AiR – Learning from the Airway Registry (September 2021)

Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

Sydney HEMS is proud of its commitment to excellence in airway management. In 2020, we achieved:

  • 400 Intubations
  • 377 RSIs
  • 1 awake nasal intubation
  • 1 primary surgical airway

These learning points form part of our commitments to governance, excellence and education. All CMAC videos are shared under a Creative Commons Licence: Attribution 2.0 Generic. Please familiarise yourself with the terms of the licence before reusing our videos.

To view these videos, you will need this password: AiRblogVideos

The AiR blog posts come from the amazing brain of Dr Clare Hayes-Bradley via the fingertips of Dr Natalie May.

Focus on: Paediatric Intubation

How Deep Is Your Tube?

In this video of a 15kg child we attended following a drowning, there are a couple of really important and useful learning points.

Firstly, the video shows how extensive and troublesome pulmonary oedema can be in these patients. It is certainly something we see commonly; this particular case had involved bystander CPR and even though there was spontaneous respiration by the time our team arrived at the patient – and our pre-oxygenation strategy achieved SpO2 100% –  there was copious white frothy fluid in the oropharynx, almost obscuring the cords, and then later seen coming back up the tracheal tube (in the later part of the video). The blade used here with the CMAC is size 4; we have used this blade size successfully in patients as young as 14m of age.

Secondly, the black lines seen just above the cords when the cuff is inflated (image below) might appear to be the lines corresponding to the cuff end of the tube but in fact these are the markings at 10cm of insertion – and in this case, this resulted in a right mainstem intubation.

 

Arrival CXR from hospital (12:25) is shown with a left sided white-out and clear bronchial tube. This resolves once the tube is pulled back (16:14).

Our Paediatric quick reference cards give an ideal depth of tube insertion by age. This is a handy guide to help avoid this common problem and we recommend confirming tube depth (given as ETT length) at the teeth/lips as soon as practical after intubation.

Paediatric Emergency Reference Card v3.0 May 2021

You can find the Paediatric Emergency Reference cards via the ITIM app.

Video Focus on: Airway Soiling & SALAD

With the case above in mind, it’s helpful to remember that we often deal with significant airway soiling. Our service carries the DuCanto suction catheter and trains for suction assisted laryngoscopy airway decontamination (SALAD).

These two videos show significant soiling.

This video shows significant soiling, presumably from gastric contents, during laryngoscopy.

This video, like the one above, shows significant airway soiling. Suction was used continuously (the SALAD technique) to provide a view in order to secure the airway in difficult circumstances.

Further CMAC Videos:

Very Pale Mucosa in a Hypovolaemic Trauma Patient

This video is notable for the significant pallor in the airway mucosa. This was a trauma patient with considerable hypovolaemia.

Unexpected Difficult View

This patient had an unexpected supraglottic mass, making laryngoscopy difficult. The epiglottis is swollen and surrounded by inflamed and friable tissues.

This patient was intubated successfully by the team and the CT scan image is shown below.

CMAC Size 4 Blade in a 2 Year Old

Another example of the successful use of the CMAC size 4 blade in a small child – in this video the patient is 2 years old.

You can see all the AiR videos here on our Vimeo page.

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Getting the hang of the Hamilton Ventilator:

About the Hamilton we use:

The Hamilton T1: A 7kg transport ventilator with a battery life up to 9 hours, this ventilator allows us to deliver between 2ml and 2000ml of tidal volume, making it suitable for all patients from neonates to adults and bariatric patients.  There is the option to set PEEP between 0 to 35cmH2O and an inspiratory flow rate up to 260Lpm. The Hamilton T1 is also able to deliver intelligent NIV with reduced leak and a specific target Fi02. The Fi02 setting range is from 21% to 100% and there is also an integrated nebuliser and high flow options. The circuits are fully disposable, lightweight and easy to carry, and significantly for us- the ventilator can run independent of compressed air if needed.

