Subcommittee Minutes 01/29/2013 iparAM3111
MAR 1 4 2013 ity
January 29,2013
MINUTES OF THE MEETING OF THE
COLLIER COUNTY PUBLIC SAFETY AUTHORITY
MEDICAL DIRECTORS SUBCOMMITTEE 1
District I
District 2 _
January 29, 2013 District 3
Naples, Florida District
District 5
LET IT BE REMEMBERED, that the Collier County Public Safety Authority—
Medical Directors Subcommittee, having conducted business herein, met on this
date at 6:00 PM in SPECIAL SESSION at the Naples Community Hospital, NCH
Heart Institute Conference Room, Naples, Florida, with the following present:
Chairman: Dr. Robert Tober, Collier County Medical Director
Members: Dr. Jeffrey Panozzo, Medical Director— COPCN
Todd Lupton—Chief Executive Officer - PR
Phil Dutcher—Chief Operating Officer - NCH
Bobby Allen, Paramedic, Collier County EMS
Physicians Regional Hospital: Dr. Eric Eskioglu, Director—Neurovascular Stroke
Dr. Brian Mason, Program Director—Neurovascular
Sandra Shunk— Stroke Coordinator
Dr. Robert Huber
Naples Community Hospital: Dr. Jeffrey J. McCartney, Chief of Neurology
Dr. Matt Bauer—Neurology
Dr. Allen Weiss
Michele Thoman—CNO disc. Cares.
Merna Martian— Stroke Coordinator
Date:
ALSO PRESENT: ;tern#:
Wayne Watson, Deputy Chief, Collier County EMS
Tabatha Butcher, Assistant Chief, Collier County EMS epies to:
Orly Stolts, Chief—North Naples Fire District
Jorge Aguilera—Deputy Chief,EMS —North Naples Fire District
Janet Vasey, PSA
January 29,2013
CALL TO ORDER:
Dr.Robert Tober called the meeting to order at 6:30PM.
PURPOSE:
Discussion of what protocol,from a pre-hospital standpoint,will be agreed upon
between the two hospital systems, i.e.,NCH/Collier County EMS and Physicians
Regional Hospital
Dr.Robert Tober,Medical Director for the Transport Pre-Hospital program for Naples/
Collier County EMS, stated he is trying to find the accord for the Protocol to move forward.
He noted he is a member of the faculty of the University of Miami/Leonard M.Miller School
of Medicine.
He responded to one of the questions asked by Dr.Mason, PRHS.
• The University does not accept LAMS scoring as a dependable criteria for moving
patients to or from a sick for stroke to a primary versus comprehensive.
• The largest segment of Broward County is under the medical direction of Dr.Nabil
El Sanadi and 62%of Broward's EMS does not follow LAMS Scoring.
• The Protocol written in November,2012 is as close as possible to the"middle of
the road"of accepted science
• The Protocol followed by Collier's EMS: conduct a fast exam with the ability
to score people pursuant to the LAMS scoring.
He noted an area of controversy, i.e.,Collier County EMS is utilizing LAMS scoring but is
not yet taking action based solely on LAMS scores.
He referred to Assessment 4, "Intracranial Hemorrhage Assessment,"of the handout and
stated if a Paramedics checks"Yes" in any of the four boxes outlined,he/she will contact
the ER for consultation for a decision, i.e.,to come to the closest facility or go to the
Comprehensive Stroke Center.
Dr.Tober referenced "IV t-PA Exclusion Criteria"stating it was standard except for the
second box: "Patient on an anticoagulant other than Coumadin (warfarin), i.e., Pradaxa
(dabigatran), Heparin Lovenox(enoxaparin),Xarelto (rivaroxaban), or Fragmin (dalteparin),
would be transported directly to a Comprehensive Stroke Center."
He further stated if the patient had any of the IV t-PA Exclusion Criteria,he/she would be
transported directly to Physicians Regional.
He reiterated that he had called many places and the same Protocol is being followed—many
are not yet scoring using LAMS Scoring. However,he decided to include it in Collier's
Protocol to utilize the score retrospectively to decide and try to validate it in our community.
He noted the Miller School of Medicine is not endorsing LAMS Scoring protocol and a large
portion of Miami-Dade County is not using it.
