A recent open label, multicenter study of flecainide acetate oral inhalation solution for acute conversion of recent-onset, symptomatic atrial fibrillation to sinus rhythm has thus far yielded favorable results. The hypothesis tested was that inhaled flecainide could quickly reach plasma concentrations necessary to restore sinus rhythm. This would reduce the number of AF induced strokes.

In the study, susceptible patients self-administered the flecainide. ECG’s and plasma concentrations of the drug were obtained, and the patient was followed for four hours with a Holter monitor to determine what adverse cardiac effects might occur. The side effects were typically mild and transient, none required treatment, and all resolved without issue. The most common side effect was a cough.

Flecainide is a potent sodium channel blocker. The advantage of using the FlecIH version is that intravenous dosing requires hospitalization and close monitoring. The PO version of the drug is extremely slow acting. Getting the FlecIH into the lungs rapidly introduces it to the heart via the pulmonary venous circulation. This flows into the left atrium, where atrial fib often occurs. This more direct route allows for reaching the therapeutic plasma levels faster with a lower concentration of the drug than is used intravenously or orally. 50% of AF was converted within 90 minutes, but most of that conversion occurred in just over 8 minutes. Being able to convert stroke inducing AF to a sinus rhythm that quickly will have a major patient care impact.

Initially, as an emergency department medication, this should result in shorter ED stays and fewer hospitalizations. The drug is expected to move into pre-hospital care shortly after it’s introduction.

I was reading a commentary a week or so ago, written by Kevin Powell, MD, PhD about getting the science right. Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant. He made a few very salient points about pediatrics and medicine in general that the same topics in EMS track with.

Powell states that “time and time again, I come back to the conclusion that, in the modern era, the second-most important thing to do is to get the science right.” He makes the point that science that supports medicine has always had flaws, but that it was better than the other options. Historically, the science was occasionally so sketchy that the key was to believe whatever the shaman was suggesting. In the last 100 years, science, rather than tradition has been relied upon to guide policy and action. For the past 50 years, evidence-based medicine has progressed, creating better standards. This is particularly true for EMS.

So, if you are wondering about the “first” most important thing, it should be self-evident. Commitment to caring for the sick, having the dedication to always supply that care is the most important thing in EMS. Part of what fuels that commitment is a belief that what you do on each call is making a difference. That belief is stronger when there is measurable, empirical evidence that the therapeutic modalities that you are using are making a difference in the overall survival of the patient.

But commitment to care is not enough. (Whoa, did I say that out loud?) The idea being we must go beyond that point. First, we must understand the science. Just doing something because it is in a protocol/delegated order that you can regurgitate is not being your best. To pivot from technician to clinician you must understand the underlying scientific basis for all of it. Yes, all of it.

Second, stop seeing things from an ‘immediate survival of the patient’ standpoint. Think instead of the patient’s disability. In doing so, your focus shifts more to the overall impact your patient care is making. If disability is your concern, you are thinking beyond the patient’s immediate survival. Our goal needs to be providing the patient to the next level of provider in optimal condition to facilitate that reduction of disability. A perfect example of this is the treatment and destination choice for a stroke victim or polytrauma patient.

This also illustrates my third thought. There are many things that we as pre-hospital care providers, can do or fail to do just once in the care of a patient that is the deciding factor in whether the patient recovers, or experiences a lethal outcome. The old adage, “You don’t know what you don’t know” comes into play here. Knowing the science prevents this.

I spent several years serving as the clinical coordinator for a hospital-based EMS system. During that period, we undertook a massive re-writing of our patient treatment guidelines. During the two-year period of research and development, I shifted the inhouse continuing education program to reflect an academic perspective to ensure a deeper understanding of the science that would support the new guidelines. To this I added a fifteen-month, 45-hour cardio-cerebrovascular element that was delivered in tandem with the usual mandatory CE. Upon introduction of the revised guidelines, we shifted back to a more traditional care-oriented CE program.

There is no question that spending the time to understand the science made the introduction of the patient care guidelines easier to facilitate. We had added several new pharmaceuticals and procedures, some of which previously had little exposure in EMS. Knowing the “why” and what pathophysiology was being fixed and how was easier to comprehend when one has a better grasp of the physiology.

I am, as always, very appreciative for your sacrifice. Be safe.

Vernon