Every day starts with the daily checks- This is an automatic test that goes through tightness, flow sensor and the oxygen cell.

Most common Vent settings we use and how to set them up:

(S)-CMV: Synchronised Continuous Mandatory Ventilation mode- a pressure- regulated volume controlled mode

SIMV: Synchronized intermittent mandatory ventilation- a volume-controlled mode.

  • Power on.
  • Complete daily pre-op checks.
  • Select mode- S-CMV.
  • Select patient adult/ped, height and gender.
  • Select Controls tab- adjust RR, I:E, Vt, PEEP and Fi02.
  • Press the white cross and return to home screen. -Select the Alarms tab to adjust alarms limits as clinically appropriate.

At Sydney HEMS we tend to default start with a Vt of 6-8ml/kg and a PEEP of 5. The I:E will be 1:2. These are then adjusted to create a patient specific ventilation strategy depending on clinical picture.

NIV: Non-invasive ventilation- CPAP or BPAP.

Power on.

Complete daily pre-op checks.

Select mode- NIV or ST-NIV.

Select patient adult/ped, height and gender.

Open Controls tab

CPAP: Set PEEP to desired level (EPAP)

BPAP: Set PEEP (EPAP) to desired level. Set pInsp to additional pressure required to generate IPAP

On NIV mode set Psupport to additional pressure required to make desired IPAP ie: IPAP – PEEP

On NIV-ST mode set Pinsp to additional pressure required to make desired IPAP ie: IPAP – PEEP

Select the Alarms tab to adjust alarm limits.

Check for % leak under the values tab- this will help inform how much oxygen you’re likely to need with you for the journey.

Setting the pressures for NIV: Don’t forget to create BiPAP, your pInsp is additive to your PEEP.

Alarms:

What do the alarm patterns mean?

High priority- Red light and 5 beep repeated.

This refers to patient factors such as apnoea, minute ventilation or a Pmax problem, a Circuit disconnection or obstruction, or an oxygen fail.

Medium priority- Yellow light and 3 beeps repeated.

This is highlighting a pressure limitation, Vt or PEEP issue.

Low priority- Yellow light and 2 beeps only.

External power loss.

Physiologically what do the alarms mean?

Minute ventilation: This refers to the amount of gas delivered to the lungs in 1 minute. MVe is usually around 6L and calculated Tidal volume x respiratory rate. If the High MVe alarm is sounding- this is to say the lungs are receiving more than this and the patient is essentially being hyperventilated. Reducing TV or RR may optimise this. However, don’t forget this is just an equation and doesn’t factor in clinical picture and your clinical goal of ventilating in a certain way. Low minute ventilation usually refers to a leak or disconnection in the circuit.

Whilst in S-CMV mode, the ventilation is pressure-regulated and volume-controlled meaning the ventilator is constantly assessing the pressure required to generate the set tidal volume and there can be wide swings in the volume delivered.

pMAX: This is the set maximum pressure limit on the ventilator. On our Hamiltons this will default to **35** and will alarm at pMax-10. If the alarm is sounding- consider what target pMax is appropriate for this patient and if anything may have happened driving a sudden increase in pressure ie. Secretions/occlusion/coughing. If all is clinically well and you just want to adjust the alarm limits, this can be adjusted in the Alarms tab.  

fTotal: The total delivered breaths plus patient initiated breaths.

PEEP alarm: If the PEEP is high this suggests a problem with the elasticity of the lungs such as pneumothorax, tension pneumothorax, contusion or pulmonary edema.  ARDS, and auto-PEEP caused by “breath stacking can also cause this. Clinically re-assess the patient, consider lung ultrasound and if autoPEEP seems the problem, consider disconnecting and manual release of pressure.

