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.
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 performance – Louise 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
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.
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.
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.
Focussing on developing self-compassion amongst health care work has the potential to reduce perceived stress and increasing effectiveness of clinical care.
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:
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.
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.
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 🙂
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!
We were pleased to host the Out of Hospital Cardiac Arrest Symposium on base back in February, and we are delighted to be able to bring you the recorded talks that featured on the day. Unfortunately we weren’t able to share the prehospital ECMOcpr demonstration due to the quality of the recording but there’s plenty more goodness here.
Born in London, UK, Dr. Yannopoulos received his M.D. from the University of Athens in Greece. He completed his medicine residency and general-cardiology fellowship at the University of Minnesota. Following an interventional-cardiology fellowship at Johns Hopkins University in Baltimore, Maryland, Dr. Yannopoulos joined the University of Minnesota faculty in 2008. In March 2010, he became the research director for interventional cardiology.
Dr. Yannopoulos is board-certified in internal medicine, cardiology, and interventional cardiology. His clinical interests include emergent cardiac care, coronary-artery disease, and congenital and peripheral intervention.
Dr. Yannopoulos’s research involves cardiopulmonary resuscitation, hypothermia, and myocardial salvage during acute coronary syndromes. He is considered an authority in cardiorespiratory interactions and hypothermia during CPR. His work in the laboratories of Dr. Keith Lurie (at the University of Minnesota) and Dr. Henry Halperin (at Johns Hopkins University) has helped change current CPR practices.
Dr. Yannopoulos is a member of the American Heart Association’s CPR guidelines-writing committee, and of the basic life support and research working-group subcommittees. He also serves on the organization committee for the AHA’s Resuscitation Science Symposium (ReSS), the largest international conference addressing CPR and emergent cardiac/trauma care. Find him on Twitter here: @DYannopoulos
Prehospital and retrieval specialist, CareFlight, NSW. Cardiac anaesthetist and ECMO lead Westmead Hospital Sydney. Flight lieutenant, Australian Defence Force. Find her on Twitter here: @nattiejpk
Dr Mark Dennis is a Visiting Medical Officer at Royal Prince Alfred Hospital (RPAH), Clinical Senior Lecturer in Cardiology – University of Sydney (USyd), and Clinical Imaging Specialist at Macquarie University Hospital. Mark completed his graduate medical degree (MBBS) with Honours at the University of Sydney where he was a University Medallist. He then completed his cardiology training at RPAH and subsequently went on to complete his PhD in congenital heart disease for which he was awarded a Research Training Program Scholarship and CSANZ Paediatric & Congenital Council Travelling Scholarship.
Mark has active clinical and research interests in cardiovascular imaging and acute cardiovascular care with mechanical circulatory support. He has completed advanced training in Cardiac Magnetic Resonance (CMR) obtaining Society of CMR Level III Accreditation and Fellowship with the Society of Cardiac Magnetic Resonance (FSCMR). He has also completed the European Advanced Cardiovascular Imaging (EACVI) CMR Congenital Heart Disease Examination and additional training in Structural Heart CT for Valvular Heart Interventions both within Australia and internationally. He holds further advanced qualifications in Echocardiography (Diploma of Diagnostic Ultrasound) and has completed the American Society of Echocardiography structural heart program. He is a member of, and provides imaging support for, the RPAH Structural Heart Team.
Specialist Intensive Care Medicine, St. Vincent’s Hospital, Sydney. ECMO Research Lead St. Vincent’s Hospital. Specialist for Anaesthesia, Intensive Care and Preclinical Emergency Medicine (Germany), Conjoint Senior Lecturer University of NSW and an ECMO Retrieval Physician. Find him on Twitter here: @HerxxAU
Dr. Richard Totaro graduated from UNSW and trained at Royal North Shore Hospital, The Princess Alexandra Children’s Hospital, Camperdown and Rush Presbyterian-St Lukes Hospitals in Chicago, Illinois. Dr. Totaro is the Director of the Intensive Care Unit at the Chris O’Brien Lifehouse and is Co-Director of the Intensive Care Service at RPAH, a leader of the ECMO service at RPAH and a VMO at Strathfield Private Hospital. He is a member the General Clinical RCA Review Committee of the NSW CEC. Dr Totaro has an interest in extracorporeal respiratory and cardiac support and is an ECMO Retrieval Physician.
Emergency Physician at Westmead Hospital in Sydney. He is a Senior Lecturer in Emergency Medicine at the University of Sydney and frequently involved with the supervision of medical and nursing staff as well as the teaching of medical students. He is a Fellow of the Royal College of Physicians (UK) and the Australasian College of Emergency Medicine. He is interested in free open access medical education (FOAM) and started the popular website http://www.emergencypedia.com in 2013. His particular interests include teamwork in healthcare, simulation based medical education, medical systems and development of the postgraduate Emergency Medicine curriculum.
Dr Coggins is currently working on the following strategic priorities as part of his role in Simulation in Western Sydney: A sustainable and evidence based simulation curriculum for junior doctors at Westmead Hospital; and Training of Skilled Facilitators to improve the future of training at Westmead, in particular in the area of healthcare ‘debriefing’. ED ECMO CPR lead at Westmead Hospital. Find him on Twitter here: @coggi33
Critical care paramedic GSA-HEMS, NSW Ambulance. Critical care paramedic educator. Clinical Senior Lecturer, Sydney University. Adjunct Lecturer, School of Biomedical Science, Charles Sturt University. Vice-chair Australasian College of Paramedicine. Find him on Twitter here: @martynichols9
Associate Director, NSW Ambulance. After graduating from the University of Oxford in Mathematics, Sophie worked as an actuary in the UK and Australia for 20 years, focusing on health care financing and funding since 2001. She completed a Bachelor of Paramedic Practice at the University of Tasmania (Rozelle campus) in 2017 and currently works as a paramedic.
Research Director GSA-HEMS, NSW Ambulance. Prehospital and retrieval specialist, NSW Ambulance. Emergency Physician, Northern Beaches Hospital. A/Prof Emergency Medicine, Sydney University. Resuscitology Faculty. Co-Chief Investigator EVIDENCE trial. Find him on Twitter here: @HawkmoonHEMS
Pre-hospital and retrieval medicine, with its high acuity patients, high adrenaline environment, noise levels, geographical challenges, and the unexpected nature of what each individual job can bring, creates an environment in which communication is critical; both in terms of communicating within our team, with partner organisations and the Aeromedical Control Centre, as well as with patients and their families.
Here’s a brief look at the different equipment we use for our day-to-day comms, as well as the less commonly used communication devices we have access to when needed.
Inside the aircraft
The AW139 comms box – this is the panel you’ll see beside the doctor’s seat:
Delving a little deeper
Air traffic control: Com1 and Com2 allow the aircraft to interact with the Sydney air traffic control tower and regional control towers when we’re landing elsewhere, including Bankstown. On this system, you often hear discussion between air traffic control and individual aircraft, planning approaches and runway management as well as aircraft identifying themselves to each other.
Com 3 – Wulfsberg Multi frequency radio: This is set to Eso Air 1 during complex missions which allows communication with agencies on scene. This would include hopsital security, marine radio and surf life saving.
Com 4 – GRN: Government Radio Network. This is a statewide two-way radio system that uses a digital control channel to automatically assign frequency channels to groups of users. This is the main system we use to communicate with ACC from our ground and air vehicles, as well as how we communicate with crews on scene and get updates en route.
During complex missions, Com4 becomes our simplex Helicopter channel allowing us to communicate down the wire. During a winch procedure we can turn off all lines to keep focus on the members of the team on the wire and avoid distraction.
Com 5: Com 5 allows us to make and receive phone calls via the aircraft mobile. Most often this will be used for clinical updates between our team and either the Retrieval consultants or receiving teams. In order to be able to use the mobile, we need to ensure the comms button on the overhead panel beside the comms lead connector is set to Radio not ICS.
So what about inside base and our road vehicles?
The Batphone: All primary taskings via RLTC (Rapid launch trauma coordinator) will come via this phone. Each base has one by the CADLink screens and status boards, and they ring out across the whole base, including outside areas. The batphone must ring 4 times and there must be a paramedic present to take the call. No jobs can be accepted until either the road paramedic confirms it is accessible or the pilot confirms they can complete this mission.
Top tips for Batphone etiquette:
-If not directly involved in the mission please stand back from the desk.
-Receiving a call should generate a sterile environment. Keep background chat appropriate and to a minimum; it’s all recorded by ACC.
-If the phone has rung 4 times and there is still no Paramedic present, answer the call “Sydney base: please standby for a paramedic” until they are present.
-Keep a clear passage/line of sight between the paramedic and pilot/ACM taking the job so communication is not impeded.
-Do not scroll on the CADLink screen whilst a tasking is being discussed, once the job has been identified and the detail screen opened.
GRN Radios: At all our bases there are free standing GRN radios. These can be left on State 1 or set on to local channel if we are monitoring specific jobs. Generally these will be situated beside or below the CADLink and status screens and beside the bat phones
Inside our road ambulance vehicles, each one has a handheld GRN radio. At the start of missions this will be set to the State 1 channel and allows us to speak to ACC. When tasked, the tasking details should tell us which local channel the job is being run on. Once we have radioed in to let ACC know we are on our way to scene, they will confirm the local zone and channel (for example, Sydney North). At this point we let them know we are now going to local channel in case they wish to speak to us further. Road ambulance, police and coordinators will all be on this line and you can ascertain valuable information about the job you’re heading to.
The MDT – Mobile Data Terminal: This refers to the computer device inside each of our cars. This is the system that all NSW ambulance cars are equipped with. Timings, addresses and mission details are all on this system. The big red button in the top left is the distress bell. If you press this, police immediately get notified and many people will suddenly appear! Don’t push it unless you fear for the safety of your team. There is a second duress button in the back of the car below the flexible light. It can be easily confused for the light switch but all those lights turn on by pressing on the head of the light.
The CAD and CADLink screen: Computer Aided Dispatch. This refers to the system used to manage all 000 calls that come through to NSW ambulance. The CADLink screen is the list of jobs on the computers beside the bat phones and allows us to see all 000 calls as they come through in real time, state-wide. When tasked to a primary, we identify the job, by time in the queue or location, and print or rapidly review the details as we head out. Please do not ‘surf the CAD’ whilst a job is being discussed. The large CADlink monitor is screen shared with those on the Pilots desks. If you scroll whilst a mission is being planned, their screen will also change and vital details for the flight plan may be missed and hard to relocate.
Outside our vehicles:
Aboard our aircraft, we carry various other means of communication for use in rural areas or when the medical team are separated from the aviation team and may need to communicate.
Satellite phone: The Satellite phone battery is checked every day as part of our checks and well worth taking the time to familiarise yourself with. Satellite phones have coverage over most of the earths surface and the sat phone we carry essentially works exactly as per a mobile phone with the crucial difference that you will need a clear view of the sky for it to operate. Remember, if you’re using the Sat phone on board any of the fixed wing aircraft, the number you’re calling may need to be dialled without the first zero. Allow plenty of time when using the sat phone – the delay can be similar to that when using radio communication.
GPS: Each aircraft is also stocked with a Garmin GPS (global positioning device). Initially developed by the military, GPS is now utilised in many of our own personal devices day to day but the purpose of our handheld GPS is for tracking and locating teams if they leave the aircraft and later need to rendezvous with different services or at a different location.
Down the wire: Every HEMS doctor on a helicopter shift checks their own personal handheld GRN radio each morning- checking battery levels, zone and channel. A helmet radio comms check with the paramedic should also be carried out at the start of each shift. When tasked on winch jobs, this radio becomes critical for communicating with the aircraft and air crewman. This radio is used for “down the wire comms” when winching, and in direct line of sight of the aircraft. While they can set to any channel and zone, this radio will be set to Admin zone and the Helicopter simplex channel during these jobs. Pre-winch as we disconnect our helmet headsets from the aircraft, we connect to our individual GRN radios and do a brief radio check to ensure it is working, that we can be heard clearly and understood. After winch insertion to a scene, we can use the radio to contact the aircrew and to arrange our extrication via direct communication with the crewman in the aircraft above us, and with our paramedic on the ground. While any winching is in progress, the aircraft Com3 will be set to ESOAir1 or Surf1, as per the comms plan. These will be deselected when not needed.
Extra acronyms and terms you may hear across the radio systems
ATC: Air traffic control
Visibility and cloud ceiling will determine whether pilots can use a visual or instrument approach to land (IFR or VFR).
SQUAWK: A squawk code is a discrete transponder code assigned, during take-off, by ATC to allow identification of individual aircraft. The name squawk refers to a historical nickname for the system first used to identify aircraft during World War II.
Traffic: As part of the crew, it’s important to always keep an eye for any approaching traffic- aka other aircraft, in your vicinity. If no one has mentioned it, speak up in case it hasn’t been seen yet. Use left or right, high or low. Often a clock face is used to identify the angle of the other aircraft relative to our position.
Mayday: The aircraft and its occupants are in immediate danger and require assistance.
Pan Pan: An urgent message regarding aircraft safety but no immediate need for assistance.
SARtime: Search and rescue time – the pilot will notify ATC of anticipated times of contact outside of which, if they don’t hear from the aircraft, they would initiate search and rescue proceedings. You might also hear the paramedic relaying a SARtime to ACC.
SARwatch: This is the generic term relating to aircraft safety and monitoring. The pilot will cancel SARwatch once safely landed to notify ATC they no longer need to be aware of them.
QNH: Air pressure at sea level.
MET: Meteorological advisory.
NOTAM: Notice to airmen.
VHF: Very high frequency radio.
Many thanks to our amazing Aircrewmen and Paramedics for their guidance in putting this article together.