Dr.Brian Mason disagreed stating LAMS Scoring is being used to"stratify the patient"to
get him/her to the appropriate center. He noted an addition had been made to the criteria,
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i.e., "Stop at the primary stroke center for a Coumadin draw." He cited the American
Stroke Association's t-PA Guidelines which do not specify a level,only if the level is greater
than 1.7. The guidelines to not recommend stopping at a center to check the INR and if it is
less,IV t-PA can be given. But that may be only one in ten patients. He cautioned that
the other nine patients might be sacrificed by the stop in the ER.
Dr.Tober stated he put the Neurologists together because he did not write the sentence in
question—it was created in the Department of Neurology. The goal is to obtain everyone's
input to write a Protocol that has everyone's approval and agreement.
He added the Miller School of Medicine remains the primary educational arm of pre-hospital
care in Miami and the curriculum does not include teaching LAMS Scoring.
Dr.Matt Bauer directed his comment to Dr.Mason and stated he was not familiar with the
data concerning stroke and patients on Coumadin. He asked if 9 out 10 people are above 1.7—
was that a study result.
Dr. Mason: "So you want to be responsible for people who stop at your institution who
are on Coumadin and you draw on them if its 1.8 and then you call to transfer
that patient and you'd rather do that than ...."
(Note: Multiple responses were given—over speak—unable to separate comments.)
Dr. Mason cited an example of a stroke patient who was delayed for six hours before he
received treatment and the result was catastrophic for the patient. He stated Dr. Eskioglu
recently treatment a patient with a level of 1.8 who was transferred over and recovered.
Dr.Mason: "We are talking about human beings. I would prefer that NCH send higher
rate IV t-PA patients to us because we have the ability to give IV t-PA and
save that patient's life in our hospital. "
Dr.Allen Weiss asked what the majority of the 67 counties in the State of Florida were
doing currently.
Dr.Mason replied the majority to not have comprehensive stroke center. He explained
the guideline stated"If a patient is over age 85 and is on Coumadin, it is contra-indicated
to use t-PA irrespective of INR." He further stated if the patient is over three hours,he/she
does not receive t-PA. Outside of the three-hour window,the patient would come to NCH.
Dr. Weiss stated he did not think the guideline was appropriate and if a patient was on
Coumadin,he/she should come to Physicians Regional Hospital.
Dr. Mason agreed stating the Protocol was adding layers to layers,making it more complex
to treat the patient.
Dr. Weiss stated he viewed the form from an EMS standpoint;"it is complex."
Q. (AW) "What's the problem with adding one more layer. What is the problem in triaging a
stroke patient to the stoke center where a physician can make the decision [regarding
treatment]?"
Dr. Mason replied that it wastes time.
( Q. (AW) "How much time to you need to get your Cath Lab ready?"
A. (BM)"Half an hour."
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Dr.Mason stated he and Eric had ample data due to their involvement with massive strokes.
He was concerned that up to an hour could be lost.
Dr. Weiss noted NCH has a turn-around time of under sixty minutes. It takes a half-hour
to get the lab ready and—by the time the patient comes in and we go the labs and get the
labs to you and decide if the patient is a candidate or not.
Dr. Mason: "That means I won't know about the patient for ..."
Dr. Weiss: "We can get the information to the whole community while triaging the patient
at a location that it closest to him/her. It's a cooperative net for the entire
community."
Dr. Mason stated it was the same argument that was discussed by the Florida Stroke Council
four years ago. Triaging of patients doesn't work.
Dr.Mason: "It doesn't work, Dr. Weiss,this is not the standard of care and I would ask you
to find a place that does that."
Dr.Weiss reiterated NCH could get a patient into a Cath Lab under sixty minutes.
Dr. Mason: "I can tell you that the last patient I had who was in a situation like this did not
get that treatment for six hours—he showed up in our hospital at 9:00—and ..."
(Overlapping dialogue—comments were not clearly understood
(The minute taker requested only one speaker at a time for the sake of clarity.)
Dr.Weiss: "That's because we are not coordinated. This is a perfect place to get
coordinated."
It was suggested to address items one at a time; LA Motor Scale was chosen to be first.
Dr.Jeffrey Panozzo: "Since this is a PSA Medical Subcommittee,what I'd like you
to do is tell us exactly what is your perspective on these key items
... the LA Motor Scale/Coumadin issue. And then,also,Dr. Weiss,
you just presented adding a rapid Protocol which seems like a
reasonable idea as well. That's why we're here—for the expertise—
for you to tell us the essence of each of those items."