Low/High Vt: The Hamilton auto-calculates Vt according to patient height and ideal body weight at 6ml/kg. High tidal volumes can be associated with barotrauma but if the alarm is saying that a higher volume is being delivered than you requested, consider that this may be patient driven. If you don’t want them breathing spontaneously, consider deeper sedation or paralysis. If Vt is low, consider why. The outcome of a consistent low Vt will be atelectasis and you may need to consider setting a higher PEEP.

Other useful things to know:

Oxygen consumption: In the system tab, the Hamilton T1 will tell you your current oxygen consumption in l/min. This particularly useful in long transfers, patients with high oxygen consumption or patients on NIV where you may need to plan ahead with how much is available or if you need to restock en route.

Auto adjusting alarm limits: In the Alarms tab, below the adjustable bars, there is a button for Auto. This will automatically set all alarm limits around the current monitoring parameter values except Vt and apnea.

The oxygen enrichment key: This is the upwards arrow with 02 written on it and will deliver 100% oxygen for 2 minutes. Pressing it a second time will cancel it. This is useful to oxygenate prior to a disconnection to suction etc.

I:E ratio: Expressed in seconds, this is the amount of time spent in inspiration compared to exhalation during the total respiratory cycle. Example: RR is 12, total cycle time is 5 seconds (60/12 = 5 seconds). If I-time set at 1 second, then 1 second is spent in inspiration, 4 seconds are available for exhalation.

What is ASV? Adaptive Support Ventilation: This is a tool on this ventilator whereby the operator set Mve is maintained but the machine establishes an optimal tidal volume and RR combination to achieve it. In passive patients, this is a volume targeted pressure controlled mode with automatic adjustment of pInsp, RR and I:E ratio. The ventilator calculates MV from ideal body weight at 100ml/kg/min. Fi02 and PEEP still need to be manually entered. There is an argument that ASV is less useful in pre-hospital/retrieval mode and better used in the ICU when patients are starting to wean from the vent.

The inspiratory hold manoeuvre: The inspiratory hold allows us to determine the plateau pressure as a marker of the alveolar pressure in the lungs. This allows us to differentiate the intrinsic PEEP of the lungs and assess the resistance of the airways. To do an inspiratory hold on a T1- The patient needs to be paralysed first. Press and hold the button with the lungs on it to trigger a breath hold, hold it down for 10 seconds (or until you see flow stop on the screen). Press the two arrows facing each other on the top left of the graph screen to freeze the graph. You can then use the wheel to move the cursor backwards and forwards to find a reasonable plateau pressure.

Patient specific ventilation: Key settings we can adjust

ARDS (can consider in trauma)

“Lung protective strategies”:

Controlled oxygen exposure

Low tidal volumes 4-6 ml/kg

Adequate PEEP (rough guide start at weight/10)

Peak pressure < 30 cm H2O (<28cm H2O driving pressure)

Asthma:

Minimise minute ventilation (reduce RR, preserving Vt to maintain MV)

Maximise time for expiration (I:E ration approaching 1:5)

Permissive hypercapnia

Pressures are reflective of bronchial spasm (therefore in acute episodes, ignore pressure alarms and focus on Vt)

Volume control mode beneficial as improving pathophysiology with treatment will prevent barotrauma reduced bronchospasm.  

COPD:

“Normal” TV (6-8ml/kg)

“Normal PEEP” (5-10cm H2O)

Tend towards Longer I:E ratio’s

Peak pressure <30cm H2O (limiting potential for bullae rupture and pneumothorax)

For more information on how best to use the Hamilton and for increasing your familiarity with it, take time to practice on the machines, explore Hamilton-Medicals online learning modules and use any down time on base to run through them with any of our expert anesthetists on base.

With thanks to Dr Satya Varnasi and Dr David Ransley for their contributions to this article.

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CGD 1st September

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Transport Physiology: Critical Care in the Air

Sydney HEMS registrar Dr Jonny Morris takes us through the impact of flight on patients and the things we should consider for patients we are transporting by air.

