Clinical Governance Day 24th September 2014

CGDFlyer

See here for directions

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Clinical Governance Day 10 September 2014

We started off the new term with a series of interesting presentations based around the theme of drowning and water rescue.

Inland Water Rescue in the UK

Thanks to the wonders of the internet, Matt Ward, Head of Clinical Practice at the West Midlands Ambulance Service presented a very informative talk on inland water rescue in the UK, in particular, the work of the Severn Area Rescue Association and its involvement in the rescue operation following the severe floods affecting Tewkesbury, Gloucester in 2007.

Drowning: pathophysiology and management

Tom talked us through the physiology of drowning and its management

An excellent summary from Life in the Fast Lane can be found here

Role of HEMS physician in water rescue

  • This is one of the few situations where the physician needs to act independently without paramedic support as the paramedic is outside the helicopter on the end of a winch cable!
  • Make sure everything is secured in the aircraft – kit can easily be blown around when the doors are open
  • Physician moves to rear left seat but remains on wander lead in preparation for receiving the patient
  • Connect BVM to oxygen supply but keep it secured within the dropdown emergency airway bag
  • Suction underneath head of the bed
  • Supraglottic airway to hand
  • Patients are usually fine (but cold) or in full cardiac arrest so prepare for both
  • Further resuscitation can be performed once landed on a nearby helipad or oval

Simulation scenarios

It seemed fitting that a day focused on water rescue should have a number of water-based simulation scenarios to put the new registrars through their paces.

The standard of practice was excellent with some great examples of teamwork and the sharing of a mental model.

Dr Rachel managing a paediatric drowning

Dr Rachel managing a paediatric drowning

Case Discussions

The day was brought to a close with a discussion of a number of interesting cases attended by the new registrars since joining Sydney HEMS. There were many learning points from each case including:

  • Regional Trauma Centres provide excellent care to a number of major trauma patients however there are times when a regional trauma centre should be bypassed in order for the patient to receive specialist care only available in a major trauma centre.
  • The Senior Retrieval Consultant (SRC) is always available to provide advice and to share in this decision making process.
  • Although the days are getting warmer, it can still get cold in the bush overnight. It is possible that you may be winched in to a patient but unable to be winched out due to poor weather or darkness. Make sure you’re prepared for the possibility of remaining with a patient overnight and consider taking thermals, a beanie, food and drink.
  • There is an excellent operating procedure for managing raised intracranial pressure. Have a low threshold for paralysing patients for the duration of transfer following adequate sedation and analgesia. Paralysis may mask seizure activity but it is effective in preventing coughing or gagging which can aggravate raised ICP.
  • Prophylactic phenytoin in intracerebral haemorrhage is controversial. Following intracerebral haemorrhage it may reduce the chance of early seizures but does not alter long-term outcome.
  • IV nimodipine is often started at the referring hospital on the advice of the receiving neurosurgeon. Consider stopping IV nimodipine during transport of the patient, particularly if there is a need to rationalise the number of IV infusions.

The next Clinical Governance Day is on 24 September 2014, when we hope to be back in the refurbished training building. More details to follow

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Build Your Own Escharotomy Man!

To make your own escharotomy training model, you will need:

1. A thick foam yoga mat (red or pink). This one was $10 from K-Mart.

Yoga Mat

2. A roll of Cling Film (Glad Wrap). Glad wrap

3. A roll of thin packing foam — the sort of stuff your new TV comes wrapped in.

Foam padding

4. Some elastic bands.

Elastic Bands

5. Around 4-5 rolls of white Cloth Tape (similar to Gaffer tape but much cheaper).

Cloth tape

6. A pair of trauma shears

trauma shears

7. A resuscitation mannequin.

mannequins

 

Assembly Instructions

1. Cut the yoga mat into sections and wrap circumferentially around the torso and limbs of your mannequin. Wrap cling film firmly over the top to secure it in place. This red/pink layer represents the viable tissue beneath the eschar — i.e. the end-point of the escharotomy procedure.

red layer 1 red layer 2

2. Next, simulate subcutaneous tissue by adding 2-3 circumferential layers of packing foam to the torso and limbs. Elastic bands can be applied to the limbs to simulate constrictor bands.

fatty layer

3. Now for the most important part! Wrap white cloth tape circumferentially around the limbs and torso to simulate  eschar.

