:36.260 operating construct and say, OK, from here on in the 0:12:36.260 --> 0:12:40.040 paramedics that work under my medical direction, we said we 0:12:40.040 --> 0:12:41.870 want the wearing and then the ninety five 0:12:41.870 --> 0:12:43.400 mask on any time you're coming in 0:12:43.400 --> 0:12:45.620 contact with a patient in eye protection. And we took 0:12:45.620 --> 0:12:48.080 those measures because we couldn't tell early on in the 0:12:48.080 --> 0:12:50.840 symptomatology of who was going to be positive became so 0:12:50.840 --> 0:12:53.300 broad it could have been someone with a febrile respiratory 0:12:53.300 --> 0:12:55.010 illness which was pretty passive demonic 0:12:55.010 --> 0:12:57.020 armonica, pretty typical. Or could could've been someone with a 0:12:57.020 --> 0:12:58.910 runny nose. And it was very hard to tell who 0:12:58.910 --> 0:13:01.730 was truly covid positive. What we're witnessing now and you 0:13:01.730 --> 0:13:03.559 tell me whether you're seeing it as well 0:13:03.770 --> 0:13:05.569 now that the surge, 0:13:05.690 --> 0:13:07.429 at least in our area, has really 0:13:07.429 --> 0:13:08.239 subsided. 0:13:08.420 --> 0:13:13.910 The acuity level is extreme with multisystem organ issues that 0:13:13.910 --> 0:13:17.270 we've not seen before. I mean, we always see patients 0:13:17.270 --> 0:13:18.500 here and there with multisystem 0:13:18.500 --> 0:13:20.390 disease, but the numbers 0:13:20.390 --> 0:13:23.510 of people who are coming in with complex medical issues 0:13:23.660 --> 0:13:27.270 that quickly turn to renal failure or. Stems and non 0:13:27.270 --> 0:13:29.910 stem is the various forms that the heart attacks, as 0:13:29.910 --> 0:13:32.670 I'm describing, and strokes, that they seem to be at 0:13:32.670 --> 0:13:34.710 a much higher number, as if these 0:13:34.710 --> 0:13:36.150 were people who left their 0:13:36.150 --> 0:13:39.420 health go for the past year and now they're suddenly 0:13:39.420 --> 0:13:42.910 flooding into the hospital once they tip over their threshold. 0:13:42.960 --> 0:13:46.079 Are you seeing that more in the EMS system or 0:13:46.080 --> 0:13:49.200 is this just something locally that I'm seeing just in 0:13:49.200 --> 0:13:51.120 my region? You know, I certainly wouldn't 0:13:51.120 --> 0:13:52.230 dispute 0:13:52.260 --> 0:13:55.800 what you're saying. I think I've had similar observations. I 0:13:55.800 --> 0:13:58.740 think of it somewhat akin to something that we've probably 0:13:58.740 --> 0:13:59.880 seen in our clinical practice, 0:13:59.880 --> 0:14:01.170 which is no one wants to 0:14:01.170 --> 0:14:03.870 be in the hospital over the holidays. So everybody tries 0:14:03.870 --> 0:14:06.210 to stay home. And then after the holidays is when 0:14:06.210 --> 0:14:08.189 we get really busy and everyone who tried to kind 0:14:08.190 --> 0:14:10.170 of hold off and could no longer do so. And 0:14:10.170 --> 0:14:13.500 I think while that's probably a crude metaphor, I think 0:14:13.500 --> 0:14:18.210 the principal is probably similar here. We saw a decline 0:14:18.210 --> 0:14:18.990 in overall 0:14:18.990 --> 0:14:21.600 EMS call volume, at least in my region over the 0:14:21.600 --> 0:14:23.970 past year. And that call volume is starting to pick 0:14:23.970 --> 0:14:25.140 back up a normalized. 0:14:25.380 --> 0:14:26.430 But indeed, 0:14:26.430 --> 0:14:28.440 it seems as though the acuity at least certainly feels 0:14:28.440 --> 0:14:30.180 that way, is getting back up there is getting 0:14:30.180 --> 0:14:31.530 higher. One of the 0:14:31.530 --> 0:14:32.520 things that we also 0:14:32.520 --> 0:14:34.320 saw which experienced 0:14:34.320 --> 0:14:35.940 it firsthand during the height of the 0:14:35.940 --> 0:14:39.630 pandemic, particularly over the winter, was 0:14:39.630 --> 0:14:43.890 as people were still home and kind of socially isolating 0:14:43.890 --> 0:14:46.140 and trying their best to adhere to public health recommendations. 0:14:46.410 --> 0:14:48.270 There was a lot less traffic on the roadways. 0:14:48.570 --> 0:14:50.130 And I saw and respond 0:14:50.130 --> 0:14:52.290 to some of the worst motor vehicle collisions in my 0:14:52.290 --> 0:14:54.540 career because I guess people were driving a lot faster. 0:14:54.540 --> 0:14:57.360 And that's my own observation. I noticed that as well, 0:14:57.360 --> 0:14:59.729 just because, you know, with knee, they weren't going to 0:14:59.730 --> 0:15:02.489 be stopped by the police because police were afraid to 0:15:02.490 --> 0:15:04.050 stop people for fear of covid. 0:15:04.350 --> 0:15:04.740 And so 0:15:04.740 --> 0:15:07.050 people felt that they could just speed and they were 0:15:07.050 --> 0:15:09.840 suddenly on the American autobahn, going just as fast as 0:15:09.840 --> 0:15:10.230 they wanted 0:15:10.230 --> 0:15:10.660 to go. 0:15:11.070 --> 0:15:13.620 OK, guys, we're going to take about a 30 second break. 0:15:13.620 --> 0:15:15.960 And when we come back, Matt, I'd like to dig 0:15:15.960 --> 0:15:19.500 into the process that EMT goes through when they arrive 0:15:19.500 --> 0:15:22.020 on a scene and get that illustration from you. We'll 0:15:22.020 --> 0:15:22.650 be right back. 0:15:33.390 --> 0:15:37.229 A moment of your time, a new podcast from Kerkow Media. 