Summary from Dr. Ben Porter (Consultant Anaesthetist working with Sydney HEMS) – thanks Ben!

Clinical Education Day Summary – 16^th October 2019

Thank you to all those involved in both the presentations and in the background helping to make todays education day a success.

SALAD Simulator

The Suction Assisted Laryngoscopy and Airway Decontamination simulator was in action again to give some fidelity to the management of severe airway soiling during induction/intubation. The simulator provides realistic catastrophic soiling of the airway and helps our crews rehearse management of passive regurgitation to minimise aspiration and hypoxia. Key learning points from today’s session included the importance of having two suction units available, noting that the portable suction unit, whilst very effective, only has a small canister capacity and a backup should always be available (usually in the form of the helicopter or road vehicle main suction unit).

Secondly, the importance of turning the patient lateral to allow passive drainage of the secretions/blood/gastric contents by gravity and maintaining this position for intubation if necessary. Time was spent practicing intubation of the manikin in the lateral position with both direct and video laryngoscopy.

Finally, use of suction assisted laryngoscopy, where one suction device is held parallel to, and in the same hand, as the laryngoscope to provide continuous suction thus allowing the working hand to be free for a second suction, or for instrumentation of the airway.

US HEMS Crash

We were arrested by a very emotive and personal talk from Justin McLean about the HEMS helicopter crash sustained by his organisation in the US in 2015. The focus of the talk was around the recovery phases following the incident and how the organisation and individual staff responded over the days, months and years after. The need for a robust strategic plan in the event of an incident was covered, and in particular; that this is reviewed regularly, accessible to all levels of staff and provides for the immediate and longer term.

Specific reference was made to communication, both within the organisation and to the wider public. In the current internet climate of rapidly available social media and news streams, it is crucial that the organisation publicly acknowledges any significant incident within minutes, particularly where the incident may have been witnessed by media groups or occurred in a very public place.

Huge thanks to Justin for sharing these difficult issues and for allowing us a very small insight into some of the incomprehensible difficulties faced by the team after such a catastrophic event.

Geriatric Retrieval, ICU Outcomes and Case Discussion

The decision to admit an elderly patient to an ICU presents challenges that differ from younger patients. There is frequently a greater burden of comorbidities, complexities with advance care planning and increasing awareness of the significance of morbidity following ICU admission. The separation of patients likely to obtain benefit from an ICU admission from those that will not can present great challenges to critical care clinicians, however this does not mean it shouldn’t be considered in the context of retrieval medicine. Exactly how these decisions should be made when tasked to retrieve a patient remains unclear, however at least historically appears to be an infrequent occurrence within our service.

In NSW the Guardianship Act 1987 governs the process of making medical decisions for patients lacking capacity and is important knowledge for any health professional. Advance Care Directives are legally binding, but can only withhold consent to particular treatments, not compel a medical professional to perform a particular treatment. Establishing whether an Advance Care Directive exists remains an important part of the assessment of a critically-ill patient and should be considered in the context of retrieval taskings.

Retrieval Team Complex Decision Making

A 90 minute debate was had on the motion “There is little role for the retrieval team in making treatment limitation decisions”. This was an informative discussion with both sides represented well and some really good thoughts vocalised by the team. At the end there was a unanimous vote against the motion supporting the believe that the GSA HEMS retrieval teams should be delivering critical care expertise to the patient in any location and thus should deliver all that this encompasses. This includes complex discussions about ceilings of care and palliation where this is appropriate.