Clinical Governance Day 22nd October 2014

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Clinical Governance Day 8th October 2014

CGD served up a mixture of cases discussions, audit, hot off the press journal articles and finished the day with a cracking multiple-casualty scenario.  

Airway Audit

In his final appearance before sadly leaving Sydney HEMS, Anthony Lewis went through a number of interesting airway cases for the month of July. There were a number of learning points:

  • Although not used as often as the bougie in our service, the stylet is an invaluable aid in the management of a difficult intubation – in this case a grade 3 view, unable to pass the bougie through the cords. A stylet in a straight-to-cuff shape allowed for endotracheal intubation on second look, with no desaturation.
  • Penetrating trauma to the neck with suspected tracheal involvement can prove to be a particularly challenging airway. Unidentified transection or near-transection of the trachea can be made worse by injudicious or vigorous intubation
  • If time allows, share the decision making with a colleague, in our case the Senior Retrieval Consultant (SRC) – that’s what they’re there for!

The Day Terrorism Arrived in Norway

Christian Buskop, anaesthetist  and current Sydney HEMS registrar

Christian Buskop, anaesthetist and current Sydney HEMS registrar

Christian gave us a fascinating and thought-provoking insight into the terrorist incidents on 22 July 2011 in Oslo and Utøya Island, from his first hand experience working with the Norwegian Air Ambulance on that day.

In the deadliest attack in Norway since World War 2, a car bomb exploded in the government quarter of Oslo, killing eight and injuring 209 people. This was followed hours later by a gunman opening fire on a youth camp on Utøya Island, 40km from Osl0. 69 people were killed on the island, with a further 110 injured.

  • Lightweight emergency stretchers were one of the most useful pieces of equipment on the day, allowing rapid movement of patients from the casualty clearing station to the trauma centre
  • In keeping with some previous mass casualty incidents, there was a degree of communication breakdown, in this case leading to confusion about the location of the casualty clearing station
  • Co-ordination of helicopter activity was challenging in poor weather conditions with uncontrolled airspace and an unsettled security setting. At one point there were 30 helicopter movements in one hour.

An excellent summary of the EMS response was published the following year and is well worth a read for anyone involved in pre-hospital care or major incident planning

Winch Review

Cameron Edgar covered several complex pre-hospital cases where winching was required, highlighting some of the logistical challenges involved.

This included a complicated multi-agency mission in the Blue Mountains involving abseiling down to the patient who had fallen 10 metres into a canyon. Following stabilisation of the seriously injured walker, he was extricated in several stages – first by ropes to the top of the canyon and then carried to a safe area prior to an accompanied stretcher winch.

The Warriewood Blowhole close to the northern beaches of Sydney is a popular site for teenagers in the warmer months and has been the scene of several winching operations in recent years. For one of the new HEMS registrars, it proved to be a particularly eventful day when a teenager sustained multiple injuries after falling when climbing down to the blowhole.

ARISE trial

While the triage scenario was running, Cliff went through the findings of the recently published ARISE study, the second of three multi-centre studies looking at Early Goal-Directed Therapy (EGDT) in sepsis.

In keeping with the ProCESS trial, there was no difference in all-cause mortality at 90 days between usual care and EGDT. While awaiting PROMISe, the final study in the trio, it seems to be that the fundamental goals in the management of sepsis are early recognition, source control, early antimicrobial therapy, considered use of fluids and vasopressors and close observation.

Triage Scenarios

To end the day the doctors and paramedics were put through their paces in pairs, in a challenging scenario involving the initial assessment of multiple casualties following a minibus crash.

Brian checks his twitter feed, leaving the HEMS registrar to do all the work

Brian checks his twitter feed, leaving the HEMS registrar to do all the work

There were many learning points from the subsequent debrief:

  • Arriving by helicopter allows for an excellent opportunity to assess the entire scene
  • Try to make brief notes as you perform an initial triage sieve. This allows for a more accurate situation report and better allocation of available resources
  • Decide beforehand whether to perform a triage sieve in pairs or individually. Working separately is possible and may be faster but requires regular communication to ensure casualties are not missed or triaged twice
  • If triage tags are not available, improvise. Consider writing on the patient with a marker pen to assign a triage category
  • It is possible to get bogged down in the treatment of a patient prior to completing a triage sieve. Consider what life-saving procedures are possible and appropriate. The military talk about: tourniquet application, basic airway manoeuvres and decompression of tension pneumothoraces
  • Make sure that the entire scene has been assessed and all casualties are triaged. It’s easy to miss a quiet patient – they’re often the ones who need help the most!

Next Clinical Governance Day is on Wednesday 22 October

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CGD summary 24/09/14

A very useful CGD with a focus on obstetric emergencies and neonatal resuscitation.

Started off with a comprehensive (and brave) talk by our medical student, Amy, on the physiological changes of pregnancy. A good run through of this can be found here.

We then had a talk from our resident NICU expert Rachel on neonatal resus – the Australian Resucitation Council flowchart can be found here.

Neil Greensmith then took us through some real life Sydney HEMS obstetric cases followed by Rachel (again!) taking us through trauma in the pregnant woman. Here’s a summary from trauma.org.

Finally, after lunch we had a couple of fun obs themed simulations, the first on neonatal resus with a PPH in a remote setting, dealt with superbly by Jamie & Cameron. The video shows how they reprioritised from neonatal resuscitation when they realised how sick the mother was..


This was followed by Mike Culshaw dealing with consummate calm with an eclamptic fit. Our sim expert Morgan has kindly written some valuable learning points on these two scenarios, which can be found here.

Thanks to everyone involved in a successful day.

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Clinical Governance Day 8th October 2014

Oct_8th_2014_CGD_Flyer2

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Clinical Governance Day 24th September 2014

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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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