0:15:37.920 --> 0:15:41.970 Currently 21 years old and today, like magic, extended from 0:15:41.970 --> 0:15:44.010 her fingertips down to the blood to take 0:15:44.010 --> 0:15:47.010 care of yourself because the world needs you and you, me. 0:15:47.040 --> 0:15:48.870 Every do gooder that asked about me was ready to 0:15:48.870 --> 0:15:51.450 spit on my dream. Fingers who are facing you can 0:15:51.450 --> 0:15:53.730 feel like your purpose in your worth is 0:15:53.850 --> 0:15:56.250 really being done to stop me from playing the 0:15:56.250 --> 0:15:59.250 piano. She buys walkie talkies, wonders to whom she should 0:15:59.250 --> 0:16:00.780 give the second. I don't love 0:16:00.780 --> 0:16:03.570 humans. We never did. We never. Well, we just find 0:16:03.630 --> 0:16:03.740 the 0:16:03.750 --> 0:16:06.540 beauty of rock climbing is that you can only focus 0:16:06.540 --> 0:16:07.380 on what's right 0:16:07.380 --> 0:16:11.910 in life. And so our American life begins. We may 0:16:11.910 --> 0:16:15.870 need to stay apart, but let's create together available on 0:16:15.870 --> 0:16:19.800 all podcast platforms. Submit your piece at Kerkow dot com, 0:16:19.800 --> 0:16:21.090 slash a moment of your time. 0:16:27.700 --> 0:16:30.310 So I wonder, Matt, before we dig into process, could 0:16:30.310 --> 0:16:34.140 you define the different types of individuals, EMS, the EMT, 0:16:34.150 --> 0:16:36.600 and tell us what their role is in the process? 0:16:37.300 --> 0:16:40.600 So EMS is the system. The emergency medical services is 0:16:40.600 --> 0:16:44.680 a system that is comprised of human beings and equipment 0:16:44.680 --> 0:16:48.040 and technologies to save lives within that system. There are 0:16:48.040 --> 0:16:52.270 a variety of levels of training, certification, licensure. The most 0:16:52.270 --> 0:16:53.110 common 0:16:53.110 --> 0:16:55.150 level of EMS 0:16:55.150 --> 0:16:59.380 clinician or emergency medical services personnel in the country is 0:16:59.380 --> 0:17:02.200 someone that's called an EMT or an emergency medical 0:17:02.200 --> 0:17:02.800 technician. 0:17:03.100 --> 0:17:06.639 And on average, these individuals have around one hundred and 0:17:06.640 --> 0:17:08.920 twenty to one hundred and sixty hours of training. It's 0:17:08.920 --> 0:17:10.899 the equivalent of about a college semester's course, 0:17:10.900 --> 0:17:12.010 and their scope 0:17:12.010 --> 0:17:12.970 of practice and knowledge 0:17:12.970 --> 0:17:16.270 includes CPR to some basic airway 0:17:16.270 --> 0:17:17.830 management. How to ventilate somebody 0:17:17.830 --> 0:17:18.820 with a bag valve 0:17:18.820 --> 0:17:20.260 mask resuscitator, how 0:17:20.260 --> 0:17:22.150 to deliver a baby, how to control 0:17:22.150 --> 0:17:26.139 severe bleeding, how to immobilize someone and safely transport them 0:17:26.140 --> 0:17:29.290 to the hospital and the basic operations of an ambulance. 0:17:29.320 --> 0:17:33.669 There are other variant levels of an intermediate type levels 0:17:33.670 --> 0:17:34.840 of EMS provider, but 0:17:34.840 --> 0:17:36.460 keeping it big and simple, 0:17:36.490 --> 0:17:38.320 the other very common level 0:17:38.320 --> 0:17:41.380 of EMS clinician or provider that staffs 0:17:41.380 --> 0:17:43.780 these ambulances and helicopters, for that matter across 0:17:43.780 --> 0:17:45.460 the country would be a paramedic. 0:17:45.700 --> 0:17:47.080 And in order to be a paramedic, you have to 0:17:47.080 --> 0:17:47.679 first be an 0:17:47.680 --> 0:17:49.570 EMT and paramedic 0:17:49.690 --> 0:17:50.320 is an EMT 0:17:50.320 --> 0:17:51.580 who's gone through about the 0:17:51.580 --> 0:17:55.060 equivalent of a thousand to 1500 hours of 0:17:55.060 --> 0:17:56.320 training in all 0:17:56.320 --> 0:17:59.170 aspects of advanced cardiac life support 0:17:59.320 --> 0:18:01.240 and the recognition 0:18:01.240 --> 0:18:05.200 and diagnosis or field interpretation of a medical emergency and 0:18:05.200 --> 0:18:07.870 the advanced interventions. These folks can do things like inserting 0:18:07.869 --> 0:18:09.250 breathing tubes to secure 0:18:09.250 --> 0:18:10.600 someone's airway, to put in 0:18:10.600 --> 0:18:12.310 IVs, to give a host 0:18:12.310 --> 0:18:16.150 of different medications, to stabilize someone having an emergency, and 0:18:16.150 --> 0:18:19.510 to deliver a variety of types of other interventions, including 0:18:19.510 --> 0:18:20.650 the specialty types of 0:18:20.650 --> 0:18:22.810 defibrillation or pacing someone's heart. 0:18:23.140 --> 0:18:23.950 So these folks 0:18:23.950 --> 0:18:25.179 really are experts 0:18:25.180 --> 0:18:28.510 in the resuscitation of people outside the hospital. The other 0:18:28.510 --> 0:18:30.940 group that I do want to specify and clarify is 0:18:30.970 --> 0:18:34.840 there are emergency medicine physicians. These are physicians. These are 0:18:34.840 --> 0:18:37.240 doctors who graduated medical school, have gone and done a 0:18:37.240 --> 0:18:41.230 residency in the field of emergency medicine. They are then 0:18:41.230 --> 0:18:41.650 board 0:18:41.650 --> 0:18:42.970 certified in emergency 0:18:42.970 --> 0:18:46.540 medicine and staff, many of the emergency departments, if not 0:18:46.540 --> 0:18:48.970 the vast majority across the country. There are other folks 0:18:48.970 --> 0:18:51.190 who are not emergency medicine trained who also staff those 0:18:51.190 --> 0:18:54.429 front lines, particularly in smaller hospitals. And by no means 0:18:54.430 --> 0:18:54.550 is 0:18:54.550 --> 0:18:58.060 that meant to deflate or to minimize their role. 0:18:58.630 --> 0:19:02.590 My specialty practice is in that of emergency medical services medicine. 