Dr.Mason: "I want to concentrate on the LA Motor Scale—those are the patients who
have a higher LA Motor Scale—those are the ones who have big clots and
don't respond well to IV t-PA. Only about 20%of patients respond well to
IV t-PA—those are the patients who are known to need further intervention."
"It is well accepted that LA Motor Scale correlates really well within our
stroke scale—which correlates with the eventual patient outcome. The
higher the stroke scale,the higher LA Motor Scale—the less likely t-PA will
be effective. Those are the areas where Eric and I come in handy—those are
the ones in which we can truly make a big difference. And when we get a
patient in our institution,we don't just use the imaging that you guys use—
we have CT Profusion Data which helps decide if we are going to do a study
on the patient or not... a procedure on the patient or not. A far as I know,
NCH does not have CT Profusion Imaging. And we did a Profusion Data to
basically find out what the infarc' size is and Eric and I will look at these
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things by the machine and we make a decision based on the Profusion Data—
not by the hour—we don't go by the clock,Matt,and I'd like to state that we
have successfully treated patients up to 12 hours using the Profusion Data.
That was a transfer by Med Flight from a hospital.
What we don't want to do is open the blood vessels to the patient's dead
brain tissue so we can have a bleed in the brain while on our table.
The LA Motor scale is well accepted and I'd like to talk about that. The LA
Motor Scale is where important patient fall under. Is it a big stroke? If it's a
big stroke,the patient needs to be in a comprehensive stroke center. If it's a
minor to moderate stroke, by all means, go to the closest place. No
arguments with that whatsoever. We all want what's best for the patient. I
can't understand how you can argue to the opposite. There's just no
argument against it—there's no literature for it ... "
Dr.Panozzo: "What are the data on patient outcomes with your clot retrieval and Profusion
Data—ultimate outcome on these patients? What is—it is this approved ... it
is established? Do we have outcome data on these procedures?"
Dr.Eric Eskiglu: "This is still an ongoing field as you know—the same thing was said when
cardiologists started doing—we have a big cardiology group here—again, a
lot of data is being done. If you look at UCLA data—the David Geffen
School of Medicine at UCLA is the largest medical school in Los Angeles
and has the largest stroke center. They take every patient that comes in
with acute stroke into the intravascular suite. They bypass ...
Dr.Panozzo: "This is an academic center."
Dr.Eskiglu: "This is an academic center and it is still gathering research and data. It's
up to the County to decide if it wants to be an early adopter.—this is a
science that's been about eight years in the making. In Europe,this is all
they do. They don't even give IV t-PA in Germany. But this is an accurate
science. The reason why the adoption rates are low is because there are not
enough people doing it. We don't have enough cardiologists. We don't have
enough intravascular people. One of your colleagues,Dr.Malik, is doing it—
you trained with him."
Dr.Matt Bauer: "I trained at a place where we had interventional neuroradiology and
interventional merit surgery and we searched and searched for patients who
were appropriate for the studies. We were very aggressive with the treatment
of this and you know I am in total agreement with this practice. I love having
you guys here and I think you are a wonderful resource. What I want to make
sure is that we do it on the appropriate patients ... that we get the patients who
need `standard' Standard of Care and if we have patients who need above
Standard of Care that we get them the best Standard of Care in the quickest and
most rapid fashion. I think—if I'm wrong,correct me—the purpose of this is
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to try to help EMS decide—it's not what to do—it's to try to help EMS decide
where to take these patients in the most effective, efficient way ... and utilize
our EMS resources in the best possible way."
"Getting back to the study on the LAMS—the study that sort of endorses this—
is that the one study on stroke ..Is that right?"
Dr. Mason: "Yes."
Dr.Bauer: "So there's some literature but these are small numbers of studies—correct?"
Dr.Mason: "They are pretty well accepted—they are established ..."
Dr.Bauer: "Are they big studies with a large number of patients? Are these studies of
500 patients, 300 patients or 78 patients?"
Dr. Mason: "They are published in stroke literature ... they don't publish ... I mean,this
is not based on 50 people.
Dr.Bauer: "Sometimes they do—and they say, 'this is a study that requires further ...'
