Courtesy of Nick Scott:
Our education day commenced with an update on the current terrorism threat, delivered by the NSW’s Counter Terrorism & Emergency Management Department. Ambulance service NSW’s role is key in being the “eyes and ears” – if you witness something suspicious report it using the national security hotline 1800 1234 00. Further information can be found at https://www.secure.nsw.gov.au/what-you-can-do/.
We had the pleasure of inviting one of our previous Registrars back – Dr Preston Fedor to deliver a fascinating talk. Preston is an Emergency Physician, Assistant Medical Program Director for Clark County EMS and a Captain, USAF, MC – 304th Rescue Squadron.
This lecture centered on a case, which involved not only complex and prolonged medical care, but also a complex rescue mission. The United State Air Force Pararescuemen (PJs) were tasked to access and care for two critically burned men aboard a ship more than 1000 miles out to sea, halfway between New York and Portugal. They flew out in an HC-130, parachuted into sea at night, boarded the ship from Zodiacs, and met their patients. Over the course of 32 hours the men cared for these patients, who required airway management (ETI for one, cricothyrotomy for another), escharotomies, continuous pain control and sedation, regular wound debridement and dressing changes, ventilator management, and more. All were eventually hoisted off the ship by a Portuguese coast guard helicopter.
As complicated as this all sounds (and it was a massive effort), the medical care was based on the adaptation of a relatively straightforward tactical medicine construct – MARCH. This is an acronym for the main priorities when caring for a patient in a tactical environment:
Massive Hemorrhage – Control it!
Airway – Open and maintain it by whatever means necessary
Respirations – Support ventilations if needed. Cover any holes in the chest. Make holes if needed.
Circulation – Access and fluids, blood, TXA
Head injury / Hypothermia – Think of head injury and avoid hypoxia/hypotension. Control the environment: get the patient off the ground, keep warm.
Over the years of wartime experience, the PJs learned that in order to fully use their paramedic skillset and better care for their patients in the tactical and prolonged care environment, that an addition to MARCH was needed. In comes MARCH / PAWS.
The PAWS stands for:
Pain control – early and often
Antibiotics (and) – antibiotics for battlefield wounds, and other meds as needed (think antiemetics)
Wounds – irrigate and debride battlefield wounds, burns as soon as feasible
Splinting – splint fractures, c-collars, spinal protection, eye shields
This framework as written is great in a tactical or prehospital environment when you can run through it, address the major issues, and then head right off to a trauma center. In the case of a prolonged care scenario (as in this case), when you may be with the patient for hours or days, MARCH / PAWS must necessarily become a cycle – continue to reassess, continue to manage these issues throughout the time you are caring for the patient. Keep going back to that airway, verify no tension pneumo is re-accumulating, tweak the vent as needed, continue sedation and pain control, clean and redress wounds, etcetera.
More important than memorizing and using these acronyms is to anticipate that these prolonged care scenarios will happen to you. This could be your next mission. So train for these situations, prepare yourself and your team for this eventuality. Find a way to stay organized and calm, and not miss any important elements of your patient’s care in the complexity and stress of these scenarios. MARCH / PAWS is one excellent way to not only keep it together, but excel.
Additional references, videos, podcast links, and other resources for this talk can be found at operationalems.com/lecturenotes.
Examining the literature:
We critiqued two papers on the day – Gavrilovski et al https://www.ncbi.nlm.nih.gov/pubmed/29706249 article regarding isolated head injuries and their association with cardiovascular instability and Rehn et al https://www.ncbi.nlm.nih.gov/pubmed/29141907 emergency vs standard response driving.
Have a read of the papers yourself – a few points brought out of our discussion was when does correlation imply causation and the use of DAG’s – Directed acyclic graphs (DAGs) are visual representations of causal assumptions and they can help to identify the presence of confounding.
Lessons from Cyclic 2:
Cyclic training had been very successful with abundant amounts of learning for the individuals taking part. One of the exercises was a night winch involving a big sick 45 yo male dirt bike rider accident, complicated by having his 12 yo son on scene. This was an unsupported scene 4 hours by foot.
These were just a few of the learning points to take away:
Before you set off on such a mission use the PEEP tool to assist mission planning:
Equipment (CAMS -comms, access, medical, survival)
These types are jobs are challenging with cold, dark, dirty and confined conditions. So, make sure you’ve the right PPE/clothing. Eye protection when walking through the Bush and don’t wear your torch hanging around the neck – think about illuminating what you’re doing!
You should mentally rehearse workflows with the team before you arrive on scene. Make decisions early about space creation, gear management, moving your patient vs temporising in sit u.
These are difficult conditions- don’t overlook optimizing the patient before interventions such as RSI. Consider using basket and immobilization equipment to help prep your patient for RSI e.g. combining the KED and basket creates a patient head up position -great for RSI but may limit access for thoracostomy. Utilize the bystanders.
All this and much more needs to be considered if the patient is to be effectively and safely treated and scene times are kept to a minimum.
The day concluded with ventilator groupwork designed to share learning about some of the finer nuances around our Oxylog 3000+ and Medumat Standard 2.