0:19:02.590 --> 0:19:06.550 So after doing a residency in emergency medicine folks and 0:19:06.550 --> 0:19:09.610 then go on to do additional training, additional time called 0:19:09.609 --> 0:19:12.670 a fellowship in Emergency Medical Services, which is really 0:19:12.670 --> 0:19:14.470 focusing on how to 0:19:14.500 --> 0:19:17.679 do many of the things we've talked about already oversee, run, 0:19:17.710 --> 0:19:20.770 facilitate emergency medical services systems and how to practice out 0:19:20.770 --> 0:19:24.190 of hospital medicine. And that represents the highest level of 0:19:24.190 --> 0:19:25.330 emergency medical 0:19:25.330 --> 0:19:27.070 services specialty 0:19:27.070 --> 0:19:29.260 that exists in the country. There are a couple other levels, 0:19:29.260 --> 0:19:31.149 but for the sake of simplicity, I would stop there. 0:19:31.840 --> 0:19:35.590 Are these fields properly funded? Is there enough of a 0:19:35.590 --> 0:19:40.300 political and governmental dedication to the field that we need? 0:19:40.510 --> 0:19:43.300 Is it working or is it a mess? Where are we? 0:19:43.760 --> 0:19:44.650 I think the 0:19:44.650 --> 0:19:46.480 answer is it's not a yes or no 0:19:46.480 --> 0:19:48.750 answer. Certainly we could do a lot more with a 0:19:48.750 --> 0:19:51.100 lot more funding. It is the easy answer. What I 0:19:51.100 --> 0:19:54.610 would say is that historically EMS has not been very 0:19:54.609 --> 0:19:59.950 well funded. Most EMS programs operate based upon a billing 0:19:59.950 --> 0:20:03.970 and reimbursement structure that was intended and designed with the 0:20:03.970 --> 0:20:08.379 recognition that ambulances were just a service, a transportation service 0:20:08.380 --> 0:20:10.330 to move a patient from point A to point B, 0:20:10.330 --> 0:20:11.200 not a highly 0:20:11.200 --> 0:20:13.750 sophisticated mobile, in some 0:20:13.750 --> 0:20:17.890 cases intensive care, capable environment capable of delivering that level 0:20:17.890 --> 0:20:21.190 of care. So certainly there is a need for greater funding. 0:20:21.190 --> 0:20:25.360 I will say specifically regarding medical direction and the physician 0:20:25.359 --> 0:20:29.800 oversight of EVMs that historically had been very poorly funded 0:20:29.800 --> 0:20:32.650 on average across the country. And it wasn't very long 0:20:32.650 --> 0:20:34.630 ago that many medical 0:20:34.630 --> 0:20:36.610 directors served in their roles 0:20:36.790 --> 0:20:39.490 as a community service and didn't even get a salary. 0:20:39.650 --> 0:20:42.340 I mean, Steve, imagine working in the ICU to serve 0:20:42.340 --> 0:20:44.350 your community at a voluntary level in addition to your 0:20:44.350 --> 0:20:47.290 other practice and pulmonary medicine or in another one of 0:20:47.290 --> 0:20:49.660 your other disciplines. I mean, that's to be asked nowadays. 0:20:49.660 --> 0:20:51.250 It's like, wow, that's a lot to ask of people. 0:20:51.250 --> 0:20:53.350 But it wasn't very long ago that that's where this 0:20:53.350 --> 0:20:56.080 evolved from. So, again, we're moving in the right direction 0:20:56.100 --> 0:20:58.360 of opioid. We we have some way to go. Is 0:20:58.359 --> 0:21:02.109 funding local or national or the combination of both. Most 0:21:02.109 --> 0:21:05.919 EMR systems are funded locally. The reimbursement structure is usually 0:21:05.920 --> 0:21:08.169 set by at the federal level and through Medicare and 0:21:08.170 --> 0:21:09.550 Medicaid reimbursement 0:21:09.550 --> 0:21:13.270 amounts for ambulance transports. But those reimbursement amounts, we're talking 0:21:13.270 --> 0:21:17.919 about hundreds of dollars per ambulance transport. That's not usually 0:21:17.920 --> 0:21:20.860 a lot to sustain these operations. So that helps augment 0:21:20.890 --> 0:21:25.760 the operation. It doesn't actually completely sustain it. Most E.M.S. 0:21:25.780 --> 0:21:29.440 programs do receive local funding, in some cases they're funded 0:21:29.440 --> 0:21:32.859 better than others. And with that comes the ability to innovate, 0:21:32.980 --> 0:21:36.040 to implement cutting edge technologies. But there are plenty of 0:21:36.040 --> 0:21:39.909 places where the rate limiting step is there lack of 0:21:39.910 --> 0:21:41.230 funding to do more. 0:21:41.830 --> 0:21:44.879 So I can't help but bring up the difficult subject. 0:21:44.920 --> 0:21:46.690 I want to talk about insurance for just a minute, 0:21:46.690 --> 0:21:49.750 because this is one of those cases where the better 0:21:49.780 --> 0:21:52.629 the job that you do and the better the job 0:21:52.630 --> 0:21:55.930 that the EMTs do, the more it costs the insurance company. 