Dr.Mason: "Most of the time,these are generated by EMS field and they are correlated
to the NI Stroke Scales, so they usually have one to two thousand patients."
Dr.Weiss: "These are pretty significant numbers."
Dr. Bauer: "In my nearly twelve years of practice here in this community,the number of
patients that are acceptable candidates for intervention—I mean,when you
think about these things—even before you were here,there were radiologists
here that did the same thing—it's a very small number compared to the
number of strokes that we see. For you,your perspective differs. You are,
essentially,a tertiary group and you are looking to bring in more patients
from everywhere and help the patients of southwest Florida.
"You have a selection bias. You are getting patients who are candidates for
your procedures. From my standpoint, I have seen a broader range over the
past twelve years and I don't see many patients who are candidates for it by
the time they get to the Emergency Room. That may change."
Dr.Mason: "Correct me if I'm wrong over that—but recent EMS Guidelines have a two-
hour window which is not the standard anywhere as far as I know—you may
have a two-hour window from the time of onset which is technically—but
two hours,there's no way."
Dr. Tober: "EMS wanted to get the patient within two hours of a stroke because they
knew that they needed another hour once they got the patient to hospital."
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Dr.Mason: "That's not correct. Even the Department of Health's internet site tells you
cast a wider net to four hours and let the doctor decide."
Dr.Tober: "We are doing that now, but I mean ...
Dr.Mason: "You were talking about treating patients but you weren't getting those
patients."
Dr. Tober: "Sure we were. We are transporting all the stroke patients."
Dr.Mason: "You are not calling a Stoke Alert—that's for sure."
Dr.Panozzo: "We heard about it. We hear about every stroke when they get to the Emergency
Room."
Dr.Mason: "Okay."
Dr.Bauer: "And even more so now because you guys have done a great job of educating
the community and the ER physicians—they know there's that availability.
So if they get a stroke and they know it's 2 '/z hours to 2 hours and 55 minutes
where they would normally say, "Well, I have a little bit of time and I know
they're not going to get t-PA anyway,' they are on edge—they are enthusiastic
—they're want to—the ER docs are onboard with this—they want what is best
for the patients."
Dr.Eskioglu: "What are your"IV t-PA"ratios?
Dr.Panozzo: "Are you are asking about the proportion of patients who were candidates for
t-PA who received t-PA or the number of patients who ...?"
Dr.Eskioglu: "The percentage of stroke patients who receive t-PA."
Merna Martian: "I am in the process of doing those numbers. I would say we're in the ten to
twenty percent range."
Dr.Mason: "That's a really wide range."
Merna Martian: "I am just in the process of compiling those numbers and I don't want to give
you an inaccurate number. What I would like to know is—something that I
would really like to know is the names of those patients who were transferred
to you because I want to follow up if they were six hours. But I can tell you
that I did follow-up on the one patient that was sent over that, apparently,you
got up to the warning floor and I can tell you that patient was sent over within
... by three hours. We did the CTA as you requested and we gave the `cryo'
that you requested before the patient was sent, so the patient was there much
prior to six hours."
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Dr.Eskioglu: "Our numbers are out there because we are part of a Joint Commission
Study for competent stroke as you known and we're one of the Centers .
Our IV t-PA ratio for December was 29%and now it's about 26.5%. We
are very aggressive with IV t-PA. I don't accept the notion that you guys
have a very narrow scope. We don't and what we're trying to do is for the
EMS to stratify these patients these patients so they don't all get put in one
bucket. If you get IV t-PA and the Center decides you are not a candidate,
then you go to the next place and lose time."
"We,by no means,want all the IV t-PA patients. I can tell you we don't
have the capability—our CEO is here—and that's not the goal. Our goal
is to get the best treatment for the patients in this area and the surrounding
communities. If they are close to downtown NCH—they're from Port
Royal—and they fit the IV t-PA criteria,they should go to NCH. There is
no reason to waste time by bringing them to our facility. If someone
doesn't fit the criteria—I see subarachnoid hemorrhage on the list—when
was the last time you ..."
Bobby Allen: "They get transferred directly out of the Emergency Room generally..."
Dr.Eskioglu: " ... why would be bring a subarachnoid hemorrhage to your facility when
you know that you don't treat subarachnoid hemorrhage?"