Wrapping 1

The tighter you can apply this layer, the better! The springy foam layers are now compressed by the restrictive tape and will spring apart when incised.

wrapping 2 wrapped

4. Your escharotomy man is now ready to use! For additional realism you can apply make-up or charcoal to simulate charring, or even lightly burn the top layer to produce an unpleasant burned smell.

burned man

5. The mannequin can now be used for simulation or practical skills teaching.

Tutees can be instructed to:

  • Draw their proposed escharotomy lines on the mannequin with a marker pen (e.g. Sharpie) to assess knowledge of correct escharotomy sites.
  • Cut with a scalpel down to viable tissue (the red / pink layer). The incision should spring open once the eschar is divided.
  • Run their fingers along the length of the wound to detect and individually divide any constrictor bands.
  • Dress the wounds (e.g. with cling film) post escharotomy.
escharotomy

Escharotomy Incision Sites

This model was trialled for the first time at our Sydney HEMS team induction and performed very well!

2014-08-06 16.02.26

2014-08-06 16.00.47

Of course, in real life the procedure is a little bloodier…

 

If anybody has a clever way to simulate active bleeding without completely destroying the mannequin then please let me know!

Escharotomy Man designed by Dr Ed Burns. Thanks to Dr Fergal McCourt for the escharotomy video. 

Further Reading

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CGD Flyer – Weds 27th August 2014

Here is the flyer for next week’s Clinical Governance Day. 

CGD Flyer (1)

Please note that as the training building is currently being refurbished, the CGD will instead be held in the conference room in the main office building (“The Castle”). 

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Is lamotrigine ketamine’s black swan?

black-swan-8288_1920.jpgThe black swan theory describes rare events beyond the realm of normal expectation. We use ketamine on a daily basis, but are there any circumstances in which ketamine simply will NOT work?

This interesting case report by an Ex-Sydney HEMS physician Daniel Kornhall describes how ketamine failed completely as an anaesthetic agent in a psychiatric patient with a toxic lamotrigine overdose.

***SCIENCE ALERT***

Lamotrigine, as we all obviously know, exerts its antiepileptic effect by inhibiting presynaptic sodium channels thus reducing the release of the excitatory glutamate and stabilising excitable neuronal membranes. Ketamine’s dissociative anaesthetic effects are a bit more of a mystery and diverse, but they are thought to involve increasing glutamate release through non-NMDA receptor pathways. It therefore follows, that if one drug prevents the release of glutamate and second drugs effects depend on its release, the second drug will not work.

With our high volume of ketamine use, incidents such as this are worth bearing in mind the next time you see a patient with a mixed polypharmacy overdose.

Lamotrigine is therefore ketamine’s black swan.


Kornhall D, Nielsen EW. Failure of ketamine anesthesia in a patient with lamotrigine overdose. Case Rep Crit Care. 2014;2014:916360. Full Text Article

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Selective Aortic Arch Perfusion

Fascinating talk on the development of this resuscitative technology by Dr Jim Manning who appeared in person at our Clinical Governance Day.

 

For further information check out EMCrit Podcast Episode 123

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Developing EM in Brazil is coming soon

DevEM2014
Several of our consultants are presenting at the Developing EM conference in Brazil.  If you’d like to hear more, organising emergency physicians and prehospital & retrieval medicine consultants Mark Newcombe and Lee Fineberg describe it and also discuss the highly successful Developing EM conference they ran last year in Cuba:

 

Check out the program and register here

 

The project is a not-for-profit venture and no SydneyHEMS specialist receives financial remuneration for involvement in the DevelopingEM conference.

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