Barsan Emergency Medicine Research Symposium 2023 - Nate Hunt presentation

1. A Comprehensive Experience Contesting
COVID-19: Perspectives from a University-
Based Critical Care EMS Service
Barsan Research Day
April 13, 2023
Nate Hunt, MD
Clinical Assistant Professor
Department of Emergency Medicine
Division of EMS
University of Michigan

2. Disclosures
• None Relevant

3. Thanks
• Spencer Masiewicz
• Christine M. Brent
• Graham C. Smith
• Brendan T Byrne
• Mark J. Lowell
• W. David Sadler
• Edward Adelmann
• Johnnie Peoples
• Mary Sabados
• James A. Cranford
• Survival Flight
• Metro Aviation
• EMS at large
• All of you
• Barsan Research Forum Crew

4. This is a story…

5. A History of COVID-19 (Abbreviated)
• Discovered late 2019
• In the US early 2020
• Michigan Declaration of Public Health Emergency: March 10, 2020
• Survival Flight’s 1st transport: March 13, 2020

6. Changes to Procedures

7. COVID Transports
• Retrospective analysis of 127 cases
• March 10 – December 31, 2020
• Only patients transported to UM
• COVID Positive:
• positive PCR test by a referring hospital prior to transport
• person under investigation (PUI) without PCR test obtained prior to transport who then had a positive
test within two days following transport
• person who had a negative PCR test prior to transport but in whom suspicion was high enough to treat
them as a PUI and then subsequently had a positive PCR test within 2 days following transport

8. COVID Transports

9. Demographics
• Average age: 47.6 years
• Range (16-83)
• 57.5% were male
Comorbidity Prevalence
Hypertension 52.0%
Obesity 42.7%
Diabetes Mellitus 34.6%
Hyperlipidemia 15.7%
Asthma 15.7%
Obstructive Sleep Apnea 12.6%
Chronic Kidney Disease 7.1%
Coronary Artery Disease 7.1%
Chronic Obstructive Pulmonary Disease 5.5%
Atrial Fibrillation 5.5%
Congestive Heart Failure 4.7%

10. ARDS and Respiratory Support
ARDS Severity Scale for Intubated
Patients
Severity Frequency (n) Percent (%)
1 Mild 11 10.4
2 Moderate 28 26.4
3 Severe 67 63.2
• All but 9 patients were intubated
• 42.5% of patients required intervention by
flight crew
• Escalation of O2 device (e.g. NRB to
BiPAP), ventilator management beyond
tidal volume, respiratory rate, or FiO2

11. Nitric Oxide
Nitric - No 10 (15.6) 19 (29.7) 35 (54.7)
Nitric - Yes 1 (2.4) 9 (21.4) 32 (76.2)
• 46 (36.2%) patients were
either on or had Nitric
started
• ARDS severity was more
likely to be severe

12. Vasopressors
Vasopressors -
No 5 (10.0) 13 (26.0) 32 (64.0)
Vasopressors - 1 3 (7.0) 11 (25.6) 29 (67.4)
Vasopressors -
2+ 3 (23.1) 4 (30.8) 6 (46.2)
• 64 (50.4%) patients
required at least one
vasopressor
• Norepinephrine was
most common
• 13 (10.2%) required at
least 2 vasopressors
• No correlation
between ARDS severity
and need for pressors

13. ECMO
ECMO - No 9 (10.7) 24 (28.6) 51 (60.7)
ECMO - Yes 2 (10.5) 4 (21.1) 13 (68.4)
• 23 (18.1%) patients on
ECMO for transport
• ARDS severity higher for
those on ECMO

14. Mortality
Survived 7 (63.6) 20 (71.4) 35 (54.7)
Expired 4 (36.4) 8 (28.6) 29 (45.3)
• 52 (41.9%) died
• Mean age was higher
• More likely to be male
• Mortality was higher
in “Severe” ARDS –
not statistically
significant (ARDS
severity at time of
transport)
• No deaths during
transport

15. Mortality by Intervention Variable Survived Expired
Total 72 (56.7) 52 (40.9)
Oxygen Support
Oxygen - HFNC 1 (50) 1 (50)
Oxygen -
Intubated 66 (57.4) 49 (42.6)
Oxygen - NC 2 (66.7) 1 (33.3)
Oxygen - NRB 2 (66.7) 1 (33.3)
Oxygen - RA 1 (100) 0
Nitric Oxide Use
Nitric - No 49 (61.3) 31 (38.8)
Nitric - Yes 23 (52.3) 21 (47.7)
Vasopressor Use
Vasopressors -
No 37 (59.7) 25 (40.3)
Vasopressors - 1 29 (59.2) 20 (40.8)
Vasopressors - 2+ 6 (46.2) 7 (53.8)
ECMO Use
ECMO - No 64 (64.0) 36 (36.0)
ECMO - Yes 8 (34.8) 15 (65.2)
• Mortality higher for patients requiring nitric
• Mortality higher for patients on ECMO
• Mortality higher for patient on 2+ pressors

16. Care Times (Cumulative)
• Mean cumulative transport
time: 137 min (43-290 min)
• Longer for intubated
patients (mean 71 min)
• If also on nitric, longer still
(mean 84.8 min)

17. Immeasurable Factors

18. Conclusions
• COVID-19 pandemic brought many challenges
• Rapid and ever-changing processes and treatment changes (+ and -)
• High level of baseline knowledge and expertise among nurses
• Continued support and education from physicians and specialists
• Able to provide high level of care to extremely sick patient population
requiring intensive bedside and en route care
• Critical care transport played a significant role in definitive care and
will be a necessary part of future large-scale events

19. Picture References
• https://ntvb.tmsimg.com/assets/p7896434_b_h12_aa.jpg?w=960&h=540
• https://www.fda.gov/files/covid19-1600x900.jpg
• https://medicine.umich.edu/sites/default/files/uofm72314b.jpg
• https://static.grainger.com/rp/s/is/image/Grainger/3EZK5_AS01?$adapimg$&hei
=536&wid=536
• https://image.made-in-china.com/2f0j00DwBagZTsbnzU/Custom-Fashionable-
Men-Medical-Scrubs-Nurse-Uniforms-for-Hospital-Workers.jpg
• https://media.istockphoto.com/id/1254418573/photo/symbolic-scales-of-the-
stones-against-the-sea-pros-and-cons-
concept.jpg?s=612x612&w=0&k=20&c=gEh-QMtaEmdPmsmq6aIAc-
Gm4PQPvOlI0a6bRqsxlO8=
• https://www.mmhealth.org/wp-content/uploads/Sick-Man-Web.jpg
• https://cdn.britannica.com/73/191073-050-BCEB0132/reaper-death.jpg

20. Questions?
Nate Hunt
nateryan@med.umich.edu