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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