Clinical Governance Day Summary 19 November

AKA ‘The Matt Ward Show’

There was a really great turnout for a jam-packed Clinical Governance Day with a series of great presentations. It was clear that everyone involved in presenting had put a great deal of time and effort into their talks, which was appreciated by the entire audience.

We were fortunate to be joined by Matt Ward, lead paramedic for Emergency Care at the West Midlands Ambulance Service in the UK. He was able to share a wealth of experience, having worked as a paramedic in th e UK for over 15 years.

Pearls from AusTRAUMA 2014

Aidan gave us a whistle-stop tour of some of the many highlights of the Australasian Trauma Society conference, recently held in Sydney. With an all-star international cast including Karim Brohi and John Kortbeek, as well as SydneyHEMS’ own Brian Burns and Oran Rigby it sounded like the audience were treated to a smorgasbord of high quality lectures, covering every aspect of trauma imaginable.

 

The conference was also an opportunity for the Australian Trauma Registry to publish their inaugural report into trauma care across Australia with 25 of the 27 designated Trauma Centres contributing data between 2010-2012.

Trauma 2015 is happening on 2-4 October in the Gold Coast – for those of you who haven’t blown your entire study leave budget on SMACC Chicago!

Optimising Acute Stroke Care

Matt presented work carried out in the West Midlands looking at the impact of prehospital assessment and hospital pre-alerts on the subsequent acute stroke care pathway.

Paramedics applied the FAST (Face, Arm, Speech, Time) rule, as well as recording the time of onset of the suspected stroke. Results showed that FAST tests were positive in 75% of cases, with the time of onset recorded in 40%. A pre-alert was phoned through to the hospital in 44% of the cases.

After adjusting for confounding factors, the study found that there was an association between a positive FAST, a recorded time of onset or a hospital pre-alert and a timely CT scan.

West Midlands Ambulance Service have recently started piloting the use of AVVV, as an equivalent to FAST but for identification of posterior circulation strokes. Although it is at a very early stage, anecdotally it sounds as though it has aided the service in the identification of a number of stroke patients who may otherwise have been missed.

  • Ataxia
  • Visual field changes
  • Vertigo
  • Vomiting

Mechanical Compression Devices in Cardiac Arrest

Screen Shot 2014-01-07 at 6.57.22 pm

Sydney HEMS team practicing with the LUCAS 2 device

Hot off the press, Matt talked through the recently published PARAMEDIC trial, comparing manual CPR to mechanical CPR in the treatment of adult non-traumatic cardiac arrest. With 4471 patients recruited, it was suitably powered to find a 2.5% difference in 30 day mortality.

In keeping with the previously published LINC trial, there was no evidence of increased survival at 30 days (6% in the LUCAS-2 group and 7% in the manual CPR group).

Subgroup analysis found a marginally worse neurological outcome in patients presenting with an initial shockable rhythm. This should be interpreted with caution however; one hypothesis was that there was a pause in manual chest compressions as well as a delay delivering the first shock due to the time taken for placement of the LUCAS device

For more detail, head over to St Emlyns where theres is an excellent review of the article

Adrenaline: Friend or Foe?

Matt then went on to talk about the upcoming PARAMEDIC2 trial, which is an exciting randomised controlled trial comparing adrenaline to placebo in the management of out of hospital cardiac arrest. The study started in March 2014, running across five different ambulance services in both England and Wales.

Population – 8000 patients following out of hospital cardiac arrest. Children and pregnant women are excluded but interestingly trauma patients will be included in this trial.

Intervention – standard ACLS treatment, receiving either adrenaline or placebo

Control – standard ACLS treatment with adrenaline as per UK resuscitation guidelines

Outcome – the primary outcome is survival at 30 days.

It is thought that data collection will be ongoing for the next three years, with a plan to publish the results by 2019.

Command and Control

Following lunch, Cameron Edgar updated the doctors and paramedics on the latest developments in the command and control policy, in particular its relevance to pre-hospital jobs where winch insertion or extraction are likely to be required.

The bottom line seems to be that:

  • The air crew do not require permission to winch into a patient’s location. The pilot and aircrew will perform a winch risk assessment prior to insertion
  • In order for a patient to be extricated by winch, a Zone Manager first needs to determine the most appropriate method of patient extrication
  • The decision will be based on advice from ground and air crews
  • Winch extrication should not be undertaken when other safe, clinically and operationally appropriate options exist
  • A pause point has been introduced prior to winching the stable, non-time critically injured patient to ensure that all available information has been thoroughly assessed before committing to a decision

Next Clinical Governance Day is on Wednesday 3 December

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