Here are some of the learning points from the Sydney HEMS Clinical Governance Day 18th June 2014:
Some reminders cropped up that are worth revisiting:
- Rocuronium dosing for RSI: At least 1.2 mg/kg is recommended. Lower doses may be a reason for a lack of first-pass success at laryngoscopy. In the next iteration of out airway SOP we will be recommending 1.5 mg/kg
- Remember to do a thorough physical (ie. MANUAL – palpation) examination of the chest (including the parts of the lateral and posterior chest wall that you can access). Crepitus, deformity, and flail segments may otherwise be easy to miss.
- In maxillofacial disruption with haemorrhage, remember to reduce the fracture before splinting it, just as you would with a deformed limb. This often requires manually moving the midface by grasping the upper teeth. The subsequent placement of balloon catheters, when inserted horizontally in the nasal space, are more likely to be effective and correctly sited.
- During intubation the bougie should not be placed blindly (ie. no view of the interarytenoid notch from which to guide anterior placement) if other steps to optimise first pass success are not in place, namely optimal positioning and external laryngeal manipulation.
- It’s Winter, and late or last light winches may result in the team being inserted to the patient but not extracted by winch, sometimes necessitating an overnight stay in the field. Make sure in your personal kit you have thermals, gloves, beanie, and light sources including a head torch. Physicians should remember that the yellow survival pack should be put into the cabin prior to leaving base. Remember where it’s kept: in the boot for the AW139 and in the hangar SAR store for the EC145. If you spend the night in a canyon in Winter you’ll wish you had it!
- Winching near to cliff tops or mountain tops can risk turbulence as the air flows off the high land. It may sometimes be necessary for safety reasons to do a higher winch at these sites to ensure the aircraft is high enough to avoid this.
- In some winch missions the access skills of a second paramedic may be required, resulting in the physician being initially left behind. Options are then to bring the patient to the physician or to deliver the physician to a rendezvous point by another means (if the patient’s injuries warrant it).
Case challenges were put to the group based on real and imaginary obstetric retrieval challenges. Those who did the prereading fared best! A reminder of the references is here:
Post Partum Haemorrhage Guidelines
Two great cases facilitated by HEMS doctors Phil Webster and Dave Monks, including a great prehospital resuscitative hysterotomy case using a model invented by Phil.
Here Dr Carla Richardson and paramedic Marty Pearce do an amazing job considering they had no idea what to expect from the scenario or the model. The case was a prehospital traumatic cardiac arrest in a near-term pregnant patient. Carla and Marty had completed intubation, bilateral thoracostomies, and started blood transfusion in the mother prior to hysterotomy.
Great reminder on the roc dosing recommendations in RSI. This still appears to be poorly disseminated and patchily employed in hospital-based practice.
Love the c-section sim. This time with an amniotic balloon and an umbilical pipe, brilliant! Definite improvement on the pilot run this time last year. Although I would point out that when Dr Gibson performed this sim he was wearing sunglasses….there’s substance and then there’s style…