0:21:55.940 --> 0:21:58.510 So it must kind of keep the two at loggerheads 0:21:58.510 --> 0:22:00.520 a little bit. Are you having challenges there? 0:22:01.210 --> 0:22:03.940 By no means am I an expert in health care economics. 0:22:03.940 --> 0:22:06.040 But from my perspective, what I would say is that 0:22:06.040 --> 0:22:09.070 EMS has actually been in some ways a victim of 0:22:09.070 --> 0:22:11.560 this in a different manner because there are only two 0:22:11.560 --> 0:22:14.950 or three levels of reimbursement that EMS programs can bill 0:22:14.950 --> 0:22:18.939 for bill insurance or bill Medicare for. So you quickly 0:22:18.940 --> 0:22:21.429 reach that cap and it's just the rest of it 0:22:21.430 --> 0:22:23.290 is just part of the service. It's part of the 0:22:23.290 --> 0:22:24.969 public safety service that's delivered. 0:22:24.980 --> 0:22:25.960 For example, 0:22:26.080 --> 0:22:28.149 if a patient is in the hospital and Stephen are 0:22:28.150 --> 0:22:29.679 taking care of them and we have to put a 0:22:29.680 --> 0:22:31.510 central line in or put a breathing tube in, each 0:22:31.510 --> 0:22:34.930 of those things are billable procedures that because there is risk, 0:22:34.930 --> 0:22:36.790 there's expertise there, sophistications need 0:22:36.800 --> 0:22:37.330 to do that. 0:22:37.840 --> 0:22:42.550 That's not necessarily the way that it works in EMS billing, 0:22:42.550 --> 0:22:44.980 where you bill for either a basic life support level 0:22:44.980 --> 0:22:46.929 of care or an advanced life support level of care. 0:22:47.140 --> 0:22:48.960 And there are some echelons in there. 0:22:49.090 --> 0:22:49.840 So it is a 0:22:49.840 --> 0:22:53.350 bit of a challenge. The opportunity, I think, that we're 0:22:53.350 --> 0:22:56.470 seeing now and there is a national initiative, it's a 0:22:56.470 --> 0:23:00.010 pilot initiative that CMS, the Centers for Medicare and Medicaid 0:23:00.010 --> 0:23:00.880 has implemented. 0:23:01.060 --> 0:23:02.409 That's called ETTY 0:23:02.410 --> 0:23:06.250 three. And this is an initiative that started before the pandemic. 0:23:06.250 --> 0:23:09.250 And this is the Emergency Treatment Transport Initiative where they're 0:23:09.250 --> 0:23:14.140 looking at allowing EMS agencies to be reimbursed even when 0:23:14.140 --> 0:23:15.310 they don't transport someone. 0:23:15.640 --> 0:23:17.260 So it used to be 0:23:17.260 --> 0:23:19.209 that the only way these EMS programs could actually be 0:23:19.210 --> 0:23:22.209 reimbursed is if they transport someone to a hospital. That, 0:23:22.210 --> 0:23:24.790 to me, seems like a flip logic. What that then 0:23:24.820 --> 0:23:28.750 does is it then incentivizes to not transport people or 0:23:28.750 --> 0:23:32.050 to not transport them to other locations, such as alternative destinations, 0:23:32.200 --> 0:23:33.820 urgent care centers, other 0:23:33.820 --> 0:23:35.770 places that if the patient 0:23:35.770 --> 0:23:37.660 meets the appropriate triage criteria, 0:23:37.660 --> 0:23:38.889 could safely and 0:23:38.890 --> 0:23:41.800 effectively get their care in a manner that's both appropriate 0:23:41.800 --> 0:23:43.090 and also fiscally prudent, 0:23:43.090 --> 0:23:45.790 which is why the consumer often goes to an emergency 0:23:45.790 --> 0:23:47.260 room for something that really isn't an 0:23:47.260 --> 0:23:47.859 emergency. 0:23:48.109 --> 0:23:51.160 Yeah, I am always interested when I speak with my 0:23:51.160 --> 0:23:53.440 patients in the emergency department. We have a finite amount 0:23:53.440 --> 0:23:55.570 of time that we can really spend at the bedside 0:23:55.570 --> 0:23:55.810 with our 0:23:55.810 --> 0:23:56.880 patients because it's 0:23:56.890 --> 0:23:59.109 just the acuity and the volumes. But when I talk 0:23:59.109 --> 0:24:01.090 to my patients and I ask them some questions about 0:24:01.300 --> 0:24:03.399 you have a primary care doctor? Oh, yes, I do. 0:24:03.680 --> 0:24:04.359 I spoke. Have you 0:24:04.359 --> 0:24:05.889 talked to your primary care doctor about the condition that 0:24:05.890 --> 0:24:08.530 brought you in today in circumstances when it's not a 0:24:08.530 --> 0:24:11.649 time critical or high acuity emergency, to your point, at 0:24:11.650 --> 0:24:11.830 least 0:24:11.859 --> 0:24:12.970 some of them don't necessarily 0:24:12.970 --> 0:24:14.679 recognize it. Oh, wow. I could have called my doctor 0:24:14.680 --> 0:24:16.540 for some of this. Let me be clear. I'm not 0:24:16.540 --> 0:24:18.429 saying that we don't want them coming to the emergency 0:24:18.430 --> 0:24:20.889 department if they need to be. But another example of 0:24:20.890 --> 0:24:23.950 how the pandemic has really revolutionized care delivery and it's 0:24:23.950 --> 0:24:24.639 really been a 0:24:24.640 --> 0:24:27.490 catalyst I think has sprung us forward probably a decade 0:24:27.490 --> 0:24:28.600 or two, has been the use of 0:24:28.600 --> 0:24:30.399 telemedicine where people can now have 0:24:30.400 --> 0:24:32.650 a television with their doctor from the comfort of their 0:24:32.650 --> 0:24:32.830 own 0:24:32.830 --> 0:24:33.850 home and then 0:24:33.850 --> 0:24:36.490 decide what the right intervention or right diagnostic workup is. 0:24:36.880 --> 0:24:39.970 So I imagine there's a moment of real stress that 0:24:39.970 --> 0:24:43.750 occurs when an EMT has to make a decision about 0:24:43.869 --> 0:24:45.939 do we put this poor fellow in the back of 0:24:45.940 --> 0:24:49.390 the ambulance or do we call for air transport? Tell 0:24:49.390 --> 0:24:52.420 me about how you train people for that kind of decision. 