‘The patient’s sats were 100% when I pushed the induction drugs. I thought the sats were fine as the pitch of the beeping from the monitor stayed the same, but when I looked back the patient had already started to desaturate!’
The Zoll X Series monitor is carried on our helicopters and road ambulances, and is widely used by retrieval services across Australia. Like many monitors it has a HR/PR tone function which can improve situational awareness, but its functionality is only briefly mentioned in the Operator’s Guide. While the above quote is fictional, it illustrates a potential source of confusion with this function.
Some of our monitors are set to HR/PR Tone ‘On’ and HR/PR Selected Source ‘ECG’ by default. This means when the ECG leads are applied to the patient, the monitor will beep with each heartbeat, however the pitch of the tone stays constant regardless of the oxygen saturations, because the selected source for the HR/PR tone is the ECG.
However, the monitor will use another available source for the HR/PR tone if the selected source is not available. For example, if only the pulse oximeter is attached to the patient, then that will be used as the source for the HR/PR tone. The pitch of the tone will change with the patient’s saturations, and is lower than if ECG is the source even with saturations of 100%.
Clinicians tend to be divided between those who prefer a quiet monitor, and those who prefer the HR/PR tone on as an audible cue to the patient’s oxygen saturations. In the latter case, it is important to ensure that ‘Sats’ and not ‘ECG’ is selected as the source of the HR/PR tone.
The education day started off with Dr Kruit speaking on ECMO in the COVID19 patient. Dr Natalie Kruit is a GSA HEMS Retrieval Specialist and a Cardiac Anaesthetist at Westmead Hospital, Sydney. To date there are around 360 COVID-19 patients worldwide being supported by ECMO, the predominance of which are on venous-venous circuits. Dr Kruit talked the group through ECMO experiences so far in COVID-19 and the challenges of its resource allocation during a global pandemic. The talk highlighted the current selection criteria being used in Australia to identify potential candidates for ECMO as well as the importance of optimising medical management as a pre-requisite to the therapy. It finished with the medical management of those patients who have been commenced on ECMO, focusing on issues experienced specifically with COVID-19 cases.
Intensive Care Unit Management of COVID-19
The second talk of the day was given by Dr Jill Lee, a Retrieval Specialist with GSA HEMS and Intensivist at Liverpool Hospital, Sydney. The talk focused around an update on the management of suspected and confirmed COVID-19 patients from a tertiary ICU perspective. The challenges of managing these patients in a period where evidence is short and there are still many unknowns was highlighted. Dr Lee spoke through the ‘new beast’ of COVID-19 and the local and literature documented challenges of testing, predicting clinical course and management of these patients. To finish there was discussion around the lessons learnt so far during this pandemic and what we can take forward with us in the fight to continue to keep our patients and staff safe.
Logistical Planning: Fitting a square peg in a round hole
The third speaker of the day was GSA HEMS Critical Care Paramedic Sam Immens, speaking about adaptive logistical planning using a recent case of a challenging patient extraction from a cruise ship. Sam talked through the process of the complex logistical planning surrounding what was a critically unwell patient, in a difficult access location, requiring significant interventions for medical stabilisation prior to transfer. It was highlighted that despite extensive planning unforeseeable new challenges were introduced including changes in invested parties and access options. However, through the use of pause points, adaptive logistics and anticipating potential issues these could all be overcome. A great mnemonic mentioned when considering these challenging logistical needs is PEEP CAMS:
Personnel (Qualified and Able)
Environment (Risks Assessment)
Safety Officer and Safety Plan
Thoughts on pre-hospital RSI in the era of COVID-19
The fourth speaker was Dr Clare Hayes-Bradley regarding considerations for our service in pre-hospital RSIs during the COVID pandemic. Dr Hayes-Bradley presented a summary of literature reviews around risk mitigation in potential aerosolising generating procedures (AGPs) relevant to the current pandemic. It was identified that team working to a known proven strategy of optimising first look while protecting ourselves with PPE is the overall aim. Given that we already team work to an optimised first look as standard, all we need to do is add PPE and we’re already well on our way to excellent practice. Pre-hospital services in other countries with higher community risk have adapted their practices more. Here, at GSA HEMS, we need to balance our responses against our risk – and be proportionate, otherwise we risk doing more harm than good. Our standard pre-hospital RSI with AGP PPE is appropriate currently.
The outcomes of these reviews were to recommend considering the following during prehospital anaesthesia:
Consider Plan A being VL and optimise screen position prior to first look
Be aware of potential for ‘red-out’ screen soiling with VL – suction as need
Control the bougie to avoid secretions spreading
Perform any AGPs in open well ventilated spaces where possible
Be intentional when placing down used airway kit (OPA/suction/bougie/laryngoscope) to limit contamination
Move unnecessary bystanders away and if can’t then ensure they are in appropriate PPE
HMEF with suction adaptors are available
Consider Thoracostomy as an AGP for now until evidence to say different
Emergency Medical Services Simulation Day at Killalea 2019
The final talk of the day was given by Dr Chris McLenachan, a Registrar with GSA HEMS and FACEM. The EMS simulation day is an multi-disciplinary simulation education day that last year gathered over 90 participants and observers from GSA HEMS, NSW Ambulance and the Emergency Departments of the Illawarra Shoalhaven Local Health District. The day centres around medical simulations involving critically unwell patients as their pathway moves through pre-hospital care to the emergency department. The goal of the day being to aid in familiarisation of the services in order to continually look to improve patient pathways. The origins of the day date back for years to Wollongong Base running simulations on the beautiful backdrop of Killalea. It has now grown to this regional event backed by the support and resources of GSA HEMS, NSW Ambulance and the Illawarra Shoalhaven Health Education Centre. The day yielded great positive feedback, local news coverage and plans for repeating as an annual event in 2020.