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High Performance – Australian Rugby and Sydney HEMS

Providing exceptional critical care to a severely injured patient and kicking the winning goal in World Cup Rugby to most will seem many worlds apart. Dr Nathan Trist, one of our current senior PHRM registrars, is a former professional rugby player who has insight into both of these worlds and highlights the lessons learnt across both of these fields.

In this talk he discusses high performance with Australian Wallaby player, Bernard Foley. Known as the “Iceman”, the goal kicker uses positive self talk, exceptional training and intense focus on the task at hand to perform at his best. Performing with pressure requires an understanding of how you react to these factors and developing triggers to centre yourself when this pressure arrives.

Have a process and rehearse these skills in training, trigger process activation in missions and reflect on not just actions, but thoughts in mission review.

“Keep your head down and stay tall to the kick” – Bernard Foley

The team at Sydney HEMS wanted to express our appreciation to Bernard for taking the time to talk with Nathan and the team at our recent Sydney HEMS Education day.

Lauria MJ, Gallo IA, Rush S, Brooks J, Spiegel R, Weingart SD. Psychological Skills to Improve Emergency Care Providers’ Performance Under Stress. Ann Emerg Med. 2017 Dec;70(6):884-890. doi: 10.1016/j.annemergmed.2017.03.018. Epub 2017 Apr 29. PMID: 28460863.

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Clinical Governance Day [CGD] – 7th July 2021

Attendance at CGD is open to NSW Health employees – dial in details are available on request.

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Mindhacks: Where Mindfulness Meets Medicine

Over recent years self-talk and self-compassion have been increasingly explored; notably they are key components of performance psychology. These two aspects can influence performance not just of elite athletes but also of medical professionals; while under pressure and following high-stress events as we process and reflect on our decision making. So what are self-talk and self-compassion all about and why are they relevant to us in prehospital and retrieval medicine?

Self-talk: the internal voice in which we all speak to ourselves. It can be positive or negative. There is evidence to show that self-talk can influence performanceLouise Harvey

Self-compassion: a sense of kindness, care and understanding for yourself, versus judgement, alongside a sense of mindfulness. Self-compassion has less impact on performance than on emotional wellbeing – Kristin Neff

Self-Talk

Positive and negative self-talk are the two sides of our internal narrative. Self-talk is a mixture of our conscious and unconscious thoughts and might be better recognised as our inner voice. You can think of it as an amalgamation of your values, norms and expectations. Most significantly, it can impact performance and mental wellbeing. 

NSW Aeromedical division is incredibly fortunate to have a staff psychologist, Louise Harvey; as part of our Mindhacks series she recently ran session on education day, which she began by asking us what we had said to ourselves that day. Had we reprimanded ourselves for a silly mistake? Complimented ourselves for our efforts? Recognised our own mood and expectations for the day?

The concept of self-talk, whether positive or negative, is well known and utilised; prominent applications include the world of elite sport and the ongoing management of eating disorders and body dysmorphia. Louise highlighted that there is application and relevance to the practice of prehospital and retrieval medicine too.

The way we think about situations, about experiences and about ourselves influences how we feel and respond. This is a bidirectional relationship; the way we feel also influences how we think. If we can strengthen helpful thoughts and feelings, and acknowledge and choose what to do with unhelpful thoughts/feelings, we’ll feel more empowered, confident and tend to perform better.  Often the way we speak to ourselves follows unconscious patterns. It is helpful to get to know and pay attention to how we talk to ourselves. Awareness of our thinking patterns gives us the chance to build on what is working and change what is not. Practices that build insight and awareness such as mindfulness help with this.

Helpful positive self-talk has several qualities: it’s balanced, realistic, believable, compassionate, clear and individual – it’s not about ignoring the unpleasant things or sugar coating. Helpful positive self-talk acknowledges the stressful, unpleasant and uncomfortable aspects of life, but with kindness and compassion.  Examples of this could be:

•       Unhelpful: That was really bad, everyone saw me fail. Helpful:  Attempting to do this took courage and I am proud of myself for trying.