0:24:53.020 --> 0:24:55.960 So one of the things that we do really well 0:24:55.960 --> 0:24:57.879 in EMS is we try to bring 0:24:57.880 --> 0:24:59.500 structure to chaos 0:24:59.680 --> 0:25:02.980 and we try to bring an organized and methodological 0:25:02.980 --> 0:25:04.540 approach to 0:25:04.540 --> 0:25:07.750 a complex and chaotic and potentially life threatening situation to 0:25:07.750 --> 0:25:12.220 the point that the same assessment that I do, the 0:25:12.220 --> 0:25:15.070 same fundamental assessment that I do now is a practicing 0:25:15.070 --> 0:25:18.190 emergency physician for over a decade and a half is 0:25:18.190 --> 0:25:20.350 based upon the routes that I learned as an EMT 0:25:20.350 --> 0:25:23.290 25 years ago, because it works. And so what we 0:25:23.290 --> 0:25:25.180 teach and it starts off in the classroom, it starts 0:25:25.180 --> 0:25:27.940 off with an assessment of the safety of the environment. 0:25:28.060 --> 0:25:30.459 Is there a potential for harm for the clinician, for 0:25:30.460 --> 0:25:32.980 the EMS personnel responding? And and then they use a 0:25:32.980 --> 0:25:36.070 very structured approach at looking for the life threats. 0:25:36.070 --> 0:25:39.340 First, severe bleeding and airway issue. 0:25:39.460 --> 0:25:40.750 Someone's in respiratory 0:25:40.750 --> 0:25:42.459 distress or circulatory 0:25:42.460 --> 0:25:44.770 issue like shock or cardiac arrest. 0:25:44.950 --> 0:25:46.600 And then they build and they start 0:25:46.600 --> 0:25:49.150 fixing the fixable problems. They find them in that order 0:25:49.330 --> 0:25:50.770 and then they build upon that. 0:25:50.920 --> 0:25:51.400 And then 0:25:51.400 --> 0:25:54.189 very quickly, they are then able to fill in the 0:25:54.190 --> 0:25:57.550 blanks of additional information, what we would call the history 0:25:57.550 --> 0:25:59.410 of present illness or what's going on at that 0:25:59.410 --> 0:26:00.910 moment in time that led to that 0:26:00.910 --> 0:26:04.510 emergency happening and the patient's background and medical history. And 0:26:04.630 --> 0:26:08.410 all this is done very sequentially for two reasons. Number one, 0:26:08.410 --> 0:26:09.609 to be time efficient. 0:26:09.760 --> 0:26:12.280 We'll get back to that in a second. But number two, 0:26:12.310 --> 0:26:13.149 so that we 0:26:13.150 --> 0:26:13.450 can 0:26:13.450 --> 0:26:15.220 avoid variability 0:26:15.220 --> 0:26:19.030 and avoid unintendedly missing a potential injury illness, because there 0:26:19.030 --> 0:26:20.980 is no rule that says patients can only have one 0:26:20.980 --> 0:26:23.290 emergency going on at once. And we do see that, 0:26:23.290 --> 0:26:27.369 particularly in traumatically injured patient. So based upon that assessment 0:26:27.369 --> 0:26:29.620 and the interventions that are done then need to make 0:26:29.619 --> 0:26:32.260 a decision about where this person needs to go to 0:26:32.260 --> 0:26:34.570 get the care they need, and that decision is informed 0:26:34.570 --> 0:26:35.800 based upon geography. 0:26:36.010 --> 0:26:36.909 It's based upon 0:26:36.910 --> 0:26:39.460 whether it's based on a variety of things. And how 0:26:39.460 --> 0:26:42.909 do they get that person to the closest appropriate facility, 0:26:43.090 --> 0:26:45.610 which is the doctrine that we teach and we operate 0:26:45.609 --> 0:26:49.350 under the closest appropriate facility for the emergency that they're having. 0:26:49.750 --> 0:26:50.770 And once 0:26:50.770 --> 0:26:51.970 that decision is 0:26:51.970 --> 0:26:53.800 reached, it then becomes a 0:26:53.800 --> 0:26:56.830 means of, OK, how do we facilitate that transportation, if 0:26:56.830 --> 0:26:59.439 it's going to be many, many miles or there's going 0:26:59.440 --> 0:27:02.080 to be severe traffic or other barriers, it's going to 0:27:02.080 --> 0:27:05.530 translate to time delay. The right answer may be to 0:27:05.530 --> 0:27:08.740 utilize an air asset such as a helicopter that can 0:27:08.740 --> 0:27:12.250 quickly move that patient from the scene to that definitive care. 0:27:12.530 --> 0:27:16.090 Or alternatively, the answer might be we're going to go 0:27:16.090 --> 0:27:19.090 to the closest appropriate facility by ground or close the 0:27:19.090 --> 0:27:20.080 facility because this 0:27:20.080 --> 0:27:22.360 patient is so unstable, we just have to get them 0:27:22.359 --> 0:27:26.560 stabilized and then secondarily transfer them. Are you familiar with 0:27:26.590 --> 0:27:27.970 the Israeli drone 0:27:27.970 --> 0:27:29.350 system for EMS 0:27:29.350 --> 0:27:29.969 delivery? 