Dr.McCartney: "I am the Chief of Neurology. We sent you a letter and we conceded to you
subarachnoid hemorrhages that could be clearly identified in the field. We
conceded those to you. There is no reason to talk about subarachnoid
hemorrhage."
Dr.Mason: "If you look in the Destination Protocol, it says you have to consult the ER
if it's a .... (unintelligible) ..
Dr.Tober: "Because I wrote that in there."
Dr.Mason: "Why"
Dr.Tober: "Because once the paramedic picks it up,they load the patient, and it takes
them thirty seconds to call the ER—let's say they are already in Port Royal—
give the ER a `heads up' about what they've got—let them talk to an ER
doctor downtown and corroborate with that ER doctor if they want them to
bypass the primary center and come to you."
"I wrote it as conservatively as I could. It's right there."
Dr.Mason: "Is that practical, do you think?"
Dr.Tober: "Yes, I think it's very practical. We make a lot of decisions that .. ."
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Dr.Mason: " `Cause I got two subarachnoid hemorrhages and the woman died because we
were too late."
Dr.Tober: "This Protocol has even been activated yet."
Dr.Eskioglu: "This Protocol is pointing to getting the subarachnoid hemorrhages to NCH as
primary ..."
Dr. Tober: "No, not really. Assessment Four calls to the attention of the Paramedic that
if they checked one of those four boxes,they are to call the ER to let them
know what they have—if they're very close to NCH and run it by the ER
doctor there and say, 'this is what I've got—do you want me to bypass you
and go directly to Physicians Regional?' That's what it means and we do this
all the time with patients. I'm try to ... I have a ... I have a huge..."
Dr.Mason: "I haven't heard of this ..."
Dr.Tober: "You haven't heard it yet because I haven't released it."
Dr.Mason: "I know,but where it is being done like this in the rest of the country? I
mean, I've never heard of this. You do things that really delay care and add
time. Did you ask an ED Physician because you're adding liability to
something that's life and death. Did you even ask them about that? If they
want that?"
Dr. Tober: "There are many places, including 62%of Broward County,that are not
checking these boxes and taking everybody to the closest primary stroke
center. The ER doctors are ferreting them out and then sending them to a
comprehensive."
Dr.Mason: "Is that good medicine?"
Dr. Tober: "Well, I don't know that anybody knows absolutely..positively .. what is the
right thing to do. That's why I'm trying to put you all together to come to an
accord."
Dr.Eskioglu: "For a ruptured aneurysm,the Standard of Care has not ..."
Dr. Tober: "You cannot expect the rank and file Paramedic working in our system to
necessarily make that diagnosis accurately and(to the participants) -- Speak
up if you think differently about that."
Dr.McCartney: "We concede to your organization a patient with a classic thunder-clamp
headache, stiff neck,plus neurologic deficits—that should go to Physicians
Regional straight away."
Dr.Eskioglu: "That's not happening according to this sheet because they have to stop to
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call your NCH/ER and ER physicians really don't treat these patients because
there is no treatment of subarachnoid hemorrhages at NCH."
Dr. Tober: "They certainly can recognize, based upon the paramedic's findings, and
move the patient accordingly. We've done this—I've been doing this for 35
years here."
Dr. Mason: "Can you give me an example of what would prompt an ER physician at NCH
to tell a paramedic to turn around even though NCH is closer. Because why?"
Dr.Tober: "To turn around or proceed for the very reasons that the paramedic reads one
of the assessments in Box 4 and finds the patient to be in that state—let him
share that decision with the ER."
Dr.Mason: "I'm just asking what would prompt your ED physician to tell the paramedic
to turn around and come to Physicians Regional? What would prompt him to
say that? I'm just looking for an excuse and that's ... you're saying that you
want to be sure the paramedic is bringing the patient to PRHS"
Dr. Tober: "Something these things—I guess,Brian,they're not cut and dry—they're not
black-and-white answers ... they're grey ..."
Dr. Mason: "I would like to know what you have—obviously you have some medical
knowledge that we don't know—what would cause an ER physician to tell a
paramedic to come to my place with those symptoms? I'm just kind of
curious. Maybe we didn't think of any."
Dr. Tober: "I can't speak accurately off the top of my head ..."
Dr.Mason: "What I see is—you trying to get control of the patient to NCH. That's all
you're trying to—
Dr. Tober: "That is clearly not ..."