•       Unhelpful: I’ll never be any good at this. Helpful: If I keep practicing and ask for support, I can grow my skills and confidence.

•       Unhelpful: I got that procedure wrong, I’m the worst clinician here. Helpful: I made a mistake and I’m taking responsibility for it.

Looking at some evidence:

Tod, Hardy and Oliver. Effects of Self-Talk: A Systematic Review. Journal of Sport and Exercise Psychology 2011;33(5):666–687

This systematic review looked at 47 articles exploring self-talk and its impacts on performance. Interestingly, whilst negative self-talk wasn’t proven to impede success, motivational and instructional self-talk were shown to enhance it.

Mills J, Chapman M. Compassion and self-compassion in medicine: Self-care for the caregiver. AMJ 2016;9(5):87–91.

Physician wellness is an area of developing interest but there is not a lot of research as yet. This article highlights the importance of self-care and self-compassion, and suggests the more compassion we can show ourselves, the more we show our patients too.

Raab, K. Mindfulness, Self-Compassion, and Empathy Among Health Care Professionals: A Review of the Literature. Journal of Health Care Chaplaincy. 2014.20(3):95-108

Focussing on developing self-compassion amongst health care work has the potential to reduce perceived stress and increasing effectiveness of clinical care.

Self-Compassion

Anita Alexander is a psychologist and strength finding coach as well as being a Coordinator of the NSW Ambulance Wellbeing & Resilience Program. She also spoke recently at one of our education days about self-compassion, outlining a few simple mind hacks we can all use.  

Start off by taking this simple self-compassion quiz to gauge your starting point:

https://self-compassion.org/test-how-self-compassionate-you-are/

In her talk to us, Anita referenced Dr. Kristin Neff as the leading researcher in self-compassion. Dr. Neff defines self-compassion as having three key components: mindfulness, self-kindness, and awareness of the shared humanity that we are all a part of (an understanding that we all go through difficult phases and to recognise that this is usual). The compassion discrepancy refers to the difference between how we would speak to or comfort others, compared to how we speak to and judge ourselves.

Top tips for increasing self-compassion:

  • Identify your own personal stress trigger factors so you can better anticipate them.
  • Avoid catastrophic thought processing and worst-case scenarios
  • Watch your body for the early signs of stress individual to you.
  • Set aside time to let yourself worry and try not to carry it further into your day
  • Breathing exercises- there are many online and some modern smart watches will even talk you through these.
  • Planning positive or exciting things in your day to focus towards- these don’t have to be grand or epic. Small things have the same benefit.
  • Reduce caffeine and alcohol intake
  • Plan your time management to empower you at each step. Achievable goals can re-enforce a sense of success.

https://www.accesseap.com.au/

Self-talk influences our performance but our self-talk is likely to be influenced by our level of self-compassion, so the two very quickly overlap. As clinicians we need to remember to look after ourselves as well we each other and our patients. Self-compassion doesn’t come easily to many of us but we can try to remember to treat ourselves the way we would treat someone we care about. Our work comes with intense challenges – be kind to yourself.

Resources you can turn to if you need any help or support within NSW Ambulance and Aeromedical: Please follow the links to pages on the intranet.

Kristin Neff – Ph. D. Associate Professor, Human Development, Culture, and Learning Sciences. Educational Psychology Department, The University of Texas at Austin. https://self-compassion.org/

For further support within NSW Aeromedical Services:

Louise Harvey – NSW aeromedical Senior Psychologist and Clinical Psychologist

Anita Alexander – NSW ambulance Wellbeing & Resilience Program Coordinator

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CGD Weds 9th June 2021

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What happens at HEMS Induction?

It’s been a few months since the latest cohort of HEMS registrars completed their induction; they’ve found their feet and been part of some incredible missions so far.