0:27:30.400 --> 0:27:30.939 And could you 0:27:30.940 --> 0:27:32.830 speak to that a little bit? And is that something 0:27:32.920 --> 0:27:36.670 that could be translatable to a country as expansive as 0:27:36.670 --> 0:27:39.580 ours with a population of three hundred and thirty two 0:27:39.580 --> 0:27:44.470 million versus a tiny geographical parameter? If you're referring to 0:27:44.470 --> 0:27:48.310 the drone delivery of automatic external defibrillators program, is that 0:27:48.310 --> 0:27:52.870 what you're referring to? Exactly. Super exciting and super hopeful 0:27:52.869 --> 0:27:55.659 technology that is now realistic and 0:27:55.660 --> 0:27:57.200 is now within reach. 0:27:57.400 --> 0:27:59.290 Let me come back to that in a second. The 0:27:59.290 --> 0:28:00.400 other really neat 0:28:00.400 --> 0:28:01.989 thing that is done in 0:28:01.990 --> 0:28:05.680 Israel, there's a program called United Hatzalah, which is a 0:28:05.680 --> 0:28:09.010 smartphone based program that uses medical volunteers 0:28:09.130 --> 0:28:10.000 who are trained and 0:28:10.000 --> 0:28:13.359 equipped and given medical bags to serve as first responders 0:28:13.359 --> 0:28:15.850 before the first responders get there, because there's so much 0:28:15.850 --> 0:28:18.160 traffic and roadway congestion in Israel that 0:28:18.160 --> 0:28:18.669 they have 0:28:18.670 --> 0:28:19.990 a delayed response time in some 0:28:19.990 --> 0:28:21.609 parts of the country, no different than 0:28:21.609 --> 0:28:25.320 we have here. So they're able to use smartphone technology 0:28:25.330 --> 0:28:28.870 and if you will, a civilian reservist corps who's agreed 0:28:28.869 --> 0:28:30.189 to participate and be medically 0:28:30.190 --> 0:28:31.150 trained and carry some 0:28:31.150 --> 0:28:33.070 medical equipment to slice that 0:28:33.070 --> 0:28:34.990 time down the enemy 0:28:34.990 --> 0:28:35.620 here is 0:28:35.619 --> 0:28:37.120 time. The enemy when 0:28:37.119 --> 0:28:39.670 we have one of these emergencies is time. And that 0:28:39.670 --> 0:28:41.800 time directly translates 0:28:41.800 --> 0:28:45.280 to the absence or how long our body 0:28:45.280 --> 0:28:48.880 tissue is going without oxygen or perfusion for whatever the 0:28:48.880 --> 0:28:51.130 emergency is. If it's a stroke, it's how long the 0:28:51.130 --> 0:28:53.170 brain is going. That auction, if it's a heart attack, 0:28:53.290 --> 0:28:55.060 it's how long the heart is going. That oxygen. 0:28:55.210 --> 0:28:57.580 If it's someone who's bleeding on the street, 0:28:57.580 --> 0:28:59.770 it's how long they're bleeding for before someone stops the 0:28:59.770 --> 0:29:02.850 bleeding and can allow circulation to resume. 0:29:02.860 --> 0:29:03.940 So as we 0:29:03.940 --> 0:29:06.670 look towards exciting, innovative and disruptive 0:29:06.670 --> 0:29:08.410 technologies and disruptive technologies 0:29:08.410 --> 0:29:10.090 are a good thing because they force us to kind 0:29:10.090 --> 0:29:10.150 of 0:29:10.150 --> 0:29:11.230 rethink things. 0:29:11.230 --> 0:29:13.990 Drone delivery is one example. I think that we will 0:29:13.990 --> 0:29:16.000 see more of that in the U.S. I know that 0:29:16.000 --> 0:29:17.650 there's a lot of interest in it. There are some 0:29:17.650 --> 0:29:21.040 complexities with what are referred to as these unmanned aerial 0:29:21.040 --> 0:29:23.830 systems or these systems. The term drone has 0:29:23.830 --> 0:29:25.209 kind of an uncomfortable 0:29:25.210 --> 0:29:28.420 connotation for some people, but how do we leverage technologies 0:29:28.420 --> 0:29:30.580 to do that where we can get that lifesaving piece 0:29:30.580 --> 0:29:33.700 of equipment out to the scene, the emergency as quickly 0:29:33.700 --> 0:29:33.820 as 0:29:33.820 --> 0:29:37.150 possible? One of the very first research 0:29:37.150 --> 0:29:39.610 projects I engaged in when I was in graduate school 0:29:39.670 --> 0:29:42.670 was my graduate research project. We did an analysis of 0:29:42.700 --> 0:29:43.960 the location of cardiac 0:29:43.960 --> 0:29:45.910 arrests in a community and the 0:29:45.910 --> 0:29:47.200 location of AIDS. 0:29:47.500 --> 0:29:48.940 And what we found is 0:29:48.940 --> 0:29:49.510 that the lines 0:29:49.510 --> 0:29:51.219 crisscrossed quite literally 0:29:51.250 --> 0:29:55.780 the locations with the most AIDS, automated external defibrillators, those 0:29:55.780 --> 0:29:57.070 things that hang on the wall 0:29:57.280 --> 0:29:58.420 that you pulled them off the wall 0:29:58.420 --> 0:30:00.940 and someone's having an emergency and they can deliver a 0:30:00.940 --> 0:30:03.700 shock right away. And that, combined with CPR, can really 0:30:03.700 --> 0:30:05.740 help save a lot of lives. But it's got to 0:30:05.740 --> 0:30:06.460 be done quickly. 0:30:06.700 --> 0:30:08.500 Well, we found that the location 0:30:08.500 --> 0:30:11.650 of those things was inversely coordinated with where the cardiac 0:30:11.650 --> 0:30:14.050 arrests were occurring. You guys know where the most common 0:30:14.380 --> 0:30:15.790 location for cardiac arrest are 0:30:15.940 --> 0:30:17.470 in the home. So there 0:30:17.470 --> 0:30:18.160 is a movement 0:30:18.160 --> 0:30:19.180 afoot to 0:30:19.180 --> 0:30:22.360 have more beds and homes. There are certainly we've looked 0:30:22.360 --> 0:30:24.190 at and toyed with the idea of, boy, could we 0:30:24.190 --> 0:30:27.220 work with the automobile industry on having an IED that 0:30:27.220 --> 0:30:30.010 is part of your vehicle's purchase. And it's just equipment. 