Dr. Mason: "This is not medically motivated. There is no medical science behind this—
there is no medical reason behind this. Honestly, if I were an ER physician
I'd be angry because that places those guys at liability by doing that."
Dr. McCartney: "Let me say this to you. It's clear that you guys are trying to get all the
patients—it's the old cliché, 7f the only tool you have in your tool box is a
hammer—and especially if it's a very expensive hammer—then everything
starts to look like nails.' "
Dr.Mason: "I really disagree with that thought."
Dr.McCartney: "You're free to disagree with me."
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Dr. Mason: "Feel free to disagree with me. Fortunately,medical science is behind us and
nothing else."
Dr.McCartney: "I'm not sure that medical science is behind you.
Dr.Mason: "Yes ..."
Dr.McCartney: "The stuff you're doing is not FDA approved. We have no knowledge of your
outcomes. I have some anecdotal knowledge of outcomes that are not very
complimentary to Physicians Regional."
Dr.Eskioglu: "I already told you that we're reporting everything to the Joint Commission—
all outcomes are out there ... okay? We do have complications like
everybody else,what you're saying as not really flattering,but we report
every outcome to the Joint Commission. And we're on the Comprehensive
Pilot Study—I don't think you've heard that. And we are one of the Centers
in the country and we have to report every outcome to the Joint Commission."
Dr.Mason: "Do you report your outcomes externally, sir?"
Dr.McCartney: "Yes,we do."
Dr.Mason: "Where?"
Dr.McCartney: "We have organizations that rate our outcomes for stroke ..."
Dr.Mason: "No—do you report JACO as a public transparent results?
Several responses: "Yes we do ..to 'Get with the Guidelines' ... we're members of 'Get with the
Guidelines'. "
Dr.Mason: "I don't know. There's 'Get with the Guidelines—Internal' and there's
'Get with the Guidelines—External'. Are you reporting externally so it can
be seen publically—what your treatment rates are and what your outcome
rates are? Yes or no?"
Merna Martian: "We report to 'Get with the Guidelines' —we use the standard extraction tools
—we report just as we're required to ..."
Dr.Mason: "No ... no ... no ..."
Merna Martian: "... as well. We are reporting to CMS—starting in January of this year as
everyone is required to,the four measures for stroke. So,yes,we are
reporting."
( Dr.Weiss: "We are a community hospital—we are not an academic center even though
we are affiliated with Mayo, so we want to do things that are reasonable,
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appropriate and good for the community. I think there is actually an
opportunity for all of us to work much better together than we have been in
the past. And one of the ways is to develop a Joint Protocol. Patients could
get screen quickly in one of the four hospitals and then sent appropriately to
wherever they should go."
Dr. Panozzo: "I think what we should do is shut the PSA Medical Director's meeting down
at this point since this is a publically reported meeting and the minutes are
ongoing. I will no longer participate but I will remain in the room. I think
this group should continue what they're doing right now for the good of our
community. But I think it would be wise at this point if we shut the
subcommittee down."
Dr.Tober: "I don't have strong feelings one way or the other. The Medical Subcommittee
decided that we needed this meeting so that both neurologic teams could come
together and,hopefully,have a meeting of the minds. That was the only
purpose of this meeting. Whether or not this is public or private I think is a
decision between Allen and Todd Lupton. I don't know. Do you want to
continue this as a public discussion or do you want to shut it down?"
Dr. Panozzo: "I will no longer participate—I will continue to remain in here but we should
shut the minutes down right now."
"I agree with you—the discussion is vital—the community depends on us to
get together. We have to throw aside whatever personal thoughts and come
together. There are some good ideas that I have heard—I like the rapid
sequencing a lot. We can do something like that. Let's solve the problem.
But you are the Chair."
Dr.Tober: "Yes,and as Chair of the Subcommittee,I don't have an issue with continuing—
open or closed. I don't really care. My goal is the same as yours,Jeff,and that
is to come to an accord here so that I can create these Protocols."
Dr. Panozzo: "I just don't think we should discuss cases ..."
Dr.Weiss: "I agree with you—we need to have a discussion. It's going to help everybody
look for a solution—ultimately,we want to get this done"
Dr.McCartney: I agree. It's"Modus Vivendi."
