By Chris Mclenachan
Workflow in suspected C0VID-19
The day started with the GSA HEMS Education Team holding a Q+A on the new Inter-hospital transfer workflow for suspected or confirmed COVID19 patients. The links to the recorded demonstrations of the workflows by the team can be found in the communications book.
Staff Support from the Staff Psychology service
The first talk of the day was given by Louise Harvey, the Senior Staff Psychologist for NSW Ambulance Aeromedical Services. Louise spoke regarding the staff psychology service which provides support under the banners of employee support, trauma support and manager support. The reasons for referral are also broad and range through traumatic occupational exposures, workplace issues and personal issues. The staff psychological service provides confidential services in which needs can be assessed, voluntary support planning and referral occur and the provision of short term psychological support can be provided. In regards to significant events at the work the initial follows up occurs with Team Leaders, Peer Support Officers and chaplains. If further support or psychological support is required, then the staff psychology service can be referred to on a voluntary basis. The talk finished with Louise highlighting the importance of looking after ourselves and the self-care wheel.
Wellness and Moral Injury
The second talk of the day was given by Reverend Mark Layson, the NSW Ambulance Chaplain at Bankstown Aeromedical Unit. His current PhD thesis is focused around moral injury in emergency workers and is built upon his years of experience in the police force, as a firefighter and now as a NSW Ambulance chaplain. The issue of moral injury from medical decision making was discussed, in particular injury around resource allocation decisions that may occur during the CoViD19 pandemic. Mark spoke regarding the varying definitions of moral injury from the introverted definition of Litz to the extroverted definition of Shay. However, he led on to explain that despite the varying definitions they tend to agree that the result is the impairment or destruction of the capacity for trust, an injury that transcends the mind and body, to the soul.
The talk went on to discuss how we process these events with potential moral injury, moving away from injury and towards personal and moral growth, summarising with the NSW Ambulance stepped Approach to processing these;
- Self: self-forgiveness and outward benevolence
- Peer Support: companion to allow communalizing grief
- Chaplaincy: expert companion and a dialogue with benevolent moral authority
- Psychology: expert knowledge and directed support
Prone Positioning and Retrieval Medicine
The third talk was given by David Ransley, Intensive Care Specialist and Medical Retrieval Registrar with GSA Aeromedical Retrieval Unit.
The talk was an overview of prone positioning from an ICU perspective, a topic of interest for the retrieval unit in light of the CoViD19 pandemic and potential resultant increase in Acute Respiratory Distress Syndrome (ARDS) cases. It was highlighted that the literature and experience of transporting patients prone is sparse and that this talk was designed to generate discussion of its potential role in the upcoming months. The indications for prone ventilation in the acute were identified as refractory hypoxaemia in Acute Respiratory Distress Syndrome. The proposed benefit of the therapy being an improvement in oxygenation through increased V/Q matching and increased homogenous alveoli ventilation, as well as reducing ventilator associated lung injury. The talk went on to identify the risks associated with prone positioning including the initial physiological instability and the issues of managing adverse events such as extubation and cardiac arrest in these patients, all of which would be exacerbated by being in the transport environment.
The presentation generated discussion around the risk vs benefit and feasibility of prone position transport for the future. Additional discussion focused around the feasibility of aiming to transport these patients only during their period of supine ventilation, which is generally around 8 hours as opposed to the 16 hours they spend prone.
Ventilation with the T1 Hamilton
The fourth talk was given by Ben Porter on the T1 Hamilton ventilator, which are in the process of being rolled out in the NSW Ambulance Medical Retrieval Unit. Ben is an Intensive Care Specialist, Anaesthetist and a Medical Retrieval Registrar with GSA Aeromedical Retrieval Unit.
The talk started with a refresher in volume vs pressure control and their respective waveforms, with the general principles of Volume control being better for ventilation and pressure control for oxygenation. The Hybrid mode on the Hamilton T1 of SIMV+ was highlighted to deliver Volume control ventilation with a pressure control waveform possibly providing the benefits of both.
A couple of key points with the Hamilton T1 settings were clarified;
- Importance of setting the patients height as part of ventilator set up as the ventilator will use this to calculate Ideal Body Weight (IBW) and thus predicted minute ventilation. The Hamilton T1 will use this to provide optimum ventilation parameters and alarm limits, and functions down to a minimum height setting of 30cm.
- If changing the Respiratory Rate you need to review and adjust I:E ratio through Inspiratory Time, it does not adjust automatically.
- In Pressure Control and Non-Invasive Ventilation settings the Psupport and Pcontrol are summative with the PEEP to give the inspiratory pressure.
- At GSA HEMS the initial settings have been programmed to a male patient of height of 174cm (70kg) with 7mls/kg (TV 490mls), RR 12, PEEP 5cmH20, Fi02 100% and I:E ratio of 1:2.
The remainder of the talk used the Hamilton T1 online simulation ventilator to work through two cases of challenging ventilation.
The Hamilton ventilators are being rolled out currently and there is one for reviewing on the Bankstown Base. Ben is very happy to be contacted (either by email or phone) if anyone has any questions or wants further training.