One of our latest additions, Dr Fran Arnold, wanted to share some of their thoughts, experiences and expectations as they venture into the sometimes daunting, challenging and extremely exciting world of prehospital and retrieval medicine.

What is induction all about?

Without a doubt, we’re hugely lucky to have just completed one of the most impressive, thorough and brilliant inductions of our careers. After some introductory activities to get to know each other, week 1 took us straight into our inter-hospital training week. From simulations, workflow training, a triage and tasking exercise, ultrasound storm, obstetric revision, meeting Wallace-the NSWAS therapy dog, organisational induction and the first of many of pack checks, we hit the ground running and induction was off to a strong start.

A weekend of recovery led into week 2 and straight into pre-hospital week, with guests from Canberra and the Royal Flying Doctor Service joining us. Pig lab procedure training, a major incident drill, more excellently delivered high fidelity simulation, more pack checks and the most fun OSCE most of us have ever done, all too soon, the full team graduated with our wings and week 3 was upon us.

Week 3 and 4 were flight school, and faced with the task of following a phenomenal medical induction, the team at Toll (the aviation providers to the NSW aeromedical service) rose to the challenge to deliver a really high quality training programme.

Human factors, aviation training, winch training – both simulated and in the (literal) field – and the basics of helicopter crewmanship. It was all so well delivered and inspiring, and under the watchful guidance of our Toll Mentors, we all survived winch insertions, stretcher winch extrications and the dreaded dunk in our HUET training. A few crazy folk even climbed out with smiles on their faces!

So it’s been a huge welcome and epic privilege to go through this level of training, but what did we take from it all?

For some of us, this world is new and daunting, for others, a return to a familiar environment, but the key messages that will stick with us are as follows:

  • Cross-training roles together; some of our critical care paramedics completed induction with us and it was great to get to know them.
  • The power of well-delivered safe-space simulation and practicing what good looks like.
  • The power of a wellbeing-enlightened organisation & culture
  • Don’t have a helicopter crash! But if we do….we now know what to do
  • Be an active part of the crew, not just a passenger. 
  • Always do what the aircrew tells you.
  • We all come from around the world with a huge range of lived experiences and different skills. But most importantly, we’re all in it together (and we all love the beach!)

Huge thanks to Karel Habig, Clare Richmond, Rob Scott, Daniel Schmidt, James Koens and the massive team of consultants, CCPs, aircrew, flight nurses, paramedic educators and paramedic student volunteers for getting us to this point.

A consultant colleague in my last job, Dr Grimsmo, whom I was lucky to work alongside for the RFDS, introduced me to the idea of ‘setting people up for success‘ and how powerful it can be. The induction we’ve been through is testament to this and we’re eager to get out there and do our bit to serve our population and deliver the best standards of care we can. Look up to the skies – we’re on our way! And if you’re joining us this coming August – you have a lot of fun ahead 🙂

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HETI PHRM Education Session

Understanding the prehospital and retrieval system is core knowledge for all Emergency Registrars, whether you undertake a special skills post during your training or not.

We are collaborating with HETI to provide PHRM education for Emergency and Critical Care registrars of all grades.

This year’s topics are – “Life, Limb, Sight saving Procedures” with Fergal McCourt – how do you make the decision, and what do you do! “Paramedic Profiles” – Learn about what paramedics do before they arrive in the Emergency Department with Critical Care Paramedic Katie Stucken. “Transfer Teams” – thinking about transferring patients across the state or across the hospital, and how those teams prepare and work together with Clare Richmond. Nathan Trist, one of our senior registrars will lead “Coffee and Cases” our case based deep dive into PHRM with the team. You will also have a chance to talk to the ACEM staff about the diploma of PHRM and get tips on how to work in PHRM in the future.

We are offering this as an online event, and will aim to post some of the talks following the event. Sign up on the link on the flyer!

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