[Definition of modus vivendi (n):
1. compromise: a practical arrangement that allows conflicting people,
groups, or ideas to coexist in the same community]
Dr. Tober: "What we would like to do is adjourn the Medical Subcommittee of the PSA
( but continue the reason for this meeting—to try to come to accord."
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Discussion ensued between members of the Public Safety Authority concerning whether or not
they could remain in the room. It was decided they could remain but could not participate in the
meeting by voicing an opinion regarding the proceedings or the topics.
(7:10 PM)
(Note: The transcriber was requested to stop the verbatim recording but to remain and take
notes.)
Dr. Tober stated under the existing protocols, paramedics are able to call the ER
physician as necessary since all patients are potentially unstable. The same
encouragement would continue under any new protocols. He admitted the ensuing
discussion could be complicated.
He stated his thought was to schedule a meeting where the stroke specialists from both
facilities could come together to draft a protocol.
Dr.McCartney concurred that you can't expect a paramedic to make diagnoses in the
field. It was conceding the obvious by encouraging the phone call to the ER physician.
Suggestion: Delete the phrase"Possible Intracranial Hemorrhage"from Assessment#3.
Consensus: Unanimous support for the revision.
Dr.Mason suggested scheduling conversations every 3 months to present patient studies
and outcome.
He stated he could re-assess his previous position. He was aware that people in the
community will always stop at the closest available ER. He will review the statistics with
patient safety as the key component.
He reiterated that Physicians Regional cannot handle all the patients in Collier County.
Only those that fit the criteria should be directed to his facility.
• It was noted an article in a medical publication on stroke in 2012 stated 32%of
patients are over-triaged.
• Nationwide literature indicates over-triaging is acceptable by a margin of 36%
Dr.Mason suggested writing a paper.
Discussion of Triage Protocols within the State of Florida:
• EMS field personnel can declare a Stroke Alert if the patient meets the criteria.
• Dr.Mason reiterated asking a paramedic to make a decision in the field
concerning potential, in some cases, can delay treatment.
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January 29,2013
• Dr. Tober stated the protocols in use have been developed over the past 15
years and are revised when necessary
Discussion of LAMS Scoring:
• Dr.McCartney stated it was not a tool
• Dr.Mason reiterated in the matter of public safety,there is scientifically proven
data to support its use
• It was suggested the LA Motor Scale/Coumadin issue should be addressed
• A starting point was suggested: if a patient is not better within 30 minutes,the
patient is transported to the closest ER for further evaluation.
• Dr. Mason stated he wants NCH to catch the patient who would benefit from
Physician Regional's services. He wants to find patients who need PRHS the
most.
• Dr. Tober stated the LAMS Scoring is new—he asked if the transportation
destination should be modified based on LAMS Scoring.
• Suggestion: Form a Q/A Committee:
o Review available data and discuss outcomes
• Meet monthly
• Adjust goals as appropriate
o Track patients can be tracked
o Meet monthly
o Make recommendations to the two neurology teams.
• Dr.Tober asked if a conservative LAMS Score was 5 or higher.
• Dr.Mason suggested 4, but to review in three months.
• Dr.Tober suggested if a patient presented with a LAMS of 4 or greater,he/she
will be immediately transported directly to the Comprehensive Stroke Center.
• An objection was noted: If the pre-hospital screening criteria is changed to
LAMS,it can never be reversed.
o Dr.Tober reiterated the protocols are frequently revised as needed.
• Dr. Panozzo supported teaching paramedics and recommended intensive in-
service. He agreed paramedics should be encouraged to call the ER to alert to
the type of patient being transported.
• Dr.Bauer stated he would support,on a trial basis only,utilizing a LAMS
score of 4 of higher to transport directly to PRHS. He also supported reviewing
the data in four months.
• Dr.Eskioglu agreed stating the protocol would be adjusted.
• Dr. Tober noted zip codes could be utilized to track outcomes based on LAMS
scores.
Consensus: The Subcommittee will meet in April to present cases and discuss
data.
(7:45 PM)
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•
January 29,2013
COLLIER COUNTY PUBLIC SAFETY
AUTHORITY—MEDICAL DIRECTORS
SUBCOMMITTEE
Robert Tober, 1 I,r airman
The Minutes were approved by the Chair on Q 1 ,2013
"as presented" [\ I r�1J
OR "as amended" [_].
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