0:30:30.010 --> 0:30:31.720 You know, you have it in the car. There are 0:30:31.720 --> 0:30:34.180 some really neat technologies that are coming 0:30:34.180 --> 0:30:37.090 online that are linking IEDs 0:30:37.090 --> 0:30:40.030 and making them what's called smart ads, which will actually, 0:30:40.030 --> 0:30:42.760 instead of it just hanging on the wall like a fixture. 0:30:43.030 --> 0:30:44.080 If there's a cardiac 0:30:44.080 --> 0:30:46.870 arrest nearby, that IED would have the ability to be 0:30:46.870 --> 0:30:49.780 monitoring the nine one one system and can alert and 0:30:49.780 --> 0:30:53.410 see someone take me to this location using technology that 0:30:53.410 --> 0:30:55.660 we already have that's in all of our pockets on 0:30:55.660 --> 0:30:58.690 our smartphones. So drone delivery is very exciting. Steve, it's 0:30:58.690 --> 0:31:01.180 one piece of this, but really what it comes down 0:31:01.180 --> 0:31:01.450 to is 0:31:01.450 --> 0:31:05.500 how do we engage bystanders, engage the 0:31:05.500 --> 0:31:09.580 people around the emergency to do something, to see something 0:31:09.580 --> 0:31:11.680 and do something. And if I can just embellish for 0:31:11.680 --> 0:31:13.510 one minute, I want to talk about a topic that's 0:31:13.510 --> 0:31:15.219 very near and dear to my heart, which is to 0:31:15.220 --> 0:31:17.530 stop the bleed initiative because to Stop the Bleed Initiative 0:31:17.530 --> 0:31:19.630 is a program that I've been very involved with at 0:31:19.630 --> 0:31:22.810 the national level. And Stop the Bleed is a program 0:31:22.810 --> 0:31:23.620 that we've really 0:31:23.620 --> 0:31:27.700 focused on not. Just the actions of recognizing 0:31:27.700 --> 0:31:30.070 life threatening hemorrhage and what to do about it, but 0:31:30.070 --> 0:31:32.670 also empowering the public to do something. 0:31:33.010 --> 0:31:33.760 And, you know, what 0:31:33.760 --> 0:31:35.200 we find is that the same 0:31:35.200 --> 0:31:36.820 people who are going to stop to 0:31:36.820 --> 0:31:39.460 do CPR or who are going to stop to put 0:31:39.460 --> 0:31:41.260 an ad on or stop to hold pressure on a 0:31:41.260 --> 0:31:43.719 bleeding wound, these are the same people who are going 0:31:43.720 --> 0:31:45.820 to help jump start your car in the parking lot 0:31:45.970 --> 0:31:49.210 or change your flat tire. These are these civically minded, 0:31:49.210 --> 0:31:50.230 altruistic people. 0:31:50.380 --> 0:31:51.550 They're the helpers. 0:31:51.700 --> 0:31:53.980 So how do we empower the helpers to help and 0:31:53.980 --> 0:31:56.380 how do we use technologies to do that? More a 0:31:56.390 --> 0:31:57.870 more interesting thing. 0:31:57.890 --> 0:31:58.300 I wonder, 0:31:58.300 --> 0:32:01.360 Matt, I've had the opportunity to visit Johns Hopkins a 0:32:01.360 --> 0:32:04.420 number of times, a beautiful facility and in a nice 0:32:04.420 --> 0:32:07.470 part of Baltimore. And I have to ask you, you know, 0:32:07.480 --> 0:32:10.660 Baltimore is an interesting town. There's some areas of absolute 0:32:10.660 --> 0:32:14.530 beauty and there's some really difficult areas of Baltimore. I wonder, 0:32:14.860 --> 0:32:18.040 could you share with us an experience or two that 0:32:18.040 --> 0:32:21.700 you had in Baltimore that really was a deep challenge 0:32:21.700 --> 0:32:24.100 and had to do with some of the areas of 0:32:24.100 --> 0:32:27.070 Baltimore that need some cleaning up. And I'm sure you've 0:32:27.070 --> 0:32:28.900 been in some interesting situations there. 0:32:29.140 --> 0:32:32.790 Yeah, it's it's a hard question, to be quite candid. 0:32:32.800 --> 0:32:35.050 I was not born and raised in Baltimore, but I've 0:32:35.050 --> 0:32:37.300 been here more than half my life. It is my home. 0:32:37.300 --> 0:32:40.750 And Baltimore is a very special place. People who find 0:32:40.750 --> 0:32:43.510 their way to Baltimore for work or academia who live here, 0:32:43.720 --> 0:32:46.570 I have great pride in Baltimore is a city of 0:32:46.570 --> 0:32:50.470 neighborhoods like many other East Coast cities. And the disparities 0:32:50.470 --> 0:32:54.040 in health care or a huge challenge? You have life 0:32:54.040 --> 0:32:57.790 expectancies that can vary upwards of of a decade based 0:32:57.790 --> 0:33:01.080 upon zip codes in a small area. That's, you know, 0:33:01.390 --> 0:33:05.290 some of those challenges that we face in Baltimore revolve 0:33:05.290 --> 0:33:06.550 around a variety 0:33:06.550 --> 0:33:07.510 of issues that are 0:33:07.510 --> 0:33:11.740 finally OK and socially acceptable to talk about from systemic 0:33:11.740 --> 0:33:13.480 racism through health 0:33:13.480 --> 0:33:17.410 care inequities, through years and years of mistrust that that 0:33:17.410 --> 0:33:20.590 is rooted from someplace and it's likely from experiences and 0:33:20.590 --> 0:33:23.410 all those things come together and find themselves in the E.R., 0:33:23.410 --> 0:33:26.890 sometimes not just the E.R. and my hospital, any E.R. 0:33:26.890 --> 0:33:29.740 across the country, because our emergency rooms, our emergency 0:33:29.740 --> 0:33:31.030 departments, our 0:33:31.030 --> 0:33:34.510 society safety net, it doesn't matter to me how many 0:33:34.510 --> 0:33:36.700 zeros in your paycheck and in what side of the 0:33:36.700 --> 0:33:37.810 decimal point those zeros 0:33:37.810 --> 0:33:39.100 are when you walk in that 0:33:39.100 --> 0:33:41.080 E.R.. I'm taking care of you like you're my family. 0:33:41.210 --> 0:33:43.030 That's what that's my oath. And that's what I'm going 0:33:43.030 --> 0:33:44.710 to do. And that's what my colleagues are going to do. 0:33:45.070 --> 0:33:47.620 US getting emergency physician with the hardest part of their job, 0:33:47.620 --> 0:33:50.290 as they will almost certainly tell you, it's telling the parent, 0:33:50.300 --> 0:33:52.060 a parent, that their child has died. 0:33:52.060 --> 0:33:52.930 If I never 0:33:52.930 --> 0:33:54.640 have to do it again, it'll be too soon. It 0:33:54.640 --> 0:33:57.640 is one of the hardest parts of my job. And 0:33:57.760 --> 0:34:00.160 how and why and by what means that happened, whether 0:34:00.160 --> 0:34:04.420 it's intentional violence or an unintentional mishap or an accident 0:34:04.420 --> 0:34:08.320 or flu thing, it's a tragedy nonetheless. But it is 0:34:08.320 --> 0:34:10.479 one of the hardest things that we have to deal 0:34:10.480 --> 0:34:11.830 with in emergency medicine. 0:34:11.830 --> 0:34:12.549 And I would 0:34:12.550 --> 0:34:15.790 say that that isn't necessarily unique to my institution or 0:34:15.790 --> 0:34:18.940 my city, but it's it's a tribute to the hardworking 0:34:18.940 --> 0:34:22.300 emergency physicians that are manning these front lines. And you're right, 0:34:22.540 --> 0:34:24.460 you don't know what's going to come through that door. 0:34:24.670 --> 0:34:27.939 And I find myself driving to work on my clinical shifts, 0:34:27.940 --> 0:34:30.190 going through a little bit of a meditation process and 0:34:30.430 --> 0:34:33.490 preparing myself for what those next eight or 10 hours 0:34:33.489 --> 0:34:36.549 might look like. And knowing that I am there and 0:34:36.550 --> 0:34:39.220 I think back to some of my earliest career mentors 0:34:39.370 --> 0:34:41.680 when I became an EMT in high school, one of 0:34:41.680 --> 0:34:44.529 my history teachers who was an EMT in L.A. I'm 0:34:44.530 --> 0:34:46.210 not from L.A., but he was an EMT in L.A. 0:34:46.210 --> 0:34:48.400 before moving to the East Coast. He looked me square 0:34:48.400 --> 0:34:49.750 in the eye and he said, I know you're going 0:34:49.750 --> 0:34:51.040 to get out there and you do great things. He 0:34:51.040 --> 0:34:55.870 says you just better remember one thing. You're OK. Your 0:34:55.870 --> 0:34:59.460 patient is not. And that has stuck with me my 0:34:59.460 --> 0:34:59.910 entire 0:34:59.910 --> 0:35:01.799 career because 0:35:01.800 --> 0:35:06.480 we're there to take care of others. That being said, violence, 0:35:06.480 --> 0:35:09.090 the trauma associated with violence is, I think, one of 0:35:09.120 --> 0:35:11.580 the things that that maybe some listeners are envisioning right now. 0:35:11.610 --> 0:35:12.810 But it goes beyond that. 0:35:12.810 --> 0:35:16.200 It goes beyond just the gunshot wounds and the assaults. 0:35:16.200 --> 0:35:19.940 It has to do with access to care, preventative medicine, 0:35:19.950 --> 0:35:22.320 preventing diseases like diabetes, 0:35:22.590 --> 0:35:23.610 obesity, 0:35:23.640 --> 0:35:28.589 dealing with nutrition, dealing with education, mentorship. It's all of 0:35:28.590 --> 0:35:30.510 these things that need to happen 0:35:30.780 --> 0:35:32.250 to unravel 0:35:32.460 --> 0:35:33.989 this very complex web that 0:35:33.989 --> 0:35:36.000 has been woven in America's urban environments. 0:35:36.840 --> 0:35:39.860 Well, Dr. Matthew Levy, thank you for joining us today. 0:35:39.870 --> 0:35:42.690 I hope you'll come back because I have a funny feeling. 0:35:43.020 --> 0:35:46.560 We just touched on the absolute outer shell of this subject. 0:35:46.560 --> 0:35:48.660 There's a lot for us to talk about. Thank you 0:35:48.660 --> 0:35:49.560 for joining us today. 0:35:49.590 --> 0:35:51.710 It's my absolute pleasure. Thank you guys so much. 0:35:52.170 --> 0:35:53.580 Matt, how can people follow you? 0:35:54.330 --> 0:35:58.910 My Twitter hashtag is at Dr. Matt Levy DRM levy. 0:35:58.920 --> 0:36:01.560 I'm on there. I'm on LinkedIn as well. My email 0:36:01.560 --> 0:36:05.990 address is just my last name, Levi Levi at JH. 0:36:06.060 --> 0:36:08.450 Am I ready? So those are my big ones. 0:36:08.730 --> 0:36:11.610 Matt, thanks for being with us today. And of course, Dr. Steve, 0:36:11.610 --> 0:36:14.219 as always, my good friend. Thank you for doing this. 0:36:14.250 --> 0:36:18.120 We really appreciate it. We're Still Practicing is produced and 0:36:18.120 --> 0:36:22.319 edited by A.J. Mosley, mastering by Steve Rexburg Music for 0:36:22.320 --> 0:36:25.650 We're Still Practicing as composed and performed by Celeste Anorectic. 0:36:26.100 --> 0:36:28.200 Don't forget the hit that follow button so you don't 0:36:28.200 --> 0:36:31.320 have to hunt around for our next episode. We'll catch 0:36:31.320 --> 0:36:45.920 you next time, everybody. Thanks for joining. From Kerkow media 0:36:46.550 --> 0:36:48.290 media for your mind.