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‘The patient’s sats were 100% when I pushed the induction drugs. I thought the sats were fine as the pitch of the beeping from the monitor stayed the same, but when I looked back the patient had already started to desaturate!’
The Zoll X Series monitor is carried on our helicopters and road ambulances, and is widely used by retrieval services across Australia. Like many monitors it has a HR/PR tone function which can improve situational awareness, but its functionality is only briefly mentioned in the Operator’s Guide. While the above quote is fictional, it illustrates a potential source of confusion with this function.
Some of our monitors are set to HR/PR Tone ‘On’ and HR/PR Selected Source ‘ECG’ by default. This means when the ECG leads are applied to the patient, the monitor will beep with each heartbeat, however the pitch of the tone stays constant regardless of the oxygen saturations, because the selected source for the HR/PR tone is the ECG.
However, the monitor will use another available source for the HR/PR tone if the selected source is not available. For example, if only the pulse oximeter is attached to the patient, then that will be used as the source for the HR/PR tone. The pitch of the tone will change with the patient’s saturations, and is lower than if ECG is the source even with saturations of 100%.
Clinicians tend to be divided between those who prefer a quiet monitor, and those who prefer the HR/PR tone on as an audible cue to the patient’s oxygen saturations. In the latter case, it is important to ensure that ‘Sats’ and not ‘ECG’ is selected as the source of the HR/PR tone.
By Dr Chris McLenachan
ECMO and COVID-19
The education day started off with Dr Kruit speaking on ECMO in the COVID19 patient. Dr Natalie Kruit is a GSA HEMS Retrieval Specialist and a Cardiac Anaesthetist at Westmead Hospital, Sydney. To date there are around 360 COVID-19 patients worldwide being supported by ECMO, the predominance of which are on venous-venous circuits. Dr Kruit talked the group through ECMO experiences so far in COVID-19 and the challenges of its resource allocation during a global pandemic. The talk highlighted the current selection criteria being used in Australia to identify potential candidates for ECMO as well as the importance of optimising medical management as a pre-requisite to the therapy. It finished with the medical management of those patients who have been commenced on ECMO, focusing on issues experienced specifically with COVID-19 cases.
Intensive Care Unit Management of COVID-19
The second talk of the day was given by Dr Jill Lee, a Retrieval Specialist with GSA HEMS and Intensivist at Liverpool Hospital, Sydney. The talk focused around an update on the management of suspected and confirmed COVID-19 patients from a tertiary ICU perspective. The challenges of managing these patients in a period where evidence is short and there are still many unknowns was highlighted. Dr Lee spoke through the ‘new beast’ of COVID-19 and the local and literature documented challenges of testing, predicting clinical course and management of these patients. To finish there was discussion around the lessons learnt so far during this pandemic and what we can take forward with us in the fight to continue to keep our patients and staff safe.
Logistical Planning: Fitting a square peg in a round hole
The third speaker of the day was GSA HEMS Critical Care Paramedic Sam Immens, speaking about adaptive logistical planning using a recent case of a challenging patient extraction from a cruise ship. Sam talked through the process of the complex logistical planning surrounding what was a critically unwell patient, in a difficult access location, requiring significant interventions for medical stabilisation prior to transfer. It was highlighted that despite extensive planning unforeseeable new challenges were introduced including changes in invested parties and access options. However, through the use of pause points, adaptive logistics and anticipating potential issues these could all be overcome. A great mnemonic mentioned when considering these challenging logistical needs is PEEP CAMS:
- Personnel (Qualified and Able)
- Environment (Risks Assessment)
- Plan (Phases)
- Communications Plan
- Medical Equipment
- Safety Officer and Safety Plan
Thoughts on pre-hospital RSI in the era of COVID-19
The fourth speaker was Dr Clare Hayes-Bradley regarding considerations for our service in pre-hospital RSIs during the COVID pandemic. Dr Hayes-Bradley presented a summary of literature reviews around risk mitigation in potential aerosolising generating procedures (AGPs) relevant to the current pandemic. It was identified that team working to a known proven strategy of optimising first look while protecting ourselves with PPE is the overall aim. Given that we already team work to an optimised first look as standard, all we need to do is add PPE and we’re already well on our way to excellent practice. Pre-hospital services in other countries with higher community risk have adapted their practices more. Here, at GSA HEMS, we need to balance our responses against our risk – and be proportionate, otherwise we risk doing more harm than good. Our standard pre-hospital RSI with AGP PPE is appropriate currently.
The outcomes of these reviews were to recommend considering the following during prehospital anaesthesia:
- Consider Plan A being VL and optimise screen position prior to first look
- Be aware of potential for ‘red-out’ screen soiling with VL – suction as need
- Control the bougie to avoid secretions spreading
- Perform any AGPs in open well ventilated spaces where possible
- Be intentional when placing down used airway kit (OPA/suction/bougie/laryngoscope) to limit contamination
- Move unnecessary bystanders away and if can’t then ensure they are in appropriate PPE
- HMEF with suction adaptors are available
- Consider Thoracostomy as an AGP for now until evidence to say different
Emergency Medical Services Simulation Day at Killalea 2019
The final talk of the day was given by Dr Chris McLenachan, a Registrar with GSA HEMS and FACEM. The EMS simulation day is an multi-disciplinary simulation education day that last year gathered over 90 participants and observers from GSA HEMS, NSW Ambulance and the Emergency Departments of the Illawarra Shoalhaven Local Health District. The day centres around medical simulations involving critically unwell patients as their pathway moves through pre-hospital care to the emergency department. The goal of the day being to aid in familiarisation of the services in order to continually look to improve patient pathways. The origins of the day date back for years to Wollongong Base running simulations on the beautiful backdrop of Killalea. It has now grown to this regional event backed by the support and resources of GSA HEMS, NSW Ambulance and the Illawarra Shoalhaven Health Education Centre. The day yielded great positive feedback, local news coverage and plans for repeating as an annual event in 2020.
This will be a virtual meeting only via videoconferencing – please do not present to Bankstown Base.
By Chris Mclenachan
Workflow in suspected C0VID-19
The day started with the GSA HEMS Education Team holding a Q+A on the new Inter-hospital transfer workflow for suspected or confirmed COVID19 patients. The links to the recorded demonstrations of the workflows by the team can be found in the communications book.
Staff Support from the Staff Psychology service
The first talk of the day was given by Louise Harvey, the Senior Staff Psychologist for NSW Ambulance Aeromedical Services. Louise spoke regarding the staff psychology service which provides support under the banners of employee support, trauma support and manager support. The reasons for referral are also broad and range through traumatic occupational exposures, workplace issues and personal issues. The staff psychological service provides confidential services in which needs can be assessed, voluntary support planning and referral occur and the provision of short term psychological support can be provided. In regards to significant events at the work the initial follows up occurs with Team Leaders, Peer Support Officers and chaplains. If further support or psychological support is required, then the staff psychology service can be referred to on a voluntary basis. The talk finished with Louise highlighting the importance of looking after ourselves and the self-care wheel.
Wellness and Moral Injury
The second talk of the day was given by Reverend Mark Layson, the NSW Ambulance Chaplain at Bankstown Aeromedical Unit. His current PhD thesis is focused around moral injury in emergency workers and is built upon his years of experience in the police force, as a firefighter and now as a NSW Ambulance chaplain. The issue of moral injury from medical decision making was discussed, in particular injury around resource allocation decisions that may occur during the CoViD19 pandemic. Mark spoke regarding the varying definitions of moral injury from the introverted definition of Litz to the extroverted definition of Shay. However, he led on to explain that despite the varying definitions they tend to agree that the result is the impairment or destruction of the capacity for trust, an injury that transcends the mind and body, to the soul.
The talk went on to discuss how we process these events with potential moral injury, moving away from injury and towards personal and moral growth, summarising with the NSW Ambulance stepped Approach to processing these;
- Self: self-forgiveness and outward benevolence
- Peer Support: companion to allow communalizing grief
- Chaplaincy: expert companion and a dialogue with benevolent moral authority
- Psychology: expert knowledge and directed support
Prone Positioning and Retrieval Medicine
The third talk was given by David Ransley, Intensive Care Specialist and Medical Retrieval Registrar with GSA Aeromedical Retrieval Unit.
The talk was an overview of prone positioning from an ICU perspective, a topic of interest for the retrieval unit in light of the CoViD19 pandemic and potential resultant increase in Acute Respiratory Distress Syndrome (ARDS) cases. It was highlighted that the literature and experience of transporting patients prone is sparse and that this talk was designed to generate discussion of its potential role in the upcoming months. The indications for prone ventilation in the acute were identified as refractory hypoxaemia in Acute Respiratory Distress Syndrome. The proposed benefit of the therapy being an improvement in oxygenation through increased V/Q matching and increased homogenous alveoli ventilation, as well as reducing ventilator associated lung injury. The talk went on to identify the risks associated with prone positioning including the initial physiological instability and the issues of managing adverse events such as extubation and cardiac arrest in these patients, all of which would be exacerbated by being in the transport environment.
The presentation generated discussion around the risk vs benefit and feasibility of prone position transport for the future. Additional discussion focused around the feasibility of aiming to transport these patients only during their period of supine ventilation, which is generally around 8 hours as opposed to the 16 hours they spend prone.
Ventilation with the T1 Hamilton
The fourth talk was given by Ben Porter on the T1 Hamilton ventilator, which are in the process of being rolled out in the NSW Ambulance Medical Retrieval Unit. Ben is an Intensive Care Specialist, Anaesthetist and a Medical Retrieval Registrar with GSA Aeromedical Retrieval Unit.
The talk started with a refresher in volume vs pressure control and their respective waveforms, with the general principles of Volume control being better for ventilation and pressure control for oxygenation. The Hybrid mode on the Hamilton T1 of SIMV+ was highlighted to deliver Volume control ventilation with a pressure control waveform possibly providing the benefits of both.
A couple of key points with the Hamilton T1 settings were clarified;
- Importance of setting the patients height as part of ventilator set up as the ventilator will use this to calculate Ideal Body Weight (IBW) and thus predicted minute ventilation. The Hamilton T1 will use this to provide optimum ventilation parameters and alarm limits, and functions down to a minimum height setting of 30cm.
- If changing the Respiratory Rate you need to review and adjust I:E ratio through Inspiratory Time, it does not adjust automatically.
- In Pressure Control and Non-Invasive Ventilation settings the Psupport and Pcontrol are summative with the PEEP to give the inspiratory pressure.
- At GSA HEMS the initial settings have been programmed to a male patient of height of 174cm (70kg) with 7mls/kg (TV 490mls), RR 12, PEEP 5cmH20, Fi02 100% and I:E ratio of 1:2.
The remainder of the talk used the Hamilton T1 online simulation ventilator to work through two cases of challenging ventilation.
The Hamilton ventilators are being rolled out currently and there is one for reviewing on the Bankstown Base. Ben is very happy to be contacted (either by email or phone) if